Policy responses for Belgium - HSRM


Policy responses for Belgium

4. Paying for services

Adequate funding for health is important to manage the excess demands on the health system. This section considers how countries are PAYING FOR COVID-19 SERVICES. Health financing describes how much is spent on health and the distribution of health spending across different service areas. The section also describes who is covered for COVID-19 testing and treatment, whether there are any notable gaps (in population coverage and service coverage), and how much people pay (if at all) for those services out-of-pocket.

4.1 Health financing

4.2 Entitlement and coverage

As stated above, a cash advance (€1 billion) was given to hospitals at the beginning of the crisis. Concrete financial mechanisms to amortize the consequences of the COVID-19 crisis on both general and psychiatric hospitals are under discussion. Indeed, the profit margin of Belgian hospitals is almost inexistent and such a crisis could lead many hospitals to bankruptcy without financial help.

The aim is to enable general and psychiatric hospitals to bear both the specific additional costs related to the pandemic ("extra costs") and the “normal costs” that continue to be incurred and whose revenues fell as a result of the drop in the normal activity.
A proposal was published on 11 June 2020 with the following compensation mechanisms:
(i) A one-time fixed payment to cover the extra-costs of preparing the hospital for the influx of COVID-19 patients (therefore independent of their COVID-19 activity). This amount could be based for example on the amount of implied FTE and on the number of COVID-19 beds created;
(ii) Recurrent fixed payments based on the COVID-19  activity, i.e. for triage (e.g. based on the number of contacts in the emergencies) and per day of hospitalization for COVID-19 (with a distinction between hospitalization in ICU or not and taking into account if ventilator or ECMO was used);
(iii) Recurrent fixed payments for extra costs not linked to the COVID-19 activity (e.g. for protective equipment, based on the number of FTE);
(iv) Fixed payments for costs not covered by the budget that are no longer covered due to a loss of revenue.
(v) Additionally, the initial hospital budget foreseen for 2020, also the variable part that normally depend on the activity, will be guaranteed.

The total amount obtained from these fixed payments and guarantees will then be deduced from the cash advance perceived at the beginning of the crisis (see above, €1 billion). If the advance perceived is superior to this total amount, the hospital could temporarily conserve this difference up to a “final evaluation” of the 2020 exercise on all hospitals. After this “final evaluation”, an additional amount could also be granted for some hospitals if judged necessary.

The royal decree setting the terms and conditions for granting this exceptional federal financial assistance to hospitals in the context of the COVID-19 coronavirus epidemic was published on November 12th: http://www.ejustice.just.fgov.be/eli/arrete/2020/10/30/2020031562/moniteur

Moreover, in the longer term, a reflection on a structural solution for dealing with pandemics and other disasters will have to be implemented and is currently under evaluation.

Concerning the 2021 budget, an additional amount on top of the budgetary objective is granted for COVID-19 expenditure:
● To control expenditure, a real growth cap has been established in Belgium since 1995 to determine the overall budgetary objective of the compulsory health insurance. This cap is determined based on the previous budgetary objective, increased by a real growth norm and indexed (health index). The real growth norm is currently set at 1.5% and will be increased to 2.5% from 2022. In 2020, the budgetary objective was set at €27 655 million. Based on this real growth norm of 1.5% and on the health index, the budgetary objectives for 2021 should have been set at €29 534 million. However, since the technical estimates (i.e. a projection of expenditure based on the observed trend) showed this budget would not be sufficient (potential deficit of €
● 539 million), the budgetary objective for 2021 was adjusted on the basis of these technical estimates and was set at €30 073.5 million for 2021. These €30 073.5 million include a budget of €402 million to strengthen the currently insufficient nursing provision (especially in hospitals), €200 million to improve access to mental health care and €600 million to make health professions more attractive, including €500 million for salary increases.
● An additional amount outside this budgetary objective is foreseen, i.e. €411.85 million on top of these €30 073.5 million, to finance specific measures related to the COVID-crisis: monitoring of COVID patients, intermediate structures, triage/sampling centres, out-of-hours services, nursing care: adjustment of basic services and flat rates, nursing care: follow-up of COVID-19 patients, reimbursement of tests, quality control, expansion of psychological care, cohort care, increased use of oxygen, protective measures and protective equipment for care providers, rehabilitation of COVID-19 patients, patient transport: increased costs for preventive protective and hygienic measures, chest CT outside the traditional system, costs for the creation of the national testing platform and incentives to extend the capacity of laboratories and Covid-19 vaccines. This additional budget currently does not yet include the followed measures: antigen tests and multiplex PCR tests; vaccination; the possible financial impact of the regularisation of the advance of €2 billion to hospitals; specific measures for vulnerable groups such as homeless people, people with disabilities, older people, uninsured people, drug addicts, etc.
● Additional efforts were also undertaken by the federated entities for the health services under their competences (e.g. residential facilities such as nursing homes and homes for older people, facilities for people with a disability, etc.). For example, the Flemish Government is allocating an additional €577 million to the care sector, on top of the €525 million already provided. From that additional budget, €412 million is foreseen to increase the purchasing power of the social and health care workforce under their competences and €165 million for structural measures to reduce the workload.

