This webpage is meant as a humble contribution to the development of healthcare in our region and to provide information about the Belgian healthcare system in English, but it is still under construction. It is written to help and support ICT people and people starting in healthcare administration, which explains both how it is being written and its growth pattern. Due to a lack of time, it will take a long time to expand this webpage (and to correct errors).
Belgium has a mixed private/public health care system, based on the system which was developed by Otto von Bismarck in Germany (e.g. The Prussian Health Insurance Act of 1883 entitled workers to health insurance). The Belgian system comprises both government at different levels (federal, regional and local) as well as private participants (e.g.: insurance companies, healthcare providers). The foundations of Belgian healthcare insurance were laid in the nineteenth century, when workers organizations created Health Insurance Associations (HIAs or mutualities) to protect affiliated members against the risk of disease and incapacity to work. With the Law of 3 April 1851 the Belgian state officially recognized these mutualities, and with the Law of 23 June 1894 it passed more important legislation which served as the legal foundation for the mutualities until its replacement by the Law of 6 August 1990 regarding HIAs and National Unions of HIAs.
With a decree of 28 December 1944 social security for salaried workers was established, which had been voluntarily until then. This decree advocated universal access to social security, and made health insurance compulsory for all salaried employees. The new law also created the National Office of Social Security (NOSS) (Dutch: Rijksdienst voor Sociale Zekerheid : RSZ; French : Office National de Sécurité Sociale: ONSS), to collect contributions for all social security sectors, and a National Fund for Sickness and Invalidity to manage the health insurance in particular.
The Law of 9 August 1963 (Edmond Leburton, Socialist) created the National Institute for Sickness and Invalidity Insurance (Dutch: Rijksinstituut voor ziekte- en invaliditeitsverzekering: RIZIV; French: Institut National d'Assurance Maladie-invalidité: INAMI) which replaced the National Fund for Sickness and Invalidity and exists to this day. The Leburton-law was modified on 25 June 1964. The Leburton reform of the compulsory health insurance also formed the basis for legislation on hospitals dated 23 December 1963 (known as Joseph Custers's Law, Christian Democrat) when the Belgian government for the first time regulated the hospital system with specific legislation.
By 1969 healthcare insurance was expanded to the entire population, with a distinction being made between major and minor risks. Belgian health insurance nowadays consists of two distinct schemes: the general scheme which covers major risks and minor risks for the whole population except for the self-employed, and the scheme for the self-employed (and their dependants) which only covers the major risks.
In recent years cost control and cost reduction became more important, which started a process of financial responsabilization for healthcare providers. Since 1995, in accordance with a Royal Decree of 12 August 1994, the mutualities were granted more direct financial responsibility for health expenditure. There is a growing tendency to accomplish a shift from in-patient care (intramural, second and third line) towards out-patient care (extramural, first line). Registration of Key Performance Indicators (KPIs) was introduced in the nineties of the twentieth century, together with intra- and transmural clinical pathways.
Activities within hospitals can be grouped into activities related to value adding activities such as curing patients (medical activities) and caring activities for patients (nursing activities) and non-value adding activities or supporting activities (administration, logistics, infrastructure, ... ). The Law on Hospitals of 7 August 1987 (Belgian Monitor of 7 October 1987) describes the different types of hospitals, such as general hospitals, specialized hospitals, psychiatric hospitals and university hospitals. The RIZIV/INAMI-code of a general hospital starts with 710 (e.g.: 710/231/03 for ZNA Stuivenberg in Antwerp), for psychiatric hospitals it starts with 720 (e.g.: 720/936/65 for Psychiatrich Centrum Broeders Alexianen in Boechout).
There are both public (mostly Public Welfare Centres : OCMW/CPAS; Dutch : Openbare Centra voor Maatschappelijk Welzijn or French: Centre Public d'Aide Sociale) and private hospitals of which the private hospitals comprise about 75 percent of the available hospitals (e.g. Caritas Catholica).
