Healthcare in Belgium

University Hospitals Leuven Sint-Rafael

AZ Groeninge

Healthcare in Belgium is composed of three parts. Firstly, there is a primarily publicly-funded healthcare and social security service run by the federal government, which organises and regulates healthcare; independent private/public practitioners, university/semi-private hospitals and care institutions. There are a few (commercially run for-profit) private hospitals.^[1] Secondly, is the insurance coverage provided for patients. Finally, industry coverage; which covers the production and distribution of healthcare products for research and development. The primary aspect of this research is done in universities and hospitals.

Organisation

Healthcare in Belgium is mainly responsible for the federal minister and the "FOD Volksgezondheid en Sociale Zekerheid / SPF Santé Publique et Securité Sociale" ("Public Administration for Public Health and Social Security"). The responsibility is exercised by the governments of the Flemish, Walloon regions and the German-speaking community. Both the Belgian federal government and the Regional governments have ministers for public health and a supportive administrative civil service.

Political and regulatory

Organisation of Care

Generally speaking, health care is organised in three layers:

• First line: the primary care function that is provided by physicians (GPs), emergency services and ERs in hospitals. Polyclinics provide non urgent first line care (such as diagnostic or follow up of patients).
• Second line: acute and immediate care provided by hospitals for patients requiring technical interventions (surgery, technical diagnostics etc.) and acute curative care.
• chronic or long-term care: is provided by rehab-clinics, service-flat care providers, old-age homes and home-care services.

Physicians

The prime care professionals that patients need are their GPs. For common diseases like cold, flu, injuries and little aches, patients contact their GPs.

Physicians in private practice are generally self-employed. Officially, they are categorized in the following framework:

• Private practice:
  • General Practitioners (family doctors): usually operate from their private practice, although some group practices are emerging. These doctors are also syndicated in local chapters that organize guard duty services during weekend and holidays and for the evening hours and during vacations. A patient can call a duty-GP 24/7 who has access to the patients medical records from their GP's.
  • Specialists: many combine their private practice with a hospital posting or with a teaching position or similar research posting. Only a few operate private clinics (mostly ophthalmologists or dentists).
  • Experts and Assessment consultants: these specialists don't see general patients, rather they evaluate patients either as a second opinion at the request of the patient or are appointed to assess patients and treatments for insurance matters or by appointment of a court.
• Clinical practice:
  • Specialists: many clinical specialists have a teaching position in hospitals (teaching staff, assistants or trainees and nurses on the job) or combine their hospital position with a teaching position at a university.
  • Research clinicians: run clinical trials and do research.

Most doctors working in hospitals also have a private practice. Exceptions are, for instance, neurosurgeons or radiologists (evidently because they cannot have an OR in their garage or invest in the high tech equipment required to do their job). Doctors are usually paid on a per medical act basis either by the patient at their private practice or by the hospital, however some specialists are employees at a hospitals payroll or for research labs or universities. Assessment consultants are paid a fixed fee for their assessment report by whoever hired them.

Emergency services

For accidents and medical emergencies everybody can call on the emergency services. There are 2 phone numbers to contact the Emergency Services Network, 100 or 112. 100 gives you access to the Ambulance service or Fire department. In larger cities the Fire department operates the Ambulances, elsewhere Ambulances might be allocated to hospitals. 112 gives you access to the Police, Ambulance Services and Fire department. The dispatching centers for the 100 and 112 services, dispatches an available ambulance from the closest hospital or ambulance center. The operator is qualified to decide to dispatch a MER-vehicle.

Hospitals and the fire department operate ambulances and some hospitals. Additionally, the Red Cross charity operates an number of ambulances as well as privately owned companies that operate ambulances for the emergency network. The Red Cross charity and a number of other "cross" charities own ambulances and have volunteers that man first-aid posts during events like football matches, cycling races, sports or other mass events. They don't participate in the daily Emergency services network, but they do liberate the Emergency Services network from allocating too much assets and resources during those mass events.

Calling an ambulance is not a free service. The ambulance will bring the patient to the nearest hospital. An ambulance is manned by two people - a driver and a paramedic. Depending on your medical condition, a MERV or Medical Emergency Response vehicle is dispatched. That vehicle is manned by three people - a driver, an ER-doctor and a senior ER-nurse. The ER-doctor will choose the nearest appropriate hospital that has the necessary facilities based on the patients symptoms and condition, or another hospital in which the patient is under active treatment.

