FIRST ANNUAL MEETING OF THE INSEAD-EHLP-class 2002 Brussels, May 23, 2003 THE PERSPECTIVE OF THE PROVIDER Marc MOENS, M. D. Vice-president of the Belgian Association of Medical Unions (BVAS-ABSy. M) Secretary-general of the Association of Belgian Professional Societies of Medical Specialists (VBS-GBS) Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 1
1. Introduction 2. Short history of organized interest groups 2. 1. Creation of Sickness Funds and Medical Trade Unions 2. 2. Physicians’ resistance and strike 3. Elements of the law of August 9, 1963 on Sickness and Invalidity Insurance 3. 1. The system of conventions 3. 2. Representativity of Medical Trade Unions 4. Representation of medical organizations in official organs 5. Our principles and objectives 6. Conclusion Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 2
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (1) • The 19 th century proletarianism led to the creation of societies of mutual assistance for the working class • Legal basis April 4, 1851 • Allowing the formation of alliances by the law of June 23, 1894 • Governmental support since March 19, 1898 • Remained unchanged until December 31, 1990 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 3
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (2) • Law of December 18, 1944 : creation of a mandatory sickness and invalidity insurance system for employees • Implementation by Decree of the Regent of March 21, 1945 creating a national committee of directors including : - 8 employees’ representatives - 8 employers’ representatives - 5 representatives of the sickness funds - 3 government commissioners : ministry of health care, social security and finance • No representation of health care providers • Publication of a provisional tariff list by Ministerial Order of April 19, 1945 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 4
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (3) • Till +/- 1950 : lots of small professional societies • July 15, 1954 : creation of the Grouping of Belgian Professional Societies of Medical Specialists (VBS-GBS) and futile attempts reach an agreement with sickness funds • October 10, 1954 : creation of the General Syndicate of Belgian Medical Doctors (ASGB) by Dr. Marcel DE BRABANTER -> shared management of the system -> shared financial responsibility -> generalized and compulsory system of third party payment Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 5
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (4) • A huge majority of physicians refused the ASGB proposals creating the possibility of rationing of care Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 6
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (5) • February 14, 1961 : prime minister Gaston EYSKENS’ « Law of Union » leads to a near-revolution • Introduces an Institute for medical control (art. 33) • Authorises the King to impose tariffs if no convention is concluded (art. 52, still existing, but somewhat modified in art. 50 § 11 of the coordinated law on medical care and allowances) • End 1963 : creation of the Belgian Association of Medical Trade Unions (BVAS-ABSy. M) in opposition to the minister of Social Affairs, E. LEBURTON, by Dr. A. WYNEN Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 7
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (6) BVAS-ABSy. M regroups the - syndicalist chamber of Liège and Luxemburg (created May 17, 1962) - syndicalist chamber of Walloon Brabant, Hainaut and Namur (created March 22, 1963) - syndicalist chamber of the Brussels metropolitan area (created May 31, 1963) - syndicalist chamber of Antwerp, Limburg and Flemish Brabant (created August 23, 1963) - syndicalist chamber of East and West Flanders (created August 29, 1963) Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 8
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (7) • Stiff resistance from physicians against the LEBURTONS’ Law with refusal of - a state-controlled medical care - financial responsibility for the medical care being offered - imposed tariffs - and demand for a social security system for physicians, • leading to a general medical strike from April 1 to April 18, 1964, Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 9
SHORT HISTORY OF ORGANIZED INTEREST GROUPS (8) • followed by the St. John’s agreement of June 25, 1964 between - the government - representatives of the Medical Trade Unions, mainly BVAS-ABSy. M - representatives of sickness funds - employers - employees trade unions • The St. Johns’ agreement remains the basis of the current system Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 10
3. Elements of the law of August 9, 1963 on Sickness and Invalidity Insurance Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 10 bis
3. 1. The system of agreements 3. 1. 1. Basic principles The law of February 15, 1993 - strengthens the role of the ° government ° social partners - employees’ trade unions - maintains the impact of the sickness funds - diminishes the influence of the providers For example : the convention physicianssickness funds needs the approval by : - the general NSIII council - the Insurance Committee - the Budgetary Control Commission Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 11
