KCE analysis of the impact of the financial aid to the patients suffering from urinary or faecal incontinence in Belgium

Sometimes, patients suffering from incontinence can receive a grant for incontinence awarded by national health insurance. Two types of grants exist at the moment: a grant for dependent persons (the large lump sum of €505.59 in 2018) and a grant for untreatable urinary incontinence (the small lump sum of about 165.03 € in 2018). The large lump sum for dependent persons was introduced in 1998 while the small lump sum was introduced in 2011, as many patients were not eligible for the large lump sum. Currently, they are being criticized for lacking coherency and require rethinking. KCE has been requested by RIZIV – INAMI to explore options for a more coherent compensation for incontinence, while taking into account the involvement of different policy levels (both the federal and federated level), and considering existing reimbursement interventions for other incontinence material. The report tries to respond to the following questions:

• Does the current payment model ensure fair access to the grants, as well as to treatments and the use of materials?
• Do the grants compensate to the real expenditures of patients?
• Is the current payment model an efficient model for compensating patients? Can efficiency gains be realized by streamlining the payment or care delivery process?
• Is the current payment model internally coherent (i.e. is the payment model in itself logical and understandable, both to healthcare professionals and patients?
• Is the payment model externally coherent (i.e. is the payment model aligned with the broader goals of care as defined in the most recent standards of care for incontinence? Does the payment model support the evidence-based management of incontinence?

The report considers patients suffering from both urinary and faecal incontinence. The focus is on patients living at home, which is a condition for being eligible for the RIZIV – INAMI incontinence lump sums. Adults and children are included, but babies are excluded. Ostomy products are not part of this study.

The authors performed a systematic search of the literature in late February 2018. Websites such as Embase, the Cochrane Library and Medline were search for high-quality systematic reviews published in 2017 or later. In addition, they searched for guidelines and reviews of incontinence societies (International Continence Society, NICE, European Association of Urology). Eventually, 52 references were used for the production of the study.

Chapter 2 of the report describes incontinence – its definition, causes and management in several patient groups.

Chapter 3 describes the current reimbursement schemes for incontinence in Belgium. The authors analyzed the reimbursement status of the following: physiotherapy sessions for pelvic re-education, continence nurse consultation, medication for incontinence, technical medical interventions, implants and other invasive medical devices and reimbursement by federated instances (for handicapped people).

Chapter 4 presents the statistics of incontinence in Belgium – hospitalization data, financial data, incidence trends.

Chapter 5 contains the cross-country analysis of this topic. The countries with whose Belgian reimbursement mechanism is compared with are: the Netherlands, France, Germany, Switzerland, United Kingdom, Italy, Australia and Canada. Some of the exciting facts provided are:

• Comparison of reimbursement methods (Belgium and Australia – periodical grants; the Netherlands (new system) – day price per patient; Germany, Switzerland and old Dutch system – reimbursement per item; Italy and the UK – free provision by the NHS)
• Eligibility criteria for reimbursement of absorbent material in these countries
• Comparison of amounts reimbursed
• Professionals involved (diagnosis/opinion) in obtaining compensation
• Comparison of the status of absorbent materials for incontinence for patients living at home are in the health benefit basket (excluded only in France and for the German community in Belgium)

Chapter 6 is short and presents the costs of absorbent materials in Belgium. The costs have been estimated by the Belgian Urology Association, UROBEL.

At the moment, several scales are used by the federal and federated instances in Belgium to assess the amount of care a person needs (Katz scale, BEL profiel, zorgzwaarte instrument etc.). A new scale, BelRAI (Belgian Resident Assessment Instrument) is being developed with the goal to become the unique scale of measurement. Chapter 7 tries to answer the question “ Could the BelRAI also be used for granting the lump sums for incontinence?” The authors have concluded that the incontinence questions in BelRAI could potentially be used for the incontinence lump sums. With this questionnaire, the lump sums could potentially be refined on the basis of type and severity of incontinence, but the questionnaire would need to be complemented with a form filled out by a GP/physician to attest that the patient has gone through a care trajectory. However, the feasibility and appropriateness should be further tested when BelRAI becomes more operational.

Furthermore, the authors have interviewed 23 stakeholders from the entire healthcare system in order to perform a policy analysis. The policy analysis is in Chapter 8 of the report, and it contains the assessment of current situation and proposals for improvement for several aspects of incontinence: reimbursement pathways, access to lump sums, indications for eligibility, validity period of receiving grants, patient categorization, stakeholder awareness, authorities’ part, etc.

See the full report in English here.

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