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2.5.5.1 Price-cost relationships

A general disadvantage of the mixed fee-for-service and lump sum system is that it consists mainly of negotiated tariffs with little or no relation to real production costs^2,3,

34. Therefore, it could be considered to develop a better insight in the actual cost structure and the tariff. This issue has been introduced in different working documents of the NIHDI. Studies have to be planned to investigate direct costs of different profiles of care delivery:

• The costs for personnel: the actual time spent in care delivery is the main personnel cost. A difficulty is that personnel cost structures are different for employee-nurses and self-employed nurses2.

• The material costs: although several technical nursing interventions require the use of disposable materials such as perfusion tubes etc. and generate significant material costs, there is no general rule for compensating material costs and it is not known which proportion of the costs is due to material costs.

o Reimbursement of disposables: generally, it is presumed that reimbursement includes the payment of the disposable materials needed for administering these nursing interventions. However, often specific needles and other materials are needed. Prices may vary in the private dispensary.

2.5.5.2 The home nursing nomenclature A diversity of home nursing tasks

The financing of home nursing has to be discussed against the background of an evolving healthcare sector and evolving home care sector in particular. One of the issues to be considered is the wide diversity of activities and tasks in home nursing. Gosset et al.

(2007)⁴ conclude that the current activity profile of home nurses is characterized by complex interventions combining technical and non technical interventions. The latter include communication, collaboration and observation/prevention. However, complex interventions are currently not reimbursed within the NIHDI nomenclature.

Furthermore, home nurses regularly perform activities that are not included in the nomenclature list, such as preparation of medication, control of blood glucose values, (un)dressing of patients, counselling of psychiatric patients, measuring the blood pressure, peritoneal dialysis, prevention and education, emotional support of patients and their family, positioning of patients, interventions at night, ocular drops, administration, and communication with other disciplines.

Heyrman et al. (2007)³⁵ list complex technical nursing care delivery which are continuously performed at home and which are of comparable intensity and complexity as interventions carried out in the hospital. Consequently, they state that 12 complex technical home nursing activities need to be added to the current nomenclature of home nursing:

1. Administration of a peripheral perfusion 2. Intra-venous bolus injection of medication

3. Assistance in the placement of a central venous catheter via percutaneous punction

4. Red blood parts transfusion 5. Transfusion of blood plates

6. Assistance in replacing a cystocath-catheter

7. Assistance in replacing a percutaneous gastrostomy catheter 8. Assistance in ascites punction

9. Assistance in pleural punction

10. Assistance in placement of epidural catheter for analgesic treatment via PCA-pump

11. Parenteral nutrition

12. Therapeutic nutrition during less than 60 minutes

The nomenclature of nursing interventions is complex and lacks integration

The rules for combining/cumulating nursing interventions are very complex and lack consistency: for example, combining the basic care provision 1^st visit (nomenclature code 425014 on weekdays) with a visit of a specialist nurse in a patient with specific wound care is prohibited but cumulating the 1^st visit with diabetes educational care provision and follow-up visits is allowed. During the diabetes educational sessions, a specific nursing patient file on diabetes has to be created and maintained which is similar/comparable to the wound care patient file. In this matter, little reasonable arguments can be found for a different payment for a diabetic patient and a patient with specific wound care.

Insufficient specificity of nomenclature codes

There are several examples of singular nomenclature codes representing very different nursing interventions:

• the same nomenclature code represents vaginal irrigation and airway aspiration;

• nursing interventions for sub-cutaneous infusion, parenteral nutrition, intrathecal analgesia and epidural anaesthesia have one common code.

Moreover, many nursing activities are not reimbursed within the nomenclature framework. As nursing practice is evolving, new nursing interventions should be introduced in the nomenclature and interventions that have become obsolete should be removed. The fee schedule seems to be too slowly adapted to change³.

Administrative workload

Fulfilling administrative formalities for obtaining reimbursement for specific technical nursing interventions induces an administrative burden. Some initiatives have been taken in 2008 from nurses’ representatives to abandon the request for payment to the medical advisor of the patient’s health insurance organisation.

2.5.5.3 Control procedures

The main role of the medical advisors is to control 10% of the overall prevalent patient population under lump sum payments. However, no control is foreseen for the increasing number of patients receiving hygienic care delivery in the fee for service system. It could be discussed whether control of the proper use of the evaluation instrument should be expanded to all patients receiving hygienic care (inclusive hygienic care in the fee-for-service payment system).

An additional problem is that no criteria are available for identifying a systematic abuse of the assessment instrument, neither is it clear which sanctions are to be foreseen and which appeal procedures are available for nurses.

In some NIHDI reports global average numbers of visits per day are shown for the global care delivery in the Belgian population (see higher, note CCW 2008/35 of June 2008), but systematic analyses of individual nurses care practices or home nursing organisations are lacking, although this would be a relatively simple job for a mutuality or NIHDI using administrative data on invoices of nursing care provision.    

Key points

• Four payment systems contribute to the financing of home nursing at the federal level:

1. A mixed system of fee-for-service payment and lump sum payment;

2. Specific costs for home nursing organisations;

3. A subsidy for the costs related to computerization;

4. Reduced social tax contributions and Social Agreements.

• A specific arrangement covers nursing assistance in haemodialysis and peritoneal dialysis at the patient’s home.

• The fee-for-service system covers technical nursing interventions.

• The lump sum system covers nursing interventions for patients suffering from dependency/deficiencies in the activities of daily living (ADL). Patients

dependency is assessed by scores on the Belgian Evaluation Scale for Activities of Daily Living (BESADL).

• In the fee-for-service payment system, a doctor's prescription is required for reimbursement of all nursing interventions (excepted for hygienic nursing care). This is not true for nursing care delivery under the lump sum system (excepted for technical acts that require a doctor’s prescription under the fee-for-service payment system).

• To limit supply-induced care provision in the fee-for-service system, a maximum day-limit is fixed on the amount of level A lump sum payment.

• The qualification structure is highly differentiated for nurses. Specialized nurses have an extended role to autonomously take care of chronic patients with diabetes or wounds at home.

• There is a current trend to focus nurses on technical and specialized nursing activities by delegating basic nursing tasks to care assistants.

• The financing of home providers is not based on their qualification levels.

However, specific nursing interventions are only reimbursed when they are performed by specialized nurses.

• Regulations for nursing care delivery at home allow the third-party payer system. Patients only pay user charges.

• The nomenclature of nursing activities seems obsolete: a lot of complex technical home nursing activities regularly performed are not currently included.

• The nomenclature of nursing interventions is complex and lacks integration;

the rules avoiding cumulative reimbursement lack consistency.

• Control procedures are incomplete.