Organisation and payment of emergency care services in Belgium
Authors: Van Den Heede Koen , Dubois Cécile , Devriese Stephan , Baier Natalie , Camaly Olivier , Depuijdt Eveline , Geissler Alexander , Ghesquiere Annelies , Misplon Sarah , Quentin Wilm , Van Loon Christophe , Van de Voorde Carine 
Published: January 2025

1 INTRODUCTION AND SCOPE 13 -- 1.1 WHAT ARE EMERGENCY CARE SERVICES? 13 -- 1.2 WHY THIS REPORT? 15 -- 1.2.1 Objective of the study .15 -- 1.2.2 Scope of the study 15 -- 1.3 ORGANISATION OF THE REPORT16 -- 2 SCOPE AND METHODS 17 -- 2.1 INTRODUCTION17 -- 2.2 METHODS17 -- 2.2.1 Legal documents and text books .17 -- 2.2.2 Belgian data 17 -- 2.2.3 Literature 18 -- 2.2.4 Review of the literature and Belgian reports .18 -- 2.2.5 Qualitative study design18 -- 3 BELGIAN EMERGENCY DEPARTMENTS: ORGANISATION AND ACTIVITY 20 -- 3.1 EMERGENCY DEPARTMENTS IN BELGIUM: PROFILE AND ACTIVITY.20 -- 3.1.1 Specialised and non-specialised emergency departments 20 -- 3.1.2 Geographical distribution 21 -- 3.1.3 Activity profile .22 -- 3.2 CRITICAL APPRAISAL: A RELATIVELY HIGH NUMBER OF EMERGENCY DEPARTMENTS WITH LARGE DIFFERENCES BETWEEN URBAN AND RURAL AREAS.37 -- 3.2.1 Current capacity is a consequence of (not always harmonized) policy measures: programming, recognition, financing .37 -- 3.2.2 Advantages and disadvantages of the current ED capacity 38 -- 3.3 CRITICAL APPRAISAL: ARE EMERGENCY DEPARTMENTS THE MOST APPROPRIATE ORGANISATIONAL LEVEL FOR ALL CURRENT ACTIVITY? .39 -- 3.3.1 Not all emergency department visits are urgent, but are they inappropriate? A uniform definition is lacking 39 -- 3.3.2 Throughput and outflow problems are also burdening emergency departments 44 -- 3.4 SOLUTION ELEMENTS .45 -- 3.4.1 Planning of the required number of emergency departments in the larger spectrum of acute care services 45 -- 3.4.2 Reduction of emergency department capacity 47 -- 3.4.3 Concentration of highly-specialised services in reference centres51 -- 4 EMERGENCY DEPARTMENT WORKFORCE 55 -- 4.1 PHYSICIANS AND NURSES SPECIALISED IN EMERGENCY CARE .55 -- 4.1.1 Physicians working in Belgian emergency departments.55 -- 4.1.2 Nurses with a special title in intensive and emergency care .59 -- 4.2 CRITICAL APPRAISAL: THE ED IS A DEMANDING WORKPLACE AND STAFFING SHORTAGES ARE REPORTED .60 -- 4.2.1 Emergency physician shortage: need for evaluation in larger policy context .60 -- 4.2.2 A stressful work environment with high levels of burnout for physicians and nurses 61 -- 4.2.3 Are the current policy measures sufficient to tackle the shortage? .63 -- 4.3 SOLUTION ELEMENTS .66 -- 4.3.1 Focus on emergency care .66 -- 4.3.2 Adequate remuneration 66 -- 4.3.3 New roles and workforce innovations in the emergency department.66 -- 5 OUT-OF-HOURS SERVICES FOR ACUTE CARE: THE ROLE OF PRIMARY CARE SERVICES 69 -- 5.1 OUT-OF-HOURS PRIMARY CARE SERVICES 69 -- 5.1.1 The context of primary care and out-of-hours services in Belgium .69 -- 5.1.2 Payment system for general practitioners 74 -- 5.2 CRITICAL APPRAISAL OF ORGANISED DUTY CENTRES 78 -- 5.2.1 Rationale for ODC implementation: isolated focus on better working conditions for GPs or part of a larger vision?78 -- 5.2.2 Implementation of ODCs: increased use of out-of-hours GP services did not result in a decreased use of ED attendances .80 -- 5.2.3 ODCs are geographically well dispersed but is their location well chosen?.91 -- 5.2.4 Paying for ODCs: are the budgets covering investments and operational costs and the fee-forservice payments for GPs well-balanced? 97 -- 5.3 SOLUTION ELEMENTS .99 -- 5.3.1 Integration of EDs and ODCs .99 -- 5.3.2 Payment and organisation of acute care requires one general approach 102 -- 5.3.3 The role of primary care services during office hours in acute care .103 -- 6 TELEPHONE TRIAGE FOR PATIENTS WITH NON-EMERGENCY MEDICAL CONDITIONS .106 -- 6.1 ACCESS TO THE EMERGENCY CARE SYSTEM: REFERRALS, SELF-REFERRALS OR CONTACTING THE EMERGENCY CALL CENTRE 106 -- 6.2 CRITICAL ANALYSIS.107 -- 6.3 SOLUTION ELEMENTS 109 -- 7 THE ROLE OF PATIENT COST SHARING IN PROVIDER CHOICE .115 -- 7.1 PATIENT COST SHARING FOR GP AND EMERGENCY DEPARTMENT SERVICES .116 -- 7.1.1 Patient cost sharing for emergency department services 116 -- 7.1.2 Patient cost sharing for GP services .117 -- 7.1.3 Direct payment versus third-party payer system 119 -- 7.2 CRITICAL APPRAISAL OF THE ROLE OF PATIENT COST SHARING IN THE CHOICE BETWEEN GP AND EMERGENCY DEPARTMENT SERVICES 120 -- 7.3 SOLUTION ELEMENTS 121 -- 8 PAYMENT MODELS FOR THE EMERGENCY DEPARTMENT AND ITS WORKFORCE 123 -- 8.1 THE BUDGET OF FINANCIAL MEANS 123 -- 8.1.1 Components of the closed-end hospital budget .123 -- 8.1.2 Calculation of the B2-budget for clinical costs .124 -- 8.1.3 The B2-budget for the emergency department 127 -- 8.2 THE REMUNERATION SYSTEM OF MEDICAL SPECIALISTS PROVIDING SERVICES IN AN EMERGENCY DEPARTMENT .139 -- 8.2.1 How are physician fees determined? 