All hospitals are required to deposit their accounting data to the Federal Public Service of Health (Dutch: Federale overheidsdienst (FOD) Volksgezondheid; French: Service Public Fédéral (SPF) Santé publique). To enable a quality control on the data provided by the healthcare enterprises, the FINHOSTA (Hospital Financing) application was developed for gathering the financial and statistical data through PortaHealth (since 2008).
In order to receive funding, since 1990 the activities within a hospitals need to be registered into which became the Minimum Hospital Data (Dutch: Minimale ziekenhuis Gegevens; French: Résumé Hospitalier Minimal: RHM), which comprise the Minimal Clinical Data (Dutch: Minimale Klinische Gegevens: MKG; French: Résumé Clinique Minimal: RCM) and the Minimal Nursing Data (Dutch: Minimale Verpleegkundige Gegevens: MVG; French: Résumé Infirmier Minimum: RIM ). In 2002 the way of calculating the basis for funding of hospitals was changed from the nursing day prize (Dutch: verpleegdagprijs) to the Budget of Financial Means (Dutch: Budget van Financiële Middelen).
The registration of the Minimal Clinical Data was made compulsory by the publication of the Royal Decree of 6 December 1994 (Belgian Monitor 30 December1994) which determined the rules whereby certain statistical data must be communicated to the Federal Service of Public Health. This decree was subsequently modified by the Royal Decree of 8 October 1996 (Belgian Monitor of 3 December 1996), the Royal Decree of 4 December 1998 (Belgian Monitor of 29 April 1999), the Royal Decree of 3 May 1999 (Belgian Monitor of 27 October1999), the Royal Decree of the 2 December 1999 (Belgian Monitor of 17 December 1999) and the Royal Decree of 1 October 2002 (Belgian Monitor of the 10/12/2002).
The registration of the Minimum Hospital Data was made compulsory by the publication of the Royal Decree of 27 April 2007 (Belgian Monitor of 10 July 2007) determining the rules whereby certain hospital data must be communicated to the Federal Service of Public Health. The Minimum Hospital Data consist of the Minimal Clinical Data, the Minimal Nursing Data and the Emergency and Resuscitation Mobile Service Data (Dutch: Mobiele Urgentie Groep : MUG; French: Service mobile d'urgence et de réanimation: SMUR).
The three basic ways of funding hospitals in Belgium are the Budget of Financial Means (BFM) the fees of the physicians and the hospital pharmacy.
The Minimum Hospital Data (MHD) are the basis to define the number of "justifiable hospitalisations" for which a
national benchmark is being calculated by the Belgian Federal government. Financing, which was previously based on structural
features such as the
number of acknowledged beds, takes nowadays the "justified activity of the hospital" into account
(Dutch: verantwoorde activiteit; French: activité justifiée).
This "justified activity" is based upon the case-mix of the hospital (this is the number and type of pathologies)
and also the average national length of stay per pathology group.
The Minimum Hospital Data themselves consist of a combination of administrative, medical (cure) and nursing (care) data:
The Minimum Hospital Data (MHD) themselves consist of several types of data:
Several teams within the hospital participate in the registration of the Minimum Hospital Data (MHD):
The Minimal Clinical Data (MCD) are based on the International Classification of Diseases - Version 9 - Clinical Modification, (ICD-9-CM), which is being used to code and classify morbidity data. ICD-9-CM volumes 1 and 2 are used for diagnostic codes, while volume 3 is a system of procedural codes. The ICD codes were first developed in 1893 in France by the physician Jacques Bertillion (1851-1922). They were first called the Bertillon Classification of Causes of Death. The first edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893. The World Health Organization (WHO) took over the responsibility for the ICD at its creation in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published.
