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Change is slow for Belgium’s outpatient reimbursement
The reimbursement situation in the country creates a competitive environment between outpatient centers and hospitals.
ANTWERP, Belgium — Reimbursement for outpatient ophthalmic procedures has improved over time in Belgium, but the climate is still not right for freestanding outpatient facilities. Outpatient surgery is paid for by the government only if performed in a hospital’s day-surgery department, according to a surgeon who has worked for change in this policy.
Frank J. Goes, MD, an ophthalmologist in practice here and president of the now-disbanded Belgian Outpatient Surgical Society, told Ocular Surgery News the Belgian national social security pays for medically necessary ophthalmic procedures such as cataract surgery, but not for elective or aesthetic procedures such as LASIK. Additionally, the social security and most private insurance companies do not pay for any ophthalmic surgery performed outside a hospital in an outpatient surgery center, he said.
“We have been fighting for that for 15 years. But up to now there has been no change. It will change sooner or later, but no one knows when,” Dr. Goes said.
“Private insurers go along with the government. When the government changes, they will change also,” he said. “We don’t know why; it is costly for the community and for the companies. But they simply follow the governmental rules.”
There has been some movement toward loosening restrictions on surgical reimbursement.
Dirk Van Damme, secretary of the Technical Medical Council, one of the bodies involved in the decision-making process of the Belgian Health Care System, told Ocular Surgery News that some minor, surgical interventions are now reimbursed when performed in an outpatient setting. Additionally, an increasing number of interventions are being performed in day surgery clinics of hospitals.
However, it remains that larger, more involved interventions must be performed in a hospital, which Dr. Van Damme said is done to ensure safety and quality.
The Technical Medical Council is preparing a proposal to modify rules governing surgical reimbursement. The proposal would seek to provide reimbursement for ophthalmic procedures performed in outpatient surgery centers that satisfy the conditions of a hospital day-surgery clinic.
“I anticipate that early next year this proposal could be put into bylaw. Possibly, later on, other interventions could follow,” Dr. Van Damme said.
Unfair competition
In Belgium, all patients are covered by the national social security for necessary medical care, although increasing numbers of patients purchase private insurance policies to supplement their social security. These supplemental policies pay for special treatment when undergoing a procedure such as cataract surgery.
Dr. Goes explained the special treatment is not related to the level of surgical care the patient receives. Rather, it allows more comfortable postop care or recovery, such as the provision of a private recovery room as opposed to a room with five other patients.
The situation surrounding outpatient reimbursement has created a competitive atmosphere, Dr. Goes said.
Reimbursement rates do not change with evolving technology, he said, but surgeons continue to provide the standard of care. This leads to unfair competition between outpatient surgery centers and hospitals, he said.
Outpatient centers can provide care equal to or better than hospitals, he said, but at an increased cost to the patient. Patients must pay for procedures in the surgery center entirely on their own.
“Outpatient centers will survive because we work hard. We don’t think it is fair. But we will not give them lower care just because there is no reimbursement. We will give them the highest quality medical treatment,” Dr. Goes said.
Currently, a cataract procedure performed in an outpatient center can cost a patient between 800 and 1,000 euros, depending on the lens used, Dr. Goes said, while the cost to a patient for a procedure done in a hospital is around 500 euros.
“[This is] not an enormous difference, but it is important for the surgeon and for the people that cannot afford it,” he said.
Surgery is surgery
Although he said current reimbursement rates are at a fair level, Dr. Goes said the social security program does not make distinctions between the technology used or type of procedure performed for cataract.
Reimbursement rates for cataract surgery have slowly increased, rising a few percent every 3 or 4 years. But the rates do not reflect improvements in technology and equipment, he said. A cataract procedure performed as it was 20 years ago would be reimbursed the same as a procedure performed using modern phacoemulsification technology.
“The government does not make a distinction. Cataract surgery is cataract surgery. That is it,” Dr. Goes said.
The social security office offers a modest payment for an IOL, although Dr. Goes stressed it is minimal. An old, rigid PMMA lens with a 7-mm optic diameter would be reimbursed at the same level as a new foldable lens capable of being implanted through a small incision, he said.
Dr. Goes described the current situation as politically motivated, with authorities unwilling to cede their budgetary control.
“They do not calculate. They do not look at the costs, because the problem would have been solved years ago. This is a political decision. They want to keep control — not control in the medical form, but they want to keep their power,” he said.
Belgian ophthalmic societies and other associations continue to work toward changing the situation through lobbying efforts. However, the Belgium Outpatient Ophthalmic Surgery Society was recently dissolved by its members.
For Your Information:
- Frank J. Goes, MD, can be reached at W. Klooslaan 6, B2050 Antwerp, Belgium; +(32) 3-219-3925; fax: +(32) 3-219-6667; e-mail: frank@goes.be.
- Dirk Van Damme is secretary of the Technical Medical Council of the Belgium Health Care System. He can be reached at RIZIV-INAMI, Tervurenlaan 211, 1150 Brussels, Belgium; +(32) 739-78-76; e-mail: dirk.Van Damme@riziv.fgov.be.