5.4. Specialized ambulatory care / inpatient care

Every citizen has access to medical specialists without a referral. In particular for gynaecology, ophthalmology, dermatology, paediatrics and otorhinolaryngology care, patients tend to go directly to the medical specialist instead of their GP.

5.4.1. Specialized ambulatory / outpatient care

Medical specialists can work on an ambulatory basis in hospitals (public or private not-for-profit),[12] in private for-profit clinics (called extramural centres, see Box5.4) and/or in a private practice.

In hospitals, medical specialists can hold their ambulatory consultations in the polyclinic, which is a space in the hospital separate from inpatients, and can combine this with consulting in their private practice or in extramural centres.

In ambulatory settings, medical specialists are paid on an FFS basis and patient co-payments are higher than for GP consultations. Some specialists did not agree or only partially agreed to the national official tariffs, indicating that they may charge extra-billings (see Section 3.3.4 for more details) (IMA-AIM, 2019a). There is no registered information on the amount of extra-billings charged to patients in ambulatory settings. In the case of hospitalization, a recent study showed that the amount of extra-billings charged to patients in single-bed rooms increased, potentially due to the ban on charging extra-billings for double or multiple-bed rooms (IMA-AIM, 2019c).

5.4.2. Inpatient care

Inpatient care refers to a patient admitted into a licensed hospital, public or private, who is not discharged on the day of admission. According to the Belgian Hospital Act, several standards and criteria have to be met for a health care establishment to be licensed as a hospital (see Section 2.4.2) (Justel 7 November 2008). A hospital consists of hospital services including medico-technical services (such as imaging and radiotherapy), hospital departments, hospital functions and care programmes. Hospital functions are transverse; that is to say, they are not aimed at a specific patient group and extend across the different services of the hospital (pharmacy, palliative care, blood bank, intensive care, emergency care). A care programme is a coherent set of care services working in a multidisciplinary and transverse way for a well defined target patient group (such as reproductive medicine, cardiology, oncology, paediatrics and geriatrics). A distinction is made between basic care programmes for regular conditions and specialized care programmes for rarer conditions, which are not available in every hospital (BS-MB 8 August 2014a). Licensing criteria are defined for the different services, departments, functions and care programmes. For several services, functions and care programmes, there are also programming criteria based on a national planning (see Section 2.4.2) (MoH, 2016c).

Length of inpatient stays

Between 2000 and 2017, the average length of stay (ALOS) in inpatient curative care beds decreased from 8.2 days to 6.6 days, which is in line with neighbouring countries (see Fig5.2). Multiple factors have contributed to the decrease over time, including financial incentives to increase efficiency and shorten stays, medico-technical progress, the development of home care services and the expansion of day care. A projection study predicted a further reduction of ALOS to 5.94 days in 2025 (Van de Voorde et al., 2017).[13] Examples of initiatives to decrease length of stay concern the inpatient stays of women with normal deliveries (see also Box5.5). The ALOS for a normal birth is considered an appropriate indicator for the efficient use of health care services due to the comparable case-mix of patients. In Belgium, the ALOS for a normal birth decreased from 4.96 days in 2010 to 3.11 days in 2016, which is now close to the EU15 average (2.8 days in 2016; data available for 13 countries).

Fig5.2

Initiatives on inpatient care

Since 2015, an Action Plan of both the Federal State and Federated entities to reform the current hospital landscape has been drafted (see Chapter 6) (Van de Voorde et al., 2014, 2017). Initiatives on care concentration, including referral agreements, are in progress. For example from January 2020, complex surgery of the pancreas and oesophagus are only reimbursed in a limited number of hospitals with proven experience (NIHDI, 2019c). There are also initiatives to stimulate the integration of care between settings (see Box5.5).

Quality of inpatient care

Quality criteria are embedded in the licensing criteria specific to hospital services, departments, functions and care programmes. Inspection ensures that hospitals comply with these quality criteria at the levels of structure, processes and results. Since the 6th State Reform (1 July 2014), assessing the quality of a hospital is an exclusive competence of the Federated entities. However, if they decide to establish new criteria, they may not impact the Federal competences or impact the Federal budget.

In Flanders, inspections are performed unannounced, whereby a care trajectory of a certain type of patient is followed. In addition, the Flemish Indicators Project for Patients and Professionals (VIP²) measures the quality of care in most Flemish general hospitals. The hospitals choose which indicators they measure. Results appear (if the hospital agrees) on a website www.zorgkwaliteit.be (Flemish Agency for Care and Health). The German-speaking community regularly organizes announced quality inspections in hospitals in collaboration with the Flemish organization. In Brussels and the Walloon region, the organization Plateforme pour l’Amélioration continue de la Qualité des soins et de la Sécurité des patients (PAQS) has set up quality indicators in close collaboration with the sector for benchmarking (each hospital receives its own results compared to the average) (PAQS, 2018). Nevertheless, these data are not yet collected in a systematic way. In the case of hospital accreditation, which is voluntary, an external organization assesses the extent to which the hospital offers quality and safe care. Since 2008, hospitals can receive accreditation for a limited number of years, with an increasing number of hospitals obtaining accreditation (58% in 2019) or in the process of obtaining accreditation (27% in 2019).

Since 2018, a P4P programme for general hospitals also grants an additional budget to hospitals that score well on an indicator set of four hospital-wide and seven pathology-related indicators (see Section 6.1). Participation is voluntary.

Quality initiatives concerning the measurement of patient experiences are described in Box5.6. Additional quality initiatives are described in Box2.4 in Chapter 2.

5.4.3. Day care

In Belgium, the formal description of day care is day hospital and is only reserved for licensed hospitals (BS-MB 5 December 1997; BS-MB 7 March 2008), with established procedures for selection of patients, safety, quality control, continuity, reporting and cooperation with various medico-technical services (NIHDI, 2013). It can be for a surgical intervention (called surgical day care) or a number of diagnostic tests, therapeutic tests, or oncological therapies (called medical day care).

Technical acts that are performed in a consultation room or the consultation ward of a polyclinic (such as suturing wounds), as well as care acts performed in a private clinic (such as refractive eye surgery) are considered ambulatory care and not day care. Some acts (such as surgical tooth extraction) can be performed both in ambulatory and day care settings.

The proportion of day care admissions represented 60.6% of all general hospital stays in 2014. In the period 2008–2014, day care admissions showed an average annual growth rate of 4.3%. Most day care admissions were for non-surgical procedures (including intravenous therapy and chemotherapy), representing 78% of the number of day care admissions in 2014 (Van de Voorde et al., 2017).

The shift to day care varies between hospitals and between interventions. Some incentives have been introduced to promote day care. However, the payment rules are complex (some interventions are financed within a closed-end budget and others, on a nominative list, are paid for by lump sums) and lack transparency. As a consequence, they fail to give clear incentives to health care providers. Additional mechanisms are needed to both encourage day surgery and avoid a suction effect on procedures that could easily be performed in the doctor’s consultation room; see the KCE Report 282 for more details on day care (Leroy et al., 2017).

A trend analysis for planning hospital capacity for 2025 concluded that more beds for day care will be necessary (Van de Voorde et al., 2017).