Reimbursement of radiotherapy in
Belgium
The old reimbursement system
The new system
The desired system
Nicolas Jansen
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 patients privately 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 and staff on a department level
Time period 2 : now
Reimbursed individual medical acts
Financing of machines and staff on a department level
Supplements only possible for certain patients.
Time period 2 : now
Reimbursed individual medical acts
Financing of machines and staff on a department level
60% is paid by the federal government
Time period 2 : now
Reimbursed individual medical acts
Financing of machines and staff on a department level
We need an increase of >10%
A linear reduction of 1-2% was imposed in 2012
Time period 2 : now
Reimbursed individual medical acts
Financing of machines and staff on a department level
Reimbursement evolution
2002 2003 2004 2005 2006 2007 2008 2009 2010
Time period 3a : near future
Reimbursed individual medical acts
Financing of machines and staff on a department level
Time period 3b : future
Reimbursed individual medical acts
Financing of machines and staff on a department level
Time period 4 : needs to be defended
Reimbursed individual medical acts
Financing of machines and staff on a department level
based on a national analysis of needs
and 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 is
a real need in a given area or not.
Time period 3a : ongoing negotiations
Reimbursed individual medical acts
Financing of machines and staff 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
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
Place of brachytherapy
Reimbursed individual medical acts
Financing of machines and staff on a department level
Place of brachytherapy : period 2
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
Brachy cost total
• All reimbursed acts (including
simulation, planning, afterloader, …)
• Not seeds, no hospital stay costs
• 3.900.000 euro in 2011
Place of brachytherapy : period 3
Reimbursed individual medical acts
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
• …
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 BRACHYTHERAPY AMOUNTS IN ‘K’, not euro
rubriek 0 No treatment delivered rubriek 5 Simple brachytherapy rubriek 6 Standard brachytherapy rubriek 7 Complex brachytherapy 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
