Reimbursement of radiotherapy in Belgium

The old reimbursement system

The new system

The desired system

Nicolas JansenLiege University Hospital

Introduction Belgium ≠ The Netherlands Flanders = Wallonia

4 time periods

1. Historical situation

2. Activity based reimbursement system (2001-2012)(minor modifications 2003)

3. The new quality stimulating reimbursement system (2013-…)

4. A new FINANCING based on needs and quality (202x-...)

Time period 2 : now

Gifts, sponsoring

Supplements paid by patientsprivately or by private insurance

Reimbursed individual medical acts

To cover the complete running of the department(medical and paramedical wages,

goods, physics, medical immobile material,accelerators, …)

Financing of machines andstaff on a department level

Time period 2 : now

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Supplements only possible for certain patients.Not always accepted by patients for ‘essential treatments’.

Time period 2 : now

Reimbursed individual medical acts

Financing of machines andstaff on a department level

60% is paid by the federal government40% is NOT paid by the regional governments

Time period 2 : now

Reimbursed individual medical acts

Financing of machines andstaff on a department level

We need an increase of >10%A linear reduction of 1-2% was imposed in 2012The amounts have not been adapted to the index of living costs

Time period 2 : now

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Total amount of these

Reimbursement evolution2002 2003 2004 2005 2006 2007 2008 2009 2010

53 60 73 72 73 80 78 89 94

Time period 3a : near future

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Time period 3b : future

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Hoped for but no positive news

Time period 4 : needs to be defended

Reimbursed individual medical acts

Financing of machines andstaff on a department level

based on a national analysis of needsand the expected evolution of the patient population

If a good reimbursement is available for a given treatment,‘everyone’ will start offering this treatment whether there isa real need in a given area or not.

Time period 3a : ongoing negotiations

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Controversy

• How to get from time period 2 to time period 4 ?– Extremely gradually, through negotiations,

via step 3 (approach of the VBS/GBS at this moment)

– Jump to step 4 directly, by a strong political will to do so, after strong lobying (approach favoured by the new radiotherapy platform)

What is the GBS/VBS

• « Verbond der Belgische Specialisten »– Official representation of medical

specialists for discussions with the government

– There is a global group (for all specialists)– And there is a specific group for radiation

oncologists≠ BVRO : scientific organisation≠ Het college : quality stimulating body

TREATMENT PREPARATION  

personalised immobilisation 125 125

simulation 300 300

second simulation 150 150

image fusion (simple, 2 techniques) NA 75

image fusion (complex, > 2 techniques) NA 150

delineation NA 250

2D+-planning / calculation ME 250 150

3D-planning (standaard) 250 + 125 375

3D-planning (intensive) 250 + 125 + 125 + 100 600

4D radiotherapy preparation NA 250

adaptive radiotherapy NA 150

individual shielding 75 or 150 100

TREATMENT EXECUTION AND QUALITY MEASURES    

Category 1 (extern simple) 500 500

Category 2 (extern complex standard fractionation) 1600 or 2000 2000

Category 3 (extern complex hypofractionation) 1200 or 1600 1500

Category 4 (extern complex stereotactic treatment) 2000 2000

image guidance at start 100 100

image guidance (correction protocol / start and weekly control) 100 500

image guidance online daily and intensive 100 1000

4D radiotherapy delivery NA 300

patient individual QA NA (100) 200

in vivo 100 100

existing, original price

existing, lower price

new

old new

Place of brachytherapy

Reimbursed individual medical acts

Financing of machines andstaff on a department level

Place of brachytherapy : period 2

Reimbursed individual medical acts

Brachy cost versus external

• Percentage of total cost of the basic brachy procedures in a given year versus the costs of the total cost of the external beam treatments in the same year

• Reduction is based on decrease in number of patients treated

2002 2003 2004 2005 2006 2007 2008 2009 2010

4,9 5,6 6,7 7,2 6,4 6,1 5,5 5,6 5,0

Does not include simulation, planning, seeds, afterloader, …

Brachy cost total

• All reimbursed acts (including simulation, planning, afterloader, …)

• Not seeds, no hospital stay costs

• 3.900.000 euro in 2011

• =4% of total radiotherapy costs

Place of brachytherapy : period 3

Reimbursed individual medical acts

4%

Brachytherapy : present situation

• 2 ‘complexity levels’

• For each complexity level 2 situations :– After an external beam radiotherapy (boost)– Brachytherapy alone

Brachytherapy : present situation• Problems

– Complexity levels are organ based– Brachytherapy is reimbursed less if given as a boost, even is

the time and efforts invested are more or less the same

• First bad news for prostate brachytherapy by permanent seed implants :– no more simulation (2011) : minus K300– Price of seeds is government controlled at 47,7 € /seed,

including transport and all other material used during the procedure. Max 100 seeds/patient (2012)

Brachytherapy : future situation 3a

– 3 complexity levels• Not image based (cheloids, …)• Simple image based (geometrical, or CT/ultrasound)• Idem, full 3D plan with multiple OAR and TV delineated

– Equal reimbursement as boost or not– Quality stimulating measures of external

radiotherapy are also valid for brachytherapy• Delineating• Image fusion• In vivo dosimetry• …

– No reduction in reimbursed amounts

   

Compulsory activity

   

Compulsory activity, but only one of these activities within the frame (and one per treatment)

   

Accepted activity

   

Accepted activity, but only one of these activities within the frame (and one per treatment)

   

Forbidden activity

 ONLY BRACHYTHERAPYAMOUNTS IN ‘K’, not euro

rubriek 0Notreatmentdelivered

  rubriek 5Simplebrachytherapy

rubriek 6Standardbrachytherapy

rubriek 7Complexbrachytherapy

  rubriek 8

kilovolt

A. Treatment execution    500 1000 1250  

B. Treatment preparation              

First simulation        300 300    

Second simulation              

Simple image fusion        75  

Complex image fusion       150   

Delineation        250  250    

Simple planning      150      

Standard planning      375    

Complex planning        600  

4D planning          

Adaptive planning              

         

C. Quality/safety measures              

Afterloading      100 (400) 100 (400) 100 (400)    

Fixation system    125 125 125  

Protective systems              

IGRT (once)              

IGRT (standard protocol)          

IGRT (daily, online)          

4D treatment execution              

Patient specific phantom dosimetry          

In vivo dosimetry    100 100 100  

TYPICAL TOTAL 650 2075 2750

• Conclusion for the BELGIAN reimbursement system– Present reimbursement is not adapted to needs– New reimbursement system …

• is not guaranteed at all• does include quality stimulating measures• is not a major change• respects brachytherapy reimbursements

– No existing plans for a reimbursement system based on objective needs and quality