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Claims based risk adjusted budget allocation in integrated care in Belgium

Author:

Ri (Henri) De Ridder

retired, formerly NIHDI, BE
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Abstract

Belgium contracted 12 pilots for implementing quadruple aim in social and health care. ‘more value for the same money’ is supported by a guarantee that benefits for the health insurance are available for financing higher value services not yet covered by health insurance. Observed expenditure is compared with risk adjusted expected expenditure for a predefined population in each project. The paper explains  theoretical background and  practical consequences.

Fragmentation in health and social care goes with avoidable costs and suboptimal quality of care. Belgian authorities started a journey towards integrated care through pilots in 12 locoregional territories, covering 2,5 million inhabitants. Pilots commit to realise quadruple aim. Consortia of local communities, authorities, social and health care and insurers have defined action plans. They contracted from 2018 with the National Health Insurance (NHI) for implementation. Except for integrator function,projects do not get additional money. A budget guarantee warrants health insurance expenditure for the pilot population to be maintained for 4 years at its predicted level when real expenditure is lower by avoiding low value care. These ‘efficiency gains’ can be reinvested in high value activities not yet covered bij NHI. This 100% shared saving will support innovation including shifting from fee for service to population based financing. Not for profit insurers administrate reimbursment of claims. A national database contains detailed information at individual level, both on characteristics of the insured as on service utilisation. Yearly calculation is made of the expected expenditure at pilot population level, derived from national observed expenditure. By regression, for each pilot, the mean expenditure per individual in a national reference population is calculated taking into account a set of individual characteristics (age group, sex, morbidity, …) and applied to the size of population in the pilot region. Outlier individuals and expenditures are excluded from calculation.

Pilots target primarily people with chronic conditions and global population at a longer run. Pilots choose if budget guarantee pertains to the entire population or to a subset of people with chronic conditions. Pilots also define if the guarantee pertains to the full extent or to a restricted set of expenditure .

Methodoligical problems have arisen when using a claims based risk adjustment for identifying savings. Some of them were unknown when the program has been defined. Project contracts have no provisions to deal with problems like outlierformulas, morbidity factors that cannot be derived from claims data, absence of claims data for social care and confidence intervals.  The timeline of datagathering and accounting creates a delay in paying out savings. The budget guarantee is paid out in the fiscal year following the one in which the saving was realised. These problems call for solutions before considering the structural use of claims based data to define population based care financing.  

Conclusions: There are limits in using risk adjustment based on claims for defining global budgets for integrated care, although the principle seems attractive in a fee for service reilbursment system. Pilots will be a source of precious information on caveats.

How to Cite: De Ridder R (Henri). Claims based risk adjusted budget allocation in integrated care in Belgium. International Journal of Integrated Care. 2019;19(4):467. DOI: http://doi.org/10.5334/ijic.s3467
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Published on 08 Aug 2019.

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