Hospitals

The Federal Service for Public Health describes the hospital sector^[22] in the following manner:

General structure

There are, generally speaking, two distinct types of hospitals: General hospitals and Psychiatric hospitals. Psychiatric patients are not mixed with general hospital population.

There are 209 hospitals subdivided in this way:

• 68 Psychiatric hospitals care for psychiatric patients that require care in a controlled, restricted environment. Some of these hospitals also offer therapy day clinics for patients that stay at home.
• 141 General hospitals which, as a general rule, are involved in providing non-surgical care for primarily adults with services such as cardiology, pneumology, gastro-enterology & endocrinology. They also provide a maternity ward and most of them have an emergency response unit. Pediatric and geriatric care units are available for those particular types of patients.
  • 113 general hospitals function as "acute hospitals."
    • 7 of which are University hospitals. They are directly linked to universities and provide for teaching and research facilities.
    • 16 general hospitals with University status that have special provisions to collaborate with universities and colleges both for teaching and research purposes.
  • 20 specialized hospitals that are smaller and provide care for very specific groups of patients like heart and vascular diseases, pulmonary diseases, locomotor disorders, neurological problems, palliative care, chronic diseases or psychogeriatric care.
  • 8 geriatric hospitals with care specifically for the elderly and their particular health problems.

The vast majority of hospitals are publicly funded. They are independent units or part of a larger organization that get funding from the public health service based on the activities they deploy, number of beds operated, specialist knowledge etc... In Belgium, there are only a handful of privately owned/operated hospitals that work outside and without the public health service funding. They provide luxury services and luxury accommodation for patients that can afford such exclusive services.

Outside these categories there are:

• day-clinics where ambulant patients can have therapy and return home. Many hospitals have sections for dayclinics.
• polyclinics where different specialists see patients who do not need to stay overnight in the hospital for diagnosis or post therapy controle. Many general hospitals operate polyclinics, but there are institutions outside hospitals that operate only as a polyclinic.

In a general hospital any of the following departments may be at the disposal of patients, but not all general hospitals offer all these facilities and departments:

• ER: emergencies and trauma center usually backed up by an ICU (intensive care unit).
• OR: not all hospitals provide surgical treatment and OR's.
• Polyclinic consultations, ambulance or out-patient care: patients can come during office hours to see a specialist either in the diagnostic phase, therapeutic phase or post-therapy follow-up consultations.
• Technical interventions: technical interventions are consultations using diagnostic tools such as collection of blood or bodily fluid-samples, and lab testing; medical imaging (rx, CT-scan, MRI or ultrasound); EEG, ECG and extended monitoring outside acute illness situations;
• Nursing units: standard hospital ward type of sections where patients get 24/7 care, post-op recovery
• Specialized units may be sections in a broader general hospital, independent units within a general hospital or independent specialized clinics:
  • Neo-natal and Pediatric clinics
  • Re-hab and recovery clinics
  • Geriatric clinics
  • Palliative care units
  • Psychological assistance units
• Research units: units within a general hospital that are specialized in running and caring for and following of patients/participants in clinical trials.

Nursing

Different levels of nursing training are available: basic nurse, midwife, full nurse

• Nursing in hospitals: in hospitals, the nursing work ranges from basic care nurse (doesn't perform any medical acts), nursing assistants, full-nurse, chief ward-nurse, trauma nurse or paramedics, ER- or OR- nurses and chief-nurse. Each of these positions require a different level of formal training, on-the-job training, accumulated experience and responsibilities. Nurses seldom work over their competence, because according to the Peter-principle, it would cause casualties. Nurses in care units work shifts two or 2 twohifts/day and 365d/year. Many nursing wards in general hospitals are currently chronically understaffed, exceptions being ER, OR and ICU. Some post surgical wards such as cardio-, thoracic- and neuro surgery units that operate MCMU's ( Mid-care monitoring units) often are less prone to understaffing because of the risks involved for patients.
• Nursing in research and polyclinic environment: nurses in research and polyclinic environments often have a more family friendly and limited 5d/w 8hr/d working patterns than their counterparts in the hospital care nursing units, however not all nurses like to work in such environments.
• Ambulant nursing (home care): when patients go home they often require follow-up of their hospital care like wound dressing, injections and bathing. Specialized ambulant nursing services provide such nurse-at-home services for recovering patients and for elderly people living at home. These services also dispatch basic care nurses, that do not perform medical acts for patients and elderly that require help with their daily hygiene and (clothes) changing.