The International Classification of Diseases, Clinical Modification (ICD-9-CM) has the following structure:
The 2010 ICD-9-CM Volume 1 Diagnosis Codes are grouped into categories. For example ICD-9 code 250.0
means diabetes mellitus with no complications. For diabetes mellitus, a fifth (5th) digit classification is
used, where 250.00 means " diabetes mellitus without mention of complcations" (250.0) and the fifth digit 0 means "type II
or unspecified type, not stated as uncontrolled". The code 530.81 means gastro reflux disease (GERD), whic consists of
the code "other specified disorders of the esophagus" (530.8), further specified into "esophagal reflux" (530.81).
In the case of code 530.81, "reflux esophagitis" (530.11) is excluded.
A V code designates a patient who is accessing the healthcare system for some reason that does not require a diagnosis, usually a preventive reason. For example V70.0 is the code for a general health check up. The E section, deals with external causes of injury.The overview below is based on the 2009 editions of ICD-9-CM.
After coding the primary diagnosis into ICD-9-CM, the ICD-9-CM are being grouped into Major Diagnostic Categories (MDC). Each MDC is assigned to an All Patient Refined Diagnosis Related Groups (APR-DRG), which is more homogeneous for medical treatment as for cost of treatment. The Major Diagnostic Category is being used to calculate the average cost for each type of pathology and stay in the hospital to determine the acceptable activity (Dutch: verantwoorde activiteit). The acceptable activity is meant to match the activity within the hospital with its budget. In psychiatric hospitals or psychiatric departments of general hospitals, the equivalent Minimum Psychiatric Data (Dutch: Minimale Psychiatrische Gegevens: MPG; French: Registres de Données psychiatriques minimales: RPM) are being used.
The Major Diagnostic Categories are being converted into All Patient Refined Diagnosis Related Groups (APR-DRG), which are more homogeneous for medical treatment as for cost of treatment. The classification of cure data into DRGs was for the first time developed at Yale University in the USA in the early 1970s. The purpose of a classification into DRGs is to relate the case mix of pathology of the hospital to its resource demand. Patients are being grouped into groups of patients with similar clinical profiles and demand of hospital resources (Resource intensity as the relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular disease).
The APR-DRGs expand the basic DRG structure by adding four subclasses to each DRG. The addition of the four subclasses addresses patient differences relating to Severity of Illness (SOI) (degree of physiologic decompensation or organ system loss of function) and Risk of Mortality (ROM, refers to the likelihood of dying). SOI and ROM indicate the requirement for the relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease. The four Severity of Illness subclasses and the four Risk of Mortality subclasses are numbered sequentially from 1 to 4 ranging from minor, moderate, major, up to extreme Severity of Illness or Risk of Mortality. To evaluate resource use or to establish patient care guidelines, the APR-DRG in conjunction with severity of illness subclass is used. For the evaluation of patient mortality the APR-DRG in conjunction with the risk of mortality subclass is being used. The APR-DRG should lead to a more appropriate indication of the utilization of resources for the hospital and physicians, based on a more accurate severity-adjusted Case Mix Index (CMI).
According to version 20 of APR-DRG there are 956 APR-DRG defined, which in turn are grouped into 26 Major Diagnostic Categories (MDC). The MDCs were created to ensure that the DRGs are clinically coherent. The diagnoses in each MDC corresponds to a single organ system or etiology and in general, MDCs are also associated with a particular medical specialty (medical, surgical). The basic organizing approach to classification in the APR-DRG system is to first assign the patient to a Major Diagnostic Category (MDC), based upon the principal diagnosis (PDX), and then to a specific APR-DRG category based upon principal diagnosis (if medical) or operating room procedure (if surgical). The principal diagnosis is the diagnosis at the end of care (final Dx). The secondary diagnosis (SDX) is about comorbity (existed before admission, POA: Present On Admission) or a complication (occurred after admission). The Principal Operation (POp) is the procedure or operation primarily done for the admission (PDX or SDX). A Secondary Operation (SOp) are all other significant procedures or operations.
