Disagreement on 2002 healthcare budget

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The level of public funding of healthcare has become a major issue of controversy in Belgium in the run-up to the announcement of the government's state budget for 2002 in October 2001. The actors in the healthcare system, which include the social partners, have been trying – in vain – since early September to agree on the healthcare budget for 2002. If no agreement is forthcoming, the government will step in. Doctors have taken strike action to support their demands for higher funding.

The Belgian government's drafting of the 2002 national budget, which the Prime Minister was to unveil before the federal parliament on 9 October 2001, has been marked by major disagreement on the amount of money to be allocated to the public funding of healthcare.

The insurance committee of the National Sickness and Disability Insurance Institute (Institut national d'assurance maladie-invalidité/Rijksinstituut voor zieke- en invaliditeitsverzekering, Inami/RIZIV) which has the task of coming up with objectives for the national healthcare budget, is made up of representatives of the social partners, insurance organisations (mutuelles) and care providers (eg doctors and hospitals). When this committee failed to produce an agreement on the 2002 budget, the government was obliged to put a proposed healthcare budget to the Inami/RIZIV general council. This proposal was due to be formulated on 8 October.

The positions of the various actors have been irreconcilable since talks began in September 2001: care providers (including doctors and hospital managers) have demanded a budget for 2002 of BEF 600 billion; the 'mutuelles' (the insurance bodies) want BEF 594 billion (ie an increase of BEF 52 billion over the 2001 budget); the social partners (representatives of employers and employees), who have emerged as the social security 'paymasters', asked for BEF 581.4 billion in July 2001; and at the beginning of October, the Flemish Liberal Party (Vlaamse en Liberale Demokraten, VLD), of which Prime Minister Guy Verhofstadt is a member, caused controversy when it called for a budget as low as BEF 568 billion.

'Mr Verhofstadt is seeking a medical-social disaster,' was the immediate reaction of the doctors' trade unions. The sum of BEF 568 billion advocated by VLD represents strict application of the 2.5% growth norm that has been imposed on healthcare expenditure over the last few years. Another government party, the French-speaking Socialist Party (Parti socialiste, PS) denounced the intentions attributed to the Prime Minister on the grounds that limiting the 2002 healthcare budget to BEF 568 billion would 'break the back' of the healthcare system. Several observers have stated that the objective of BEF 568 billion is all the more unrealistic as healthcare expenditure in the first six months of 2001 is estimated to have risen by 9.2% above initial objectives. At this rate, expenditure is likely to reach BEF 570 billion in 2001 (in other words, more than the figure advocated by the Prime Minister's party for 2002).

Clearly pulled in opposing directions by the demands of the various actors, the Social Affairs Minister, Frank Vandenbroucke of the the Flemish Socialist Party (Socialistische Partij, SP) said that he was sure that 'in general terms, it will be necessary to invest in healthcare to deal with population ageing, technological developments, and pay increases in the sector,' However, he also warned care providers that the current rate of increase in expenditure was not tenable. Accordingly, on 11 September, to deal with the rise in healthcare expenditure, Mr Vandenbroucke launched an appeal for concertation between the various actors in the sector. Gabriel Perl, the president of the commission on which doctors, hospital managers and mutuelles sit (the Commission Médico-Mut), was given the task of coordinating the operation. The aim, to be achieved in six weeks, was to put a series of concrete proposals to the Minister of Social Affairs. Through this concertation, Mr Vandenbroucke hopes to meet a threefold challenge:

• to reduce individual discrepancies in medical practice to an acceptable level of variation (the medical cost for a given form of treatment can vary by a factor of four depending on the region and the hospital);

• to eliminate mechanisms that enable some doctors to abuse the inefficient use of healthcare; and

• to develop techniques for cost-sharing between prescribers and individual care providers.

An intermediate report published by the working group in October 2001 sketches the broad outlines of such a system of cost-sharing for care providers. For example, doctors in 'non-hospital medicine' (eg blood tests and radiography) who did not comply with 'objective rules of good practice' could be liable to a sanction (yet to be determined). In hospital medicine, the report puts forward the idea of establishing an average cost for a series of common forms of treatment: hospitals that exceeded this cost by a particular percentage would be obliged to pay back the excess charge. These ideas are only at the proposal stage.

In early October 2001, the main doctors' trade union, the Belgian Association of Medical Trade Unions (Association Belge des Syndicats Médicaux/Belgische Vereniging van Artsensyndicaten, ABSyM/BVAS) mounted an increasing number of strike actions aimed at putting pressure on the federal government. ABSyM/BVAS has also threatened to remove doctors from the healthcare tariff agreement (convention) from 2002: this would be tantamount to jeopardising healthcare tariffs guaranteed to patients on the basis of agreements signed between mutuelles and doctors. The current agreement covers the period 2001-2. The university hospitals representative, Professor Coche, has also voiced alarm: 'If our budgets are not reviewed upwards,' he said at a press conference, 'university hospitals will be obliged to pass the additional cost on to patients. That would be intolerable.'