Pharmacy

• Main street Pharmacies: drugs and medications can only be sold by pharmacies. Supermarkets and dietshops can sell products such as over the counter food-supplements, but any product claiming a medical effect even over the counter painkillers or stomach tablets are limited to pharmacies.
• Hospital Pharmacies: will only dispense drugs and medications for administration by nurses and doctors in a hospital environment. Many of these products are not available over the counter.
• Distribution of Care products: companies that wish to produce, import and distribute substances that can be qualified as medicinal are required to have a license and are strictly monitored. Their stock movements are controlled by a very close monitoring system.

Internet medication: if a patient buys medication in another EU country from a pharmacy for his personal use, by prescription or over the counter, he can import them into Belgium in his luggage or vehicle. Belgian patients may legally buy over the counter painkillers such as paracetamol in the Netherlands where they are cheaper, and take them to Belgium. However, attempting to import prescription drugs without a prescription, unregistered or forbidden medication, or narcotics purchased on the internet or for recreational drugs illegally on the street is prohibited and customs and police track this business rather strictly. Illegally imported drugs are confiscated, and the carrier might be brought to justice and fined or imprisoned.

Health insurance

History

• May 26, 1813 (under the French regime): after a minepit disaster in Ourthe, an Emperial decree created a miners-fund. It is financed by the employers and workers and which pays miners an allowance in case of permanent disability or medical incapacitation.
• September 19, 1844 : A welfare fund "De Hulp- en Voorzorgskas voor Zeevarenden onder Belgische Vlag" ("Assistance- and providential fund for Belgian merchant navy sailors") allowing workers an insurance-like cover against illness, disability, old age pensions, work-related accidents and unemployment.
• April 16, 1849 : The Government subsidizes the cost of incorporation of the societies of mutual assistance .
• May 8, 1850: The Government creates the "Algemene Lijfrentekas (later state-owned ASLK-bank), where every Belgian can save money for his old-age pension.
• 1869 : Incorporation of the first Socialist Mutuality, "La Solidarité", at Fayt-lez-Manage, the forerunner of SOCMUT (Socialistische mutualiteit), one of the three most important entities in the modern Belgian social security system
• 1894 : The first national law concerning the finance and provision of health care in Belgium was enacted, with social insurance being introduced in 1945.^[23]

Working

Health insurance is only one of the pillars of the system of social security provided for every Belgian citizen. Every Belgian citizen has access to the social security system—it is compulsory—but there are gaps in the system where people can drop out. For example, not paying contributions is one such exit and another is homelessness (social security is only available to people with an address).

Financing the system : compulsory social security

Every wage-earning worker or employee in a factory, office, working as house personnel (maids, chauffeurs etc.), and anyone working in Belgium is registered to a central system as well as the unemployed. The self-employed, such as shopkeepers, innkeepers, lawyers, and doctors, are also registered.

Workers are paid a daily or monthly wage their gross salary. From that gross salary, their employer has to deduct a certain amount (approx 13%) for social security and another (approx 20%) for taxes. The employer has to pay these amounts directly to the Social Security Services and the Inland Revenue Service (employers make these payments for the employee and deduct these payments from his wage). On top of the gross salary, the employer has to pay an employer's contribution for social security of approx 15%-22% to the Social Security Services. Failing to make these payments regularly and on-time is closely monitored and often causes failing businesses to be taken to court for failing to comply with their social security and fiscal obligations towards their workers. This reduces the risk for workers when they remain unpaid or when their contributions are not paid for them.
The Self-employed have a system in which they have to declare their earnings and based on their earnings a contribution is calculated which is roughly 20%-22%, but they are not covered like workers. People can opt-in to the system through this self-employed scheme. The government forms its tax earnings finances in part the social security system. This is a wealth re-distribution mechanism, because the contributions are incremental, this means that the more someone earns the more this person will contribute. Moreover, for health services, the compulsory health insurance and the refund system is the same for everybody (corrected for the lowest incomes) : i.e. for a consultation at the GP everybody pays the same and gets the same refund (irrespective of their income).

Financing the system: complementary systems

There is a complementary system of health insurance offered by the mutualities (extended hospital cover and travel cover), available to all mutuality members, and there is private insurance with commercial insurance companies for extended care (hospital and aftercare) and for travel care.
These systems are pure premium based insurance system.