139 -- 8.2.2 The fee schedule for emergency physicians and other medical specialists providing services at the emergency department 140 -- 8.2.3 Fees for physicians providing services in the ED: evolution of reimbursements and cases142 -- 8.2.4 Combination of one A-fee and one or more C-fees per emergency department visit .142 -- 8.2.5 A-fees by type of emergency physician .142 -- 8.3 PERFORMANCE MEASUREMENT AND PAY FOR PERFORMANCE .147 -- 8.3.1 Quality of care in emergency departments traditionally relies on a policy of recognition norms .147 -- 8.4 CRITICAL APPRAISAL OF THE OLD CALCULATION METHOD OF THE B2 BUDGET FOR THE EMERGENCY DEPARTMENT .147 -- 8.4.1 The B2 budget is not sufficient to guarantee minimum staffing ratios 147 -- 8.4.2 Distribution of the budget among hospitals: parameters are insufficiently related to ED activity and favour large hospitals148 -- 8.4.3 The old emergency department payment system better reflected the case-mix of the hospital .149 -- 8.4.4 Hospital responses.149 -- 8.5 CRITICAL APPRAISAL OF THE NEW CALCULATION METHOD OF THE B2 BUDGET FOR THE EMERGENCY DEPARTMENT .150 -- 8.5.1 New rules did not solve the structural underpayment but only changed the distribution of the closed-end budget 150 -- 8.5.2 Emergency department caseload and workload is better reflected 150 -- 8.5.3 The pros and cons of a patient classification system for emergency department payments150 -- 8.5.4 Hospital responses.151 -- 8.6 CRITICAL APPRAISAL OF THE REMUNERATION SYSTEM OF MEDICAL SPECIALISTS PROVIDING SERVICES AT THE EMERGENCY DEPARTMENT 151 -- 8.6.1 A fee-for-service payment system contributes to a productive workforce but incentivizes the quantity of services a physician provides .151 -- 8.6.2 The fee schedule helps us to keep track of what happens within the system.152 -- 8.6.3 The fee schedule for physians working in the ED: amount of the fee 153 -- 8.6.4 Large differences between hospitals in the share of ED visits for which a C-fee is charged 155 -- 8.6.5 A system of salaried emergency physicians: less appropriate for a flexible workforce and more expensive for society 156 -- 8.6.6 The fee schedule of emergency physicians: redundant or too restricted? .156 -- 8.6.7 The size of the hospital determines the budget available for physicans on duty in the ED.157 -- 8.7 CRITICAL APPRAISAL OF THE DEVELOPMENT AND IMPLEMENTATION OF QUALITY INDICATORS FOR EMERGENCY CARE .158 -- 8.8 SOLUTION ELEMENTS 159 -- 8.8.1 The ED budget should be sufficient to cover minimum staffing levels 159 -- 8.8.2 The new calculation method for the ED budget should be evaluated regularly 159 -- 8.8.3 A mix of fixed and variable payments 160 -- 8.8.4 Variable payments reflecting the ED caseload and patient case-mix .162 -- 8.8.5 Funding for sparsely populated and remote areas 163 -- 8.8.6 A payment system to support the development of an emergency care network 163 -- 9 ORGANISATION AND PAYMENT OF EMERGENCY CARE SERVICES IN SELECTED COUNTRIES .165 -- 9.1 INTRODUCTION 165 -- 9.1.1 Background 165 -- 9.1.2 Methodology.165 -- 9.1.3 Overview of emergency care services across countries .167 -- 9.2 ORGANISATION OF EMERGENCY CARE SERVICES 170 -- 9.2.1 Framework 170 -- 9.2.2 Organisation and planning .172 -- 9.3 PAYMENT OF EMERGENCY CARE SERVICES 185 -- 9.3.1 Framework 185 -- 9.3.2 Payment of Providers 187 -- 9.4 REFORMS AND DEBATES.194 -- 9.4.1 Overview .194 -- 9.4.2 Improved availability of urgent primary care services and better coordination with emergency care .194 -- 9.4.3 Rationalizing and concentrating emergency care .197 -- 9.5 CONCLUSIONS .200 -- 9.5.1 Guiding patients through the system 200 -- 9.5.2 Reconfiguring urgent primary and emergency care.201 -- 9.5.3 Supporting integrated emergency and urgent care structures through payment .201 -- 10 INTERVENTIONS TO REDUCE EMERGENCY DEPARTMENT UTILIZATION204 -- 10.1 OBJECTIVE.204 -- 10.2 METHOD 204 -- 10.3 RESULTS .206 -- 10.3.1 Search and inclusion 206 -- 10.3.2 Methodological assessment 207 -- 10.3.3 Type of target populations included in systematic reviews212 -- 10.3.4 Type of interventions and scope of reviews 212 -- 10.4 DISCUSSION AND CONCLUSION .223