Medical specialists strike

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In September and October 2001, Belgian clinical biologists, radiologists and kidney specialists were due to strike for a total of 12 days. They were primarily protesting against 'unusual' savings and budget over-run recovery measures being applied to their sector.

Various specialists in the medical sector were due to take strike action on 17-19 September, 1-4 October and 15-19 October 2001 - a total of 12 days. The hospital departments were to operate a Sunday service on these strike days. The direct cause for this action was an accelerated recovery of health budget over-runs, as announced by the Socialist Minister of Social Affairs, Frank Vandenbroucke. The specialists assert that the current budgets do not take enough account of the real needs of the sector, and that neighbouring countries have more money available for healthcare. Minister Vandenbroucke says that he is prepared to argue for higher budgets in the coming years with his fellow ministers, but on condition that existing abuses and wastage in the medical sector are ended.

Background

In 1999, two important mechanisms were introduced to guarantee the observance of budgets in the medical sector, as follows.

Recovery of budget over-runs

Various sectors of Belgian healthcare operate a system of 'closed budget financing'. This means that the amount to be spent on a certain type of care in the course of a calendar year is set in advance. In clinical biology and medical imaging, if the budget is not fully used up (because fewer examinations are carried out than expected) the balance can be used in a subsequent year. In the reverse case, when the budget is exceeded, the over-run is recovered in a subsequent year. This is achieved through a temporary increase or decrease of a component of the prices charged by medical specialists (the 'fixed prices').'

Automatic corrections

For other healthcare sectors, including nephrology, the principle of the 'target budget' applies. This target budget is calculated on the basis of the expected number of services provided and their prices. If it turns out in the course of the year that this budget will be exceeded, corrective measures are taken - reducing prices, for example. In principle, the parties concerned (for example, doctors and the national health funds for doctors' fees) will take the initiative themselves. If, however, they take no measures, or such measures are inadequate, then the general council of the National Sickness and Disability Insurance Institute (Rijksinstituut voor zieke- en invaliditeitsverzekering/Institut national d'assurance maladie-invalidité, RIZIV/Inami) will take the corrective measures itself. The general council is the body of RIZIV/Inami representing the financiers of the system (ie employers and trade unions, national health funds and government). These measures are known as 'automatic corrections'.

Accelerated budget recoveries in clinical biology and radiology

The 'savings' announced by the Minister in clinical biology and medical imaging will bring about a faster recovery of over-runs. The closed budgets for these two sectors were exceeded in 1999 and 2000, and the law required these over-runs to be recovered consecutively in 2001 and 2002. However, Mr Vandenbroucke wants the 2001 budget to be kept in balance and has consequently amended the law. In practice, this means that in 2001 alone, half of the over-run for the two years together will be recovered in clinical biology, and the complete over-run in medical imaging. As a result, clinical biologists and radiologists will have to reimburse earlier the amounts they owe, for whatever reason. In practice, this means that for four months they will receive a reduced amount for the fixed proportion that is reimbursed for each prescription and for their consultation fees. The Minister emphatically denies that a vicious circle of increasingly drastic reductions is being created.

The response of the doctors' trade unions was swift. Above all, the largest doctors union, the Belgian Association of Medical Trade Unions (Belgische Vereniging van Artsensyndicaten/Association Belge des Syndicats Medicaux, BVAS/ABSyM), lodged a strong protest as soon as the news was announced and called for a general strike by all doctors. According to the BVAS/ABSyM deputy chair, Marc Moen, the savings would not just be limited to specialists in the abovementioned fields. However, the Kartel, a grouping of smaller doctors' unions, headed by the Belgian General Union of Doctors (Algemeen Syndicaat van Geneeskundigen van België ASGB), believed that strike action was pointless as there was still an opportunity for talks with the parties concerned. The smaller doctors' union emphasised that the hospitals and doctors who acted correctly would be hit just as much, and often even harder, by the Minister's uniform 'linear' measures.

Automatic corrections in kidney dialysis

Everything points to an over-run of the 2001 budget for expenditure on kidney dialysis. Consequently, the automatic correction mechanism has come into effect and on 1 September some prices were lowered in anticipation of an overrun. BVAS/ABSyM stated in its response, however, that the budget does not take enough account of the increase in the number of dialysis patients. This increase is the result of the general ageing of the population. Mr Vandenbroucke has in the meantime announced that the increase in the number of dialysis patients will be taken into account in the 2002 budget.

Abuses and wastage

BVAS/ABSyM's criticism about the available budget for kidney dialysis is correct, according to Mr Vandenbroucke, but has to be qualified. BVAS/ABSyM makes no mention of the differences that exist between hospitals with regard to the provision of alternative and cheaper forms of treatment in kidney dialysis, and the problem is not limited to this one medical sector.

An investigation ordered by the Minister has shown that there are substantial differences in the practices of doctors and hospitals. It was found that for the same problem or the same patient group, there are large differences in the choice of drugs, treatment, imaging techniques and clinical biology. These practical differences seem in a number of cases to relate to the provision (or non-provision) of unnecessary or superfluous examinations or treatments. According to Mr Vandenbroucke, this finding must be seen not only as an expression of differences in quality but also as a waste of resources. Health insurance reimburses all the services charged for.

Given this finding, the conflict has threatens to take on a community/regional character. There seems to be significant differences between Flanders and Wallonia with regard to medical expenditure - differences that cannot be attributed to demographic variations, for example. The Minister is avoiding the community minefield by stating that abuses are found in both parts of the country. He has called for the individual responsibility of every doctor and hospital, and wants to consult with doctors and hospitals in order to develop a system of individual financial responsibility.

Mr Vandenbroucke now wants to open the debate (including through his Internet site) on these major expenditure differences and has said that more money can be provided by the government only if the medical sector is able to deploy its budget efficiently and correctly.

Commentary

The conflict between doctors and the Minister has meant him clashing sharply with the deputy chair of the BVAS/ABSyM, Marc Moen. This collision was the result of some accusations that the doctors' leader made in various media, which were directed at the Minister and his employees regarding alleged preferential treatment for certain hospitals. It turned out later that Mr Moen could not substantiate these accusations. The relationship between the two was thereby strongly soured, which of course is impeding further negotiations and the development of solutions for the sector.

Nevertheless the most difficult problems still have to be resolved. The 2002 health budget again promises to bring considerable controversy (BE0110302N). The budget for 2001 is around BEF 540 billion, which is approximately BEF 40 billion more than in 2000. The medical world believes that at least BEF 600 billion is required for the 2002 budget. In the meantime, Mr Vandenbroucke knows that he will not have his proposed increase of BEF 50 billion accepted by his fellow ministers. He will, however, argue for a significant increase in the budget, but on condition that the abuses and wastage disappear.

As stated by the leading newspaper,De Standaard (on 18 September 2001): 'the conflict is increasingly threatening to become one between the healthcare sector which believes it has the patients behind it, and the government, employers and unions, who hope they have the taxpayers behind them. It is thought that taxpayers are no longer prepared to give unlimited funds to the bottomless pit that the healthcare sector often appears to be.' (Jürgen Oste, TESA/VUB