Covering healthcare costs

1. Consultations with GP's or specialists in their private practise

• patients pay a fee for the consultation (approx 20-€25 for a GP) and for any medical acts (e.g. dental care at the dentist) (s)he may perform directly to the doctor, in return the patient gets a receipt that lists all the medical acts performed, and if necessary a prescription for medication.
• the patient gives this receipt to his mutuality, and they refund the patient in part (depending on the patients status), average patients get about 75% refunded
• some patients have a special social security code; they pay only €1 to the doctor, and do not receive a refund receipt. The doctor is paid directly by the mutuality (3rd payer system)
• the patient takes his prescription to a pharmacist, paying only part of its price; for each medication dispensed the supplier is paid a supplement by the social security services. In some cases the medication requires extra checks and such medication is often free to the patient, although very expensive. Each sale of the medication is tracked, and the supplier paid by the social security services directly.

2. Consultations at hospitals (polyclinic)

• patients see a doctor at the hospital polyclinic just link in their private practise.
• some patients pay the hospital as they leave and get a receipt for their mutuality, just like in a private practise; however many patient come in for follow-up consultations after a medical intervention or hospitalisation. The hospitals send the bill to the mutuality (3rd payer system) and patients get invoiced for their personal part.

3. Hospitalisations and medical interventions

• patients are hospitalised and they have to pay weekly advances for their medical expenses (usually 50-€100 per week).
• all consultations and interventions, medications etc. are directly invoiced to the mutuality and to and insurance cover the patient may have (3rd payer system)
• they receive an invoice for their personal part, which is often in part refundable by their complementary insurance.
• patients who suffer accidents might never have to pay any medical expenses, as accident insurers are often charged immediately, once responsibility is established.

Managing healthcare money streams

• Private insurance : private insurance companies collect premiums and provide cover, when an "insured risk" is realised the insurance company pays.
  • Legal systems protect patients, doctors and hospitals from abusive denials of refunds by insurers a governmental complaints authority keeps an eye on policy conditions and execution.
  • Access to private insurance is of course free, however an independent ombudsman service (not an individual) oversees refusals to ensure or termination (by the insurers) due to changes in medical condition of the patient. A governmental arbitration service reviews patient cases referred to it by the ombudsman and determines fair conditions/premiums for refuses / terminated patients
• Mutuality complementary insurance: the mutuality collects premiums and pays according to the selected cover.
• Mutualities compulsory health insurance:
• The mutualities' front-office workers evaluate any refund claims superficially: is the medical act refundable and what rate, and refunds the patient nearly immediately (used to be in cash, now directly to the patients bank account)
• The receipt is the controlled through the mutuality back-office system such that one doesn't get double refunds and other abuses
• Some claims (based on the patient's status) incur supplemental refunds, which are sent by the mutuality back office to the patient's bank account
• The mutuality gets paid by the social security services
  • the amounts they pay as refund
  • a fee for operating cost: mutualities have an extensive network of offices and the number of staff runs in the thousands; they also have large computer networks and difficult software programs that are often tailor-made (because apart from the 6 or 7 mutualities no-one else needs that software, and the amount of data treated is so extensive it requires much effort)

the patients key to system

In the 80'ies an "SIS-card" (plastic creditcard-size chipcard like bank card) was introduced, the social security card. With it the Federal Government introduced a "national number", that identifies each individual uniquely based on his/her birthday. Every individual had such an SIS card, and it established their entitlement to social security.
In 2014 that system was superseded by the plastic ID card (Belgium EID card) with social security information on the card chip, readable with a simple card-reader.

According to the Euro health consumer index, which placed it in fifth position in its 2015 survey, Belgium is probably the most generous healthcare system in Europe.^[24]

Social security

Social security encompasses health, old-age (and other) pensions, unemployment, disability and handicap, both managing the finances (collection of contributions, subsides and payment of refund, allowances etc.), but also the management of different kinds of care, regulation of the market of medicines, health and safety at work, health and safety of any public service rendered to the general public, Monitoring and safety of the food chain etc. .. just the overview in the regulatory services involved at different government levels in chapter 1 provides an insight in the complexity of the matter of social security.

See also

• Flemish insurance for non-medical care
• List of hospitals in Belgium
• Public Centre for Social Welfare

References

External links

Wikimedia Commons has media related to Healthcare in Belgium.