There are 25 Major Diagnostic Categories (MDC) defined:
In the APR-DRG system, the Severity of Illness (SOI) and Risk of Mortality (ROM) metrics are being used for mortality risk adjustment within each Diagnosis Related Groups (DRG). The SOI indicates how sick the patient is, while the ROM indicates the likelihood of death of the patient. Be aware that the SOI and ROM are categories and not scores. The four levels of SOI and ROM are:
Example of coding the SOI for Diabetes Mellitus.
Care data are registered into Minimum Nursing Data (MND), which are based on the American NIC-classification (Nursing Interventions Classification).The Minimum Nursing Data, now MND-II (Dutch: Minimale Verpleegkundige Gegevens-II or Verpleegkundige Gegevens van de Minimale Ziekenhuisgegevens: VG-MZG) which provide an indication of the nursing effort related to the degree of dependency of the patient on assistance. The Minimum Nursing Data are being registered in all non-psychiatric hospitals since 1988. Before 2000, only the traditional hospitalisations were registered. Since 2000 day hospitalisations and the the newborns who are not with their mother are being registered. The registration of the Minimum Nursing Data is limited to four sample periods, day 1-15 of March, June, September and December. Within these time frames the Federal Service (Dutch: Federale Overheidsdienst : FOD; French: Service Public Fédéral: SPF) assigns five days of which the data have to be delivered.
Within the framework of Minimum Nursing Data the following data are registered:
The VG-MZG data are organized in 4 hierarchical levels (such as the NIC):
(Dutch: Mobiele Urgentie Groep : MUG; French: Service mobile d'urgence et de réanimation: SMUR)
The Minimum Financial Data (MFD) (Dutch: Minimale Financiële Gegevens: MFG) contain for every hospitalization all reimbursed codified medical services (based on the nomenclature of medical services) and the related costs for the medical insurance. The MFD are related to the data on pathology contained within the Minimum Hospital Data (MHD), which provides a cost per pathology.
The Minimum Social Data (Dutch: Minimale Sociale Gegevens) are being used for the social stratification of the patient population of a hospital, which is being used for the B8 part of the Budget of Financial Means (Dutch: Budget Van Financiële Middelen: BFM).
The Minimum Hospital Data (MHD) are being analyzed and used for financing hospitals (see next section), based on the "justified activity" of the hospital (Dutch: verantwoorde activiteit; French: activité justifiée).
The principle of justified activity is defined as follows:
The principle used within the context of justified activity takes into account the number of "real hospitalisations" which are the number of days between admission and dismissal of the patient (Dutch: Reëel Aantal Ligdagen: RAL), the number of "invoiced hospitalisations" (Dutch: Gefactureerd Aantal Ligdagen: FAL) which are invoiced according the legal rules for tarification and invoicing (Dutch: Tarificatie en Facturatie or Tar/Fac) and the "justified hospitalisations" (Dutch: Verantwoord Aantal Ligdagen: VAL). The "justified hospitalisation days" (VAL) are defined after comparison of the number of hospitalisaton days to the national benchmark.
For each hospitalisation, the number of "justified hospitalisation days" is calculated, based on the "national average number of hospitalisation days" (Dutch: nationale gemiddelde ligduur: NGL) for each:
The parameters of the number of "justified hospitalisation days" (Dutch: VAL) are being defined as follows:
The number of "justified hospitalisation days" should be equal to the "national average number of hospitalisation days" (VAL = NGL), but is for an individual hospital equal to the number of "invoiced hospitalisations" (VAL = FAL). The actual number of "justified hospitalisation days" for a hospital is the "national average number of hospitalisation days" plus the ("invoiced hospitalisations" minus the border outliers of type 2) : VAL = NGL + (FAL - limit of outliers type 2). This is taken into account for the financing of the hospital activities (loss when higher, profit when lower).
For hospitalisations of a type of which there are less than 30 nationwide, no "national average number of hospitalisation days" is being calculated, also when the patient dies within 3 days, mistaken hopsitalisations, and some APR-DRG categories.
This category comprises those hospitalisations of which the day of admission is the same as the day of dismissal. For this category, the number of "justified hospitalisation days" (Dutch: VAL) is 0.81 day. These surgical treatments are listed in the nomenclature "List A" with their RIZIV/INAMI codes.
