Simplification of patient cost sharing
Authors: Farfan-Portet Maria-Isabel , Devos Carl , Devriese Stephan , Cleemput Irina , Van de Voorde Carine 
Published: January 2025

SYNTHESIS 6 -- 1. INTRODUCTION 6 -- 1.1. COMPLEXITY OF PATIENT COST SHARING FOR AMBULATORY PHYSICIAN-PATIENT CONTACTS 6 -- 1.2. SIMPLIFICATION WITHIN THE CONTOURS OF THE CURRENT HEALTH INSURANCE SYSTEM 7 -- 2. A SUCCESSION OF AD HOC MEASURES SINCE 1963 8 -- 2.1. THE HEALTH INSURANCE ACT OF 9 AUGUST 1963 LAID THE FOUNDATIONS OF THE CURRENT SYSTEM 8 -- 2.2. BUDGET-DRIVEN REFORMS 8 -- 2.3. INCENTIVE-BASED REFORMS 9 -- 3. POLICY OPTIONS TO SIMPLIFY THE CURRENT STRUCTURE OF CO-PAYMENTS AND COINSURANCE RATES FOR PHYSICIAN-PATIENT CONTACTS 9 -- 3.1. GLOBAL FINANCIAL IMPACT FOR RIZIV/INAMI AND FOR PATIENTS PER POLICY REFORM 11 -- 3.1.1. GP consultations 12 -- 3.1.2. GP visits 12 -- 3.1.3. Specialist consultations 12 -- 3.2. FINANCIAL IMPACT FOR PATIENT SUBGROUPS OF ALTERNATIVE POLICY REFORMS 14 -- 4. DISCUSSION AND CONCLUSION 14 -- SCIENTIFIC REPORT 17 -- 1. INTRODUCTION 17 -- 1.1. GENERAL BACKGROUND 17 -- 1.2. RESEARCH QUESTIONS AND SCOPE OF THE STUDY 18 -- 1.2.1. Scope of the study 18 -- 1.2.2. Research questions 19 -- 1.3. METHODS 20 -- 1.4. CONTENT OF THE REPORT 20 -- 2. A HISTORICAL OVERVIEW OF THE STRUCTURE OF CO-PAYMENTS AND COINSURANCE RATES FOR GP AND SPECIALIST- PATIENT CONTACTS 20 -- 2.1. MAIN LEGISLATIVE REFORMS SINCE 1963 20 -- 2.1.1. The Health Insurance Act of 1963 20 -- 2.1.2. Changes in cost-sharing rules as a response to a new economic context 22 -- 2.1.3. Changes in cost-sharing rules to steer patient demand 23 -- 2.2. DETERMINING FACTORS OF THE CURRENT STRUCTURE OF CO-PAYMENTS AND -- COINSURANCE RATES 28 -- 2.2.1. GP office consultations 28 -- 2.2.2. GP home visits 30 -- 2.2.3. Specialist consultations 37 -- 3. PATHWAYS TO SIMPLIFY THE STRUCTURE OF CO-PAYMENTS AND COINSURANCE RATES FOR PHYSICIAN-PATIENT CONTACTS 40 -- 3.1. DESCRIPTION OF THE DATA 41 -- 3.2. MICROSIMULATION TECHNIQUE AS A TOOL FOR THE ANALYSIS OF POLICY MEASURES 41 -- 3.3. PRINCIPLES GOVERNING SIMPLIFYING REFORMS 42 -- 3.3.1. General principles governing cost-sharing differentiation 42 -- 3.3.2. General principles governing cost-sharing simplification 43 -- 3.3.3. Limited financial impact and in line with current legal stipulations 43 -- 3.4. SIMULATION RESULTS: FINANCIAL IMPACT FOR RIZIV/INAMI AND FOR PATIENTS 43 -- 3.4.1. Financial impact for patient subgroups of reforms for GP consultations 44 -- 3.4.2. Financial impact for patient subgroups of reforms for GP visits 50 -- 3.4.3. Financial impact for patient subgroups of reforms for specialist consultations 55 -- 3.4.4. Global financial impact for RIZIV/INAMI and patients per policy reform 59 -- APPENDICES 63 -- APPENDIX 1. CONSTRUCTION OF THE FINAL DATASET 63 -- APPENDIX 1.1. SELECTION OF NOMENCLATURE CODES 63 -- APPENDIX 1.2. SETTING UP THE BASELINE SIMULATION 72 -- APPENDIX 1.3. ADAPTING THE SAMPLE TO THE EVOLUTION OF PREFERENTIAL REIMBURSEMENT -- AND GMD/DMG BETWEEN 2009 AND 2011 74 -- APPENDIX 1.4. DEFINITION OF VARIABLES USED IN THE ANALYSIS 77 -- APPENDIX 2. TECHNICAL DETAILS OF THE SIMULATIONS 81 -- APPENDIX 2.1. NUMBER OF PATIENTS AND AVERAGE NUMBER OF CONSULTATIONS AND VISITS PER PATIENT SUBGROUP 82 -- APPENDIX 2.2. TECHNICAL DOCUMENTATION SHEETS 88 -- REFERENCES 105