Social security contributions are the main public funding revenue sources, but with the economic crisis, around €3 billion of expected social contributions were not collected. A “financial equilibrium contribution” is provided by the Federal government to offset any deficits in the financing of social security. Because of the COVID crisis, this financial equilibrium contribution has increased from €2.8 billion to €10.6 billion to close the 2020 accounts without deficit. In addition to the increase in the cost of medical care, other social security items were hit hard (such as the massive use of temporary unemployment or corona parental leave).

About 99% of the Belgian population is covered by the compulsory health insurance for a large range of services. This compulsory health insurance is managed by the National Institute for Health and Disability insurance (NIHDI). Various measures related to the COVID-19 crisis have been taken by the NIHDI (1-2):

• PCR tests carried out by the Reference Centre of UZ Leuven  at the beginning of the crisis were fully covered by the NIHDI. For tests carried out in other laboratories, from March 9th the NIHDI asked the laboratories to temporarily suspend invoicing patients. Then on April 2nd, the reimbursement of these tests was agreed such that molecular tests are reimbursed if the procedures defined by Sciensano are followed and if the laboratory meets certain quality requirements (see NIHDI for details, https://www.inami.fgov.be/fr/covid19/Pages/conditions-remboursement-tests-detection-coronavirus-pandemie-covid19.aspx). These tests are fully reimbursed, the patient does not have to pay co-payments and extra-billings are not allowed. A maximum of 2 PCR tests per patient was allowed. This limit was removed from April 22th.
• Antigen tests are reimbursed since April 1th (also with a limit of maximum 2 tests, which was removed on April 22th) and according to the procedures defined by Sciensano. Negative or doubtful results must be followed by a molecular test. No molecular tests can be performed in case of a positive result. These tests are fully reimbursed (no co-payment and no extra-billings).
• Serologic tests are reimbursed since June 3th (maximum 2 tests per 6 months period) but only as complementary diagnosis or to assess the serologic status of health professionals working in care facilities with a high risk (such as hospitals, laboratories and nursing homes). In these conditions (see https://www.inami.fgov.be/fr/covid19/Pages/conditions-remboursement-tests-detection-coronavirus-pandemie-covid19.aspx for details), these tests are fully reimbursed (no co-payment and no extra-billings). Otherwise, people have access to serologic tests but have to pay a maximum amount of €9.60.
• The NIHDI is developing a global mechanism that allows different types of health professionals to provide care for their patients without physical contact, to bill these services to the sickness funds, and to allow patients to be reimbursed (see section 2.2). Specific codes in the national established fee schedule were created to allow physicians to give medical advice by phone during the COVID-19 crisis period. For these consultations by phone, the use of the third party payer system is also promoted (mandatory for vulnerable patients entitled to an increased reimbursement and strongly recommended for others patients) and there are no patient co-payments. 
• Additionally, because of the postponing of non-urgent consultations and care, the implementation of some pharmaceutical treatments, the renewal of reimbursement authorisations for some pharmaceuticals and health products, and the following of rehabilitation conventions could be impacted. Temporary measures were therefore taken to avoid interruptions in these types of care.
• Triage centres have been initiated to screen patients at risk of infection with COVID-19 so that patients do not have to go to a General Practitioner's (GP) waiting room or hospital emergency department, where they could infect others. Since March 23rd 2020, these initiatives have received funding from the NIHDI, i.e. the same fee for all physicians working in these centres, a flat rate for nurses, paramedics and care coordinators (per half day) and a flat rate for administrative staff.
• It is apparent that the health sector will suffer from this crisis, particularly financially. After the crisis, the NIHDI will assess all the issues with representatives of each profession.
• To support the mental health of the population, the reimbursement of psychological care has been extended: Since March 2019, to improve the accessibility of ambulatory psychological care, visits to a clinical psychologist have been reimbursed for adults aged between 18 and 64  years; who suffer from common mental health disorders (i.e. depression, anxiety, and alcohol abuse); and who are referred by a GP or psychiatrist. Since 2nd April 2020, this reimbursement has been extended to people < 18 years old and > 65 year old to cover the whole population. While such enlargement was already foreseen before the COVID-19 crisis (the decision of March 2019 was a first step); the measure has been accelerated to support the population during the crisis.
• Regarding user fees, no co-payment required from patients in the new financing mechanism allowing for teleconsultations during the crisis. Extra-billings to patients for protective equipment is also forbidden during this crisis (but specific fees paid by the NIHDI have been foreseen for protective equipment of health professionals).

