Belgian perspectives on how to improve health care

ROI could be better

Belgian health care is expensive.  Total expenditure on health care as a percentage of GDP has consistently increased, from 6,3% in 1980 to 9% in 2000 and 11,1% in 2008 (1). This makes Belgium the third biggest spender in the OECD on that measurement.  One would hope that would also make us the third healthiest country in the OECD, but that isn’t the case.  Compared to other OECD countries, health-adjusted life expectancy in Belgium is ranked 15th (Japan is ranked 1st, followed by Sweden and Switzerland).  As a recent OECD study suggests, spending more on health care does not necessarily translate into a better health status (2).  

Three challenges

The Belgium health care system is faced with at least three major challenges.  Firstly, it needs to improve efficiency dramatically—and quickly—if it wishes to avoid a budgeting crisis. Secondly, the system needs to adapt to changes in demand as a result of the ageing population and the associated rise in chronic conditions.  Thirdly, the effectiveness of the system—in the broadest sense, covering curative and preventative measures—needs to improve, because it can.  As various experts in this edition argue, these issues are interrelated.  A more efficient, more integrated and more proactive system will be more effective.  The problem is that this requires change and innovation in the way health care is organized; that is difficult because the current system lacks incentives for change.

Happy patients but the wrong incentives

Belgians are pretty happy with their health care system; in fact, public satisfaction ranks as one of the highest in the world according to statistics that the OECD published (3) in a recent paper.  There are several reasons for this.  Like other European countries, the Belgian system is well-equipped with good infrastructure and well-trained medical professionals (although there is an escalating shortage of nurses).  In addition—and this is in contrast to many other developed countries—there are hardly any waiting lists for medical interventions.  And most importantly, there is total patient freedom.  Belgians can shop around for their medical care, although ‘shopping’ is the wrong word because health care is nearly free.  In contrast to the British, who can also shop around for private care (if they wish to avoid the NHS) but are then expected to pay private prices, the Belgians are covered by publically funded health insurance.  It is a system that has all the advantages of the free market (freedom!) but without the built-in efficiency mechanisms (price).  As a result, health care providers are incentivized to perform a maximum number of medical services, which in turn means that Belgian doctors tend to work long hours (to cram as many consultations as possible in a day) and that hospitals compete for patients and referrals on the basis of reputation and patient experience (e.g. by minimizing waiting times).  

Furthermore, as Professor Marc Noppen argues in his opinion piece, Belgian doctors have been trained as soloists that rely on ‘personal engagement, accountability and responsibility.’  Not only are doctors not trained to approach clinical medicine in terms of process-driven teamwork, they also have little incentive to do so, because the financing system is based primarily on the volume of direct medical interventions.  

The implications of all this are that the Belgian health care system creates happy patients and happy doctors, but lacks built-in incentives for greater efficiency and effectiveness. Government policy has been trying to push health care providers toward greater teamwork, standardization and efficiency but are in effect having to prescribe how things get done (e.g. by defining care paths for specific conditions, by financing the ‘multidisciplinary consult’, etc.).  At base, the system remains one that is focused primarily on the means as opposed to the ends of health care.  The system rewards medical interventions, primarily on a volume basis, and leaves it up to individual doctors (and patients) to decide whether these interventions are the most efficient and effective.  The problem is that the incentive to deliver efficient and effective health care is mainly an ethical decision.  As Professor Noppen (UZ Brussel) and Dr. Bruno Holthoff (ZNA) suggest, their organisations’ focus on efficiency and quality could have detrimental effects on their financing. 

A distorted market

Competition in a free market has its strengths.  It rewards those who deliver maximum value for least cost, and thus is a tremendous incentive for innovation.  Competition is all about the ends (value and costs); the means are fair game for innovation.  The Belgian health care system enjoys a degree of competition in the sense that patients can choose their doctor and hospital.  It is a distorted market, however, because patients have very little information about the effectiveness of health care providers (it is purely a reputation game – there is very little publically available outcomes data) and have no incentive to seek out the most efficient care.  

Innovation should be the foundation

Several remedies have been suggested to improve the Belgian health care system.  For one, a more integrated and proactive approach is required.  Prevention and curative health care policy (currently a split responsibility between the regions and the federal government) needs to be reintegrated.   Risk groups such as people with diabetes (or at risk for diabetes) need to be identified earlier on—before they get sick—and systematically followed up by a more coordinated health care system.  This requires data sharing hence the need to get on with the eHealth program.  The treatment and management of increasingly prevalent chronic conditions needs a more coordinated and process-driven approach that is reliant, as far as is possible, on remote care, home care and the patient as co-decision maker and member of the team.  

All this is important, but probably the most fundamental issue that needs addressing is the encouragement of innovation.  This will require changes to the financing system whereby good outcomes and improved efficiency are rewarded.  The financing system will also need to allow for easier collaboration among the various actors in the health care system and encourage provider groups—consisting, for example of a cluster of hospitals, local clinics, home care services and health insurance companies—to innovate in the way they work together and compete on the basis of (publically available) outcomes data and efficiency.  Finally, it will require a lot more relevant data capture, data analysis, and most importantly a lot more transparency in the way that data is used.  The Belgian health care system requires change, that much is certain; and although there is a fair amount of consensus about what the priorities should be in the short term, in the long term new challenges will emerge that require new remedies.  The danger is that policy makers will be tempted (or pressurized) to subject the system to increasing micro-management and thereby destroy the needed flexibility in the system for innovation to happen.  In the long term, only innovation will do.