3. 1. 2. The Medical Technical Council elaborates the nomenclature of medical services 27 M. D. -members + 1 president 9 sickness funds 7 university 11 medical unions Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 12
3. 1. 3. Erosion of free choice in the course of the years Same reimbursement for patients treated by physicians in/out the convention still remains but the legislation is curtailing therapeutic freedom more and more introducing for example reference prices for some hospitalised patients Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 13
APR-DRG’s SURGERY : number and description 73 Lens procedures w or w/o vitrectomy 97 Tonsillectomy & adenoidectomy procedures 179 Vein ligation & stripping 225 Appendectomy 228 Inguinal & femoral hernia procedures 263 Laparoscopic cholecystectomy 302 Major joint & limb reattach proc of lower extrem exc for trauma 313 Knee & lower leg procedures except foot 318 Removal of internal fixation device 482 Transurethral prostatectomy 513 Uterine & adnexa procedures for ca in situ & nonmalignancy 516 Laparoscopy & tubal interruption 540 Cesarean delivery 560 Vaginal delivery Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 14
APR-DRG’s internal medicine : number and description 045 046 047 134 136 139 190 202 204 244 465 Cva w infarct Nonspecific cva & precerebral occlusion w/o infarct Transient ischemia Pulmonary embolism Respiratory malignancy Simple pneumonia Circulatory disorders w AMI Angina pectoris Syncope & collapse Diverticulitis & diverticulosis Urinary stones w esw lithotripsy Urinary stones w/o esw lithotripsy Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 15
3. 1. 4. From « fee for service » to agreed lump sum payments (1) • Fee for service remains for most medical acts • Slowly introduction (since 1988) of agreed lump sum payments - laboratory medicine : 75 % - radiology : +/- 31 % Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 16
3. 1. 4. From « fee for service » to agreed lump sum payments (2) • More lump sum payments for - accreditation system (all physicians) - global medical record (G. P. ’s) - disposability (G. P. ’s) - medical record software programmes (G. P. ’s) - local G. P. ’s circles organizing grand duties (- subsidizing general medical pratices) Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 17
3. 1. 5. Acceptance of convention between physicians and sickness funds A convention is not accepted - if > 40 % of the physicians refuse or - if > 50 % medical specialists refuse or - if > 50 % G. P. refuse Counting is elaborated by each legal district. Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 18
Refusals to join the convention of December 12, 2002 Number absolute in % General practitioners Medical specialists 17. 913 22. 753 2. 804 4. 439 15, 65 19, 51 Total 40. 666 7. 243 17, 81 Number refusals Table 1 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 19
Percentage of refusals to acceed the convention between physicians and sickness funds 10. 12. 1990 18. 12. 1992 (*) 13. 12. 1993 11. 12. 1995 (°) 03. 11. 1997 ( ) 18. 12. 2000 19. 12. 2002 All physicians General practitioners Medical specialists 12, 57 51, 50 19, 27 16, 50 15, 60 14, 77 17, 81 9, 78 37, 80 18, 42 16, 18 14, 28 11, 85 15, 65 16, 35 63, 73 20, 02 16, 77 16, 71 17, 16 19, 51 Table 2 * Document Moreaux Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 20
Refusals to join the convention physicians – sickness funds of December 19, 2002 (in %) Flemish region Walloon region Brussels region All physicians General practitioners Medical specialists 13, 87 21, 04 24, 20 7, 23 24, 58 25, 94 19, 25 18, 12 23, 08 17, 81 15, 65 19, 51 Total Table 3 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 21
3. 2. Representativity of medical associations (1) To be legally representative, a medical association must : • Have both medical specialists and G. P. 's • Have members in at least 2 of the 3 regions • Exist at least 12 months • Count at least 1. 500 affiliated individual members, registered with the NSIII Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 22
3. 2. Representativity of medical associations (2) Only 2 organizations fulfil the 4 Criteria : • BVAS-ABSy. M (D + F; G. P. 's + M. S. ) • Cartel * Confederation of Belgian Doctors - Belgian Gouping of G. P. 's (F, G. P. ’s) - Belgian Syndicate of Medical Specialists - General Syndicate of Belgian Medical Professions (D; G. P. 's + M. S. ) * Syndicate of Flemish General Practitioners (D) Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 23
3. 2. Representativity of medical associations (3) • counting of members failed since 1964 • elections at four years intervals were incorporated in the law in 1996 and carried into effect since 1998 • the results determine the number of seats in the NSIII councils, committees, commissions … for example in the National Commission Physicians-Sickness Funds Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 24