Because all non-essentials and non-urgent interventions and consultations had to be either cancelled or postponed from 14 March 2020 (up to 4 May) and in order to guarantee the quality and continuity of care, a series of health care insurance rules have also had to be adapted, in particular with regards to the reimbursement conditions linked to the patient's age or to maximum time limits or follow-up period. Concerning hospitals, and in order to cope with the new working conditions, new health care insurance rules have also been defined for emergency departments, intensive care units and COVID-19 specific care units. An update of all measures taken by the NIHDI can be found on: https://www.inami.fgov.be/fr/covid19/Pages/default.aspx

Measures were also taken for self-employed people who would not be able to pay their social contributions: Self-employed workers may submit a written request to their social insurance fund to request a one-year deferral of payment of provisional social contributions. Other economic measures are described in section 6.

Uninsured people can be covered by the public centre for social assistance (OCMW – CPAS) of their municipality. Some categories of vulnerable people can also benefit from health care through other provisions: Undocumented migrants are entitled to receive care via Urgent Medical Aid (UMA). During the COVID-19 crisis, measures have been taken to facilitate the administrative procedures and all care provided to undocumented migrants - between 14 March and 31 May 2020 will be considered as UMA. For asylum seekers, health care costs are either covered by the Federal Agency for the Reception of Asylum Seekers (Fedasil) or by the Ministry of Social Integration via the local welfare centres (OCMW-CPAS), depending on where they are living. Refugees and Belgian residents born with a foreign nationality are covered by the compulsory health insurance. Concerning prisoners, they are covered by the Ministry of Justice but a reform that aims to integrate all prisoners into the compulsory health insurance system is underway (that already started before the COVID-19 crisis) (3-5).

(1) NIHDI (2020). COVID-19 : Mesures exceptionnelles de l’assurance soins de santé et indemnités. Brussels : National Institute For Health and Disability Insurance (https://www.inami.fgov.be/fr/covid19/Pages/default.aspx, accessed April 2020)
(2) Personal communication with NIHDI: Daubie Mickael and Meeus Pascal
(3) De Devos C, Cordon A, Lefèvre M, et al. (2019). Performance of the Belgian health system – Report 2019. Brussels: Belgian Health Care Knowledge Centre (https://kce.fgov.be/sites/default/files/atoms/files/KCE_313C_Performance_Belgian_health_system_Report.pdf).
(4) Service de lutte contre la pauvreté, la précarité et l’exclusion sociale (2020). Aperçu des mesures COVID-19, en soutien aux situations de pauvreté et de précarité. Bruxelles : Service de lutte contre la pauvreté, la précarité et l’exclusion sociale (https://www.luttepauvrete.be/wp-content/uploads/sites/2/2020/04/200409-aper%C3%A7u-covid-19-FR.pdf, Accessed April 2020) ;
(5) Personal communication with Dauvrin Marie (KCE).