The unjustified classical hospitalisations are those of which the day of admission is not the same as the day of dismissal.
For this category, the number of "justified hospitalisation days" (Dutch: VAL) is also 0.81 day.
To be categorised as an unjustified classical hospitalisations, to the following criteria (all) apply:
The funding of the operational activities of an hospital originates from three main sources, besides the patient himself:
The patient himself pays a certain amount for each day he stays in the hospital, a personal contribution for the administered medication, technical interventions, laboratory, medical imaging. Supplementary payments are due in case of the professional situation of the physician (fee supplements), single or double room and certain supplements for materials. Additional costs related to the hotel-services of the hospital are added to the invoice (television, phone, ... ).
The government funding of building activities is controlled by the so called building calendar (Dutch: bouwkalender) (Agreement of 19 June 2006 - Belgian Monitor of 19 January 2007 for the period 2006-2015). The building calendar regulates the maximum allowed expenses at a federal level and the partitioning of the budget at a regional level (Flanders, Wallonia, Brussels). The calculation of the maximum funding per hospital is regulated by the Ministerial Decision (Dutch: Ministerieel Besluit: MB) of 11 May 2007 (Belgian Monitor of 6 June 2007).
The Royal Decree of 25 April 2002 defines the way of calculating and distributing the Budget of Financial Means (Dutch: Budget van Financiële Middelen: BFM) of the hospitals. Since 1 July 2002 the BFM replaces the former nursing day price (Dutch: verpleegdagprijs), which was in use since the Ministerial Decision of 2 August 1986. Since 2002, the number and type of hospitalizations (case-mix of pathologies) drives the funding of hospitals instead of the number of nursing days.
The BFM-based financing of hospitals is based on the specific activities of a hospital, which is based on the type of pathology and acceptable beds (Dutch: verantwoorde bedden) as previously it was based on the organization of the hospital based on recognized beds (Dutch: erkende bedden). A transition period from 2002 to 2006 was taken into account. The BFM is meant to fund the non-medical activities of a hospital, which comprises mainly the nursing activities, the hotel facilities and the infrastructure. About 85 percent is being paid as a fixed amount each year, while 15 percent is variable. The 85 percent of the BFM each year is paid in monthly parts by the HIAs (mutualities), while the remaining 15 percent is paid according to the number of a certain amount per nursing day and half for each admission.
The BFM has three parts A, B and C and which are split into a total of 16 divisions. Part B1 comprises about 25 percent, part B2 about 45 percent and part B4 comprises about 11 percent of the BFM. So about 80 percent of the BFM is comprised of the parts B1, B2 and B4. The allocated budget is subject to revisions, such as the number of nursing days (until 1 July 2002). The delay in revising this number of days, is up to 10 years. This system will eventually be replaced.
A1 : The depreciation (a certain percentage of the amount) of the movable and property investments and the financial
charges of associated investment credits.
A2: The charges of short term loans (fund credits and straight loans) meant to bridge the period until the HIAs payments for provided services.
A3: The investments and depreciation costs of certain technical services; radiation therapy (medical use of ionizing radiation) and medical imaging techniques such as Nuclear Magnetic Resonance (NMR) and Positron Emission Tomography (PET).
B1: The general services of a hospital, such as general and administrative costs, maintenance, heating , meals,
laundry and linen.
B2: The clinical services, which comprise mainly the costs of the nursing and caretaker staff, costs of basic medication and medical consumables.
B3: The operational costs of certain technical services, such as NMR, radiation therapy and PET.
B4: Costs which result from legal obligations or which are related to the launching of pilot projects.
B5: The operational costs of the hospital pharmacy.
B6: The costs which result from additional social benefits which are incorporated in the sector agreements (of 1991 and 2000), beside the nursing day price.
B7: The specific costs which are related to certain university-related tasks of the university hospitals (B7A) and certain non-university hospitals (B7B), particularly in the domain of research, training and development of new technologies.