Composition National Commission Physicians. Sickness Funds Physicians Sickness Funds BVAS General practitioners 2 BVAS Medical specialists 5 Total BVAS -ABSy. M 7 Cartel General practitioners 4 Cartel Medical specialists 1 Total Cartel 5 General total 12 12 Table 6 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 25
Participation in medical elections 1998 Number of ballots sent Absolute number % of total 2002 Number of ballots received Absolute number % of total Number of ballots sent Absolute number Number of ballots received % of total Absolute number % of total General practitioners Medical Specialists 16. 919 20. 464 45, 26 54, 74 11. 755 14. 659 69, 48 71, 63 17. 872 22. 218 44, 58 55, 42 10. 341 12. 241 57, 86 55, 09 Total 37. 383 100, 0 26. 414 70, 66 40. 090 100, 00 22. 582 56, 33 Table 4 Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 26
Results of the medical elections June 30, 1998 and June 25, 2002 (in percentage) 28, 1 Medical specialists 89, 2 87, 1 60, 1 General practitioners 59, 0 69, 1 9, 9 9, 7 31, 7 36, 9 General practitioners 0, 6 1, 3 0, 6 1, 7 total Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 39, 7 Medical specialists General practitioners total Invalid/blank 2002 Medical specialists Cartel 1998 total BVASABSy. M 1, 2 3, 0 100 Table 5 27
3. 2. Representativity of medical associations (4) Numerous other medical associations are not representative • Medical specialists - Grouping of Belgian Professional Societies of Medical Specialists (G. B. S. -V. B. S. ) - numerous scientific societies • General Practitioners : strongly dispersed and regionalized - Flemish and Francophone local circles of G. P. 's grouped in UHAK and FAG - a Flemish and a Francophone scientific society (WWVH and SSMG) - a Parliament of Flemish G. P. 's Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 28
4. Representation of medical associations in official bodies (1) 4. 1. At the NSIII • Service of Medical Care - Insurance Committee - Budgetary Control Commission - National Commission Physicians-Sickness Funds - National Council for the Promotion of Quality - Accreditation system including - Accreditation Management Group - Joint Committee by Speciality - Working Group on Ethics and Economy - Technical Council for Accreditation - Appeal Commission - Commission of Profiles - Evaluation Committee on Medical Practice relating to Medication • Service of Medical Assessment and Control - Service Unit - Committee - Appeal Board Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 29
4. Representation of medical associations in official bodies (2) 4. 2. At the Federal Public Service, Public Health, Safety of the Foodchain and Environment • Certification of M. D. 's • Legislation on hospitals • Others on - nursing care - paramedical professions - clinical biology - … Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 30
5. Principles-objectives (1) Ten basic rules : 1. The patient has a central position 2. The physician respects the Code of Medical Ethics and in particular Article 36 "The physician is free as to his/her diagnosis and therapy. He/She will refrain from prescribing useless examinations or expensive therapies or to perform superfluous acts" 3. The patient is free to choose his medical doctor 4. The physician is free to decide between diagnostic and therapeutic alternatives 5. The protection of medical confidentiality is crucial Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 31
5. Principles-objectives (2) Ten basic rules : 6. Physicians ensure the continuity of quality care 7. There is an equivalence between general practitioners and medical specialists 8. There is an equivalence between medical specialists as such 9. An identical pathology gives rise to identical fees, irrespective of the place * Academic or non academic institution * Region * Hospital care or out-patient care 10. In other words, the implementation of a just and objective legislation on the entire territory. Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 32
5. Principles-objectives (3) For the new government to be appointed, we reiterate our vision • Stop the creation of costly and overlapping structures • Give support to the co-operation agreements existing on a small scale between health care providers belonging to the same profession and between providers pertaining to several professions (general practitioners - medical specialists - physicians - nursing staff - paramedics - physiotherapists…) • Restrict the interference of the State in health care • Stop excessive standards and bureaucracy Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 33
6. CONCLUSION Continuing the concertation model between health care providers and sickness funds, under supervision of the State, is the best option to maintain and promote the high reputation and international level of the Belgian health care system Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 34
Words to remember : "Pas de médecine sans médecins" Dr. André WYNEN) Marc MOENS, M. D. INSEAD-EHLP Brussels May 23, 2003 35
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