In particular due to the implementation of their emergency plans (see section 2.1), general hospitals face financial pressure, such as a loss of revenue due to the cancellation of planned interventions, but also additional costs related to equipment purchase, remuneration of personnel and activity loss coverage, structural modifications, etc.

In order to guarantee the sustainability of their activities, Federal authorities have decided to create a very short-term financial mechanism to provide a cash advance to hospitals by mid-April at the latest, for a total amount provisionally set at €1 billion. The use of such cash advance would subsequently be treated on the one hand, as "accepted" exceptional costs and on the other hand, as a degree of coverage of revenue losses according to a level that must still be defined. These mechanisms will be applied to all activities within hospitals and will be defined in consultation with all stakeholders concerned (1-2).

Moreover, March 19th 2020, the provisional twelfths of the State budget for the months of April, May and June were approved, with an exceptional provision of €1 billion. This decision was taken in order to very quickly meet any expenditure that would be deemed necessary in the context of the fight against the coronavirus. This of course relates to essential health care measures but also to the necessary decisions to help and support workers and companies affected by the exceptional measures taken in the context of the crisis (see section 6). If it should later become clear that the billion euros is insufficient, this amount could be increased further (3).

Subsidies to support the crisis efforts are also granted by the federated entities for the health services under their competences (e.g. residential facilities such as nursing homes and homes for older people, facilities for people with a disability, etc.) (4-5) (see also section 6 on economic measures).

There have also been calls for donations. The King Baudouin Foundation, for example, an independent foundation of public utility, has set up a 'Solidarity Care Fund', which can receive donations from companies and individuals. The fund will be allocated to initiatives in hospitals and residential care institutions (older people, youth care, people with a disability, etc.) throughout the country according to need (6).

(1) NIHDI (2020). COVID-19 : Mesures exceptionnelles de l’assurance soins de santé et indemnités. Brussels : National Institute For Health and Disability Insurance (https://www.inami.fgov.be/fr/covid19/Pages/default.aspx, accessed April 2020);
(2) Personal communication with NIHDI: Daubie Mickael and Meeus Pascal;
(3) Sudinfo.be (2020). Budget fédéral: les douzièmes provisoires approuvés en plénière, un milliard d’euros débloqués pour lutter contre le coronavirus. Sudinfo.be (https://www.sudinfo.be/id174665/article/2020-03-19/budget-federal-les-douziemes-provisoires-approuves-en-pleniere-un-milliard, Accessed April 2020)
(4) Flemish Agency for Care and Health (2020). Managementondersteuning voor voorzieningen in nood door corona. Brussels: Flemish Agency for Care and Health – Agentschap Zorg en Gezondheid https://www.zorg-en-gezondheid.be/managementondersteuning-voor-voorzieningen-in-nood-door-corona, Accessed April 2020);
(5) Walloon Government (2020). 115 millions d’euros aux secteurs Santé et Emploi pour faire face à la crise Covid-19 : la Wallonie payera les opérateurs dès le mois d’avril. Walloon Government (https://morreale.wallonie.be/home/presse--actualites/publications/115-millions-deuros-aux-secteurs-sante-et-emploi-pour-faire-face-a-la-crise-covid-19--la-wallonie-payera-les-operateurs-des-le-mois-davril.publicationfull.html?fbclid=IwAR0v7Q76Bg-d2rFz9PnW6K0XJNd0HQIxF4Z0tkuwdbwqkqvra8GJcmMLFLw, Accessed April 2020);
(6) King Baudouin Foundation (2020). Ensemble face au coronavirus. Brussels: King Baudouin Foundation (https://www.kbs-frb.be/fr/Newsroom/Press-releases/2020/2020_03_23_COVID_19_General_ID, accessed April 2020).