A brief history of casemix systems in Belgium

All Belgian citizens are today covered by the social security system (following the Bismarck model), which is mainly financed through employment-related social contributions and general taxation. The health care system is regulated by the state and managed by INAMI (the National Institute against Illness and Disability). In INAMI, mutualities and representatives of medical professionals negotiate medical services, such as procedures and drugs, included in the nomenclature. For each service, a national fee and percentage of reimbursement is determined. Fees cover full costs and are owed to the physician, who is paid by service for ambulatory care, outpatient and inpatient care.

The Ministry (Federal Public Service) of Public Health defines the price of a day's stay for each hospital, based upon its infrastructure, accommodation and nursing care (45 percent of hospital financing). This price is based on the advice of several committees, including members of the hospital administration, physicians, and financial partners.

Physicians' activities in hospitals are covered by the reimbursement of fees for services (41 percent of hospital financing) and drugs by fees (14 percent). Inside each hospital, physicians negotiate with the medical and financial managers to determine the portion of their fees retained for overhead costs (equipment, materials, infrastructure, worker s, etc.). This open hospital financing system (by day and by service), which operates without a predetermined budget, has generated a rapid increase in the number of days, medical services and procedures performed, resulting in an exponential growth in the overall cost.