Belgium: the crossroads of Europe
Belgium may be a relatively small country, but it packs a punch when it comes to healthcare delivery. Tatum Anderson details the standards and access to medical care for those needing treatment while in the country
First published in ITIJ 118, November 2010
Belgium may be a relatively small country, but it packs a punch when it comes to healthcare delivery. Tatum Anderson details the standards and access to medical care for those needing treatment while in the country
Belgium may not attract vast amounts of tourists in relation to many of its European neighbours; but at the crossroads of Europe, it is administrative home to the European Union (EU) and boasts a vast international community. Luckily for visitors and the significant population of expats, Belgium spends 10.2 per cent of its GDP on health, and has a high standard of care, and corresponding good health indicators. Here, we investigate how that healthcare is delivered – both to foreign residents as well as those more temporary visitors – and we look at standards and access to emergency care, including a run down of some of the top hospitals recommended by assistance companies operating in the country.
In safe hands
Belgium is home to over 10.6 million people, yet is just over 30,000 square kilometres in size, making it the second most densely populated country in Europe. It is divided along ethnic lines between Dutch-speaking Flemings and French-speaking Walloons. In addition, there are eastern German cantons, and the bilingual (Dutch and French) capital, Brussels. But for a country that is deeply divided along language, economic and political lines, there is actually little inequity between healthcare provided in the different regions, although approaches might differ slightly (the federal government manages most curative healthcare but a few elements of the health system are devolved to the communities).
If a hospital doesn’t have a GOP from someone they ‘know and trust’, immediate payment is being more frequently demanded by the hospital
Overall, there are plenty of decent hospitals in Belgium. As Dr Jan Christiaen of Falck, an assistance company that operates in several European countries including Belgium, told ITIJ: “The standard of the hospitals [in Belgium] are among the best in Europe. Access is excellent, almost no waiting lists, facilities are clean and they have well organised structures.” Of course, many of the most renowned medical facilities are located in Brussels and are frequented by expats. Erasmus hospital, a university hospital (where the crown princess gave birth to her children), Brussels Saint-Luc University Hospital and Edith Cavell Interregional Hospital Group (CHIREC), a group of private hospitals, all have excellent reputations. University hospitals are particularly renowned. They operate in Belgium’s major cities including Antwerp, Ghent, Leuven, Charleroi and Liège. There are also good Catholic organisations, such as Onze-Lieve-Vrouw Hospital (OLV) in Aalst. Furthermore, Truus Andries, project and network manager of Touring Club, which provides medical assistance for foreign tourists visiting Belgium, reckons leading Belgian institutions include Antwerp’s Middelheim Ziekenhuis and Algemeen Ziekenhuis St Lucas, which has sites in both Ghent and Brugge.
Indeed, facilities are so good in many Belgian hospitals that neighbouring countries, including the Netherlands, have agreements with Belgian hospitals for prompt access to medical care to help reduce national waiting lists. And Belgians do not generally go abroad for healthcare apart from cheaper plastic surgery