1. Reimbursement of radiotherapy in Belgium The old reimbursement system The new system The desired system Nicolas Jansen Liege University Hospital

2. Introduction  Belgium ≠ The Netherlands  Flanders = Wallonia  4 time periods 1.Historical situation 2.Activity based reimbursement system (2001-2012) (minor modifications 2003) 3.The new quality stimulating reimbursement system (2013-…) 4.A new FINANCING based on needs and quality (202x-...)

3. Time period 2 : now Gifts, sponsoring Supplements paid by patients privately or by private insurance Reimbursed individual medical acts To cover the complete running of the department (medical and paramedical wages, goods, physics, medical immobile material, accelerators, …) Financing of machines and staff on a department level

4. Time period 2 : now Reimbursed individual medical acts Financing of machines and staff on a department level Supplements only possible for certain patients. Not always accepted by patients for ‘essential treatments’.

5. Time period 2 : now Reimbursed individual medical acts Financing of machines and staff on a department level 60% is paid by the federal government 40% is NOT paid by the regional governments

6. Time period 2 : now Reimbursed individual medical acts Financing of machines and staff on a department level We need an increase of >10% A linear reduction of 1-2% was imposed in 2012 The amounts have not been adapted to the index of living costs

7. Time period 2 : now Reimbursed individual medical acts Financing of machines and staff on a department level Total amount of these

8. Reimbursement evolution 200220032004200520062007200820092010 536073727380788994

9. Time period 3a : near future Reimbursed individual medical acts Financing of machines and staff on a department level

10. Time period 3b : future Reimbursed individual medical acts Financing of machines and staff on a department level Hoped for but no positive news

11. Time period 4 : needs to be defended Reimbursed individual medical acts Financing of machines and staff on a department level based on a national analysis of needs and the expected evolution of the patient population If a good reimbursement is available for a given treatment, ‘everyone’ will start offering this treatment whether there is a real need in a given area or not.

12. Time period 3a : ongoing negotiations Reimbursed individual medical acts Financing of machines and staff on a department level

13. Time periods 2 and 3a Actual system 2012New system 2013 ? Basic principle Financing = -Small basic amount per department for staffing and equipment + -Reimbursement per medical act for the physician + -Reimburement of used medical products like seeds, isotopes, … ProblemsThe small basic amount per department is … still very small The amount per act and the acts that are reimbursable are NOT adapted to the present technical evolution of radiation oncology Problem not solved Still not the solution of time period 4 : a real FINANCING instead of a largely act-based system RisksNon acceptance by the government Envelope (maximum limit) Slow adaptation of the acts to the medical and technical evolutions Time to get it1997-20013 years now

14. Controversy How to get from time period 2 to time period 4 ? –Extremely gradually, through negotiations, via step 3 (approach of the VBS/GBS at this moment) –Jump to step 4 directly, by a strong political will to do so, after strong lobying (approach favoured by the new radiotherapy platform)

15. What is the GBS/VBS « Verbond der Belgische Specialisten » –Official representation of medical specialists for discussions with the government –There is a global group (for all specialists) –And there is a specific group for radiation oncologists ≠BVRO : scientific organisation ≠Het college : quality stimulating body

16. TREATMENT PREPARATION personalised immobilisation125 simulation300 second simulation150 image fusion (simple, 2 techniques)NA75 image fusion (complex, > 2 techniques)NA150 delineationNA250 2D+-planning / calculation ME250150 3D-planning (standaard)250 + 125375 3D-planning (intensive)250 + 125 + 125 + 100600 4D radiotherapy preparationNA250 adaptive radiotherapyNA150 individual shielding75 or 150100 TREATMENT EXECUTION AND QUALITY MEASURES Category 1 (extern simple)500 Category 2 (extern complex standard fractionation)1600 or 20002000 Category 3 (extern complex hypofractionation)1200 or 16001500 Category 4 (extern complex stereotactic treatment)2000 image guidance at start100 image guidance (correction protocol / start and weekly control)100500 image guidance online daily and intensive1001000 4D radiotherapy deliveryNA300 patient individual QANA (100)200 in vivo100 existing, original price existing, lower price new oldnew

18. Place of brachytherapy Reimbursed individual medical acts Financing of machines and staff on a department level

19. Place of brachytherapy : period 2 Reimbursed individual medical acts

20. Brachy cost versus external Percentage of total cost of the basic brachy procedures in a given year versus the costs of the total cost of the external beam treatments in the same year Reduction is based on decrease in number of patients treated 200220032004200520062007200820092010 4,95,66,77,26,46,15,55,65,0 Does not include simulation, planning, seeds, afterloader, …

21. Brachy cost total All reimbursed acts (including simulation, planning, afterloader, …) Not seeds, no hospital stay costs 3.900.000 euro in 2011 =4% of total radiotherapy costs

22. Place of brachytherapy : period 3 Reimbursed individual medical acts 4%

23. Brachytherapy : present situation 2 ‘complexity levels’ For each complexity level 2 situations : –After an external beam radiotherapy (boost) –Brachytherapy alone

24. Brachytherapy : present situation Problems –Complexity levels are organ based –Brachytherapy is reimbursed less if given as a boost, even is the time and efforts invested are more or less the same First bad news for prostate brachytherapy by permanent seed implants : –no more simulation (2011) : minus K300 –Price of seeds is government controlled at 47,7 € /seed, including transport and all other material used during the procedure. Max 100 seeds/patient (2012)

25. Brachytherapy : future situation 3a –3 complexity levels Not image based (cheloids, …) Simple image based (geometrical, or CT/ultrasound) Idem, full 3D plan with multiple OAR and TV delineated –Equal reimbursement as boost or not –Quality stimulating measures of external radiotherapy are also valid for brachytherapy Delineating Image fusion In vivo dosimetry … –No reduction in reimbursed amounts

27. Compulsory activity Compulsory activity, but only one of these activities within the frame (and one per treatment) Accepted activity Accepted activity, but only one of these activities within the frame (and one per treatment) Forbidden activity

28. ONLY BRACHYTHERAPY AMOUNTS IN ‘K’, not euro rubriek 0 No treatment delivered rubriek 5 Simple brachytherapy rubriek 6 Standard brachytherapy rubriek 7 Complex brachytherapy rubriek 8 kilovolt A. Treatment execution 50010001250 B. Treatment preparation First simulation 300 Second simulation Simple image fusion 75 Complex image fusion 150 Delineation 250 Simple planning 150 Standard planning 375 Complex planning 600 4D planning Adaptive planning C. Quality/safety measures Afterloading 100 (400) Fixation system 125 Protective systems IGRT (once) IGRT (standard protocol) IGRT (daily, online) 4D treatment execution Patient specific phantom dosimetry In vivo dosimetry 100 TYPICAL TOTAL65020752750

29. Conclusion for the BELGIAN reimbursement system –Present reimbursement is not adapted to needs –New reimbursement system … is not guaranteed at all does include quality stimulating measures is not a major change respects brachytherapy reimbursements –No existing plans for a reimbursement system based on objective needs and quality