B8: Specific costs for a hospital with a patient population with a low social profile (e.g. praxis pauperum instead of a praxis aurea).
B9: The costs which result from additional social benefits which are incorporated in the sector agreements (2005-2011).
C1: The startup costs in case of new building activities.
C2: Compensations for a shortage or a surplus on income determined with regards to the estimated budget for the present year of service or for one or more previous years of service.
C3: A reduction of the BFM for the chamber supplements which the hospital has charged for a single or double rooms (negative amount of money).
C4: The estimated surplus of income for a certain year of service for the specialised services for palliative care, units for the treatment of heavy burns and the psychiatric hospitals.
A patient in a hospital only pays the personal part of the medical costs (Dutch: remgeld), the other part the hospital receives from the HIAs. The financial transactions related to the fees are managed by the central inning department of the hospital. The received amount of money is distributed over the hospital departments (physicians), minus the costs which are not covered by the BFM.
Net fees are those directly related to the medical service provided by the physician to the patient. In the gross fees are included the infrastructure, personnel, consumables, etc. which are used to provide the medical service of the physician (cure provider).
The basic way of financing based on performance has lead to an increase in medical consumption in certain areas. In order to provide more guidance in certain medical disciplines towards the amount of services provided, a fixed fee system was implemented. The fixed fee system was introduced in 1988 for the clinical laboratory and in 1991 for medical imaging.
Physicians can opt to provide their medical services at a price in agreement with the convention between the HIAs and the medical profession or not (or only partially). Adhering to the convention provides the physician with certain social benefits granted by the RIZIV/INAMI, but puts limitations on the fees the physician can ask for his/her medical services.
Since 1 July 2006, patients in a hospital pay a fixed amount of 0.62 Euro per day for their medication for those medication the categories B, C, Cs and Cx. Medication of category A is 100 percent reimbursable, while medication in category D is not reimbursable.
For ambulatory patients (day hospital) medication is invoiced at the bases rate for hospitalized patients (net price) with in addition a fee for operational costs. A hospital pharmacy is also allowed to provide medication to homes for the elderly in the same village or adjacent villages.
The hospital pharmacy also provides cosmetics, which are being paid for by the BFM or by the patient.
This type of (prepared) medication is not invoiced to the hospitalized patient. For day care patients the outpatient rates are applied.
A daily fixed feed is provided by the RIZIV/INAMI.
Blood and (unstable) blood products are provided by blood banks (e.g. Red Cross) in accordance with article 23 of the Law of 9 August 1963. These products are paid for by the RIZIV/INAMI in accordance with the Ministerial Decree of 12 October 1998, provided a physician signs for the administration to the patient.
The RIZIV/INAMI pays the difference between the price of 0.32 Euro for each 10 ml and the 0.30 Euro paid for by the patient, of an amount of 200 ml or less. For each additional 20ml, the ZIV/AMI reimburses 0.62 Euro.
Human tissue is paid for by the RIZIV/INAMI, provided it is included in the official list of human tissue and originating for a recognized tissue bank, provided a physician signs for the administration to the patient.
Casts are reimbursed by the RIZIV in accordance with the Royal Decree of 21 May 1987. Nowadays mostly synthetic casts are being used, but the reimbursement is still based on traditional plaster.
Consumables, such as syringes, instruments, bandages, etc., are funded by part B2 of the Budget of Financial Means (BFM). Investments in medical-technical material, such as for NMR, radiation therapy and PET are regulated by the Ministerial Decree of 21 April 1987, which was expanded in 1991 and 2001. Those are part of part A1 and A3 of the BFM
A series of materials, such as active and non-active implants, prostheses and other implatable material are eligible for reimbursement. This is regulated by articles 28, 35 and 35bis of the medical nomenclature. Implantable material not included in these articles is not reimbursed.
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First version published on 21 September 2009. Last modified on 24 October 2010.
The author of this Webpage is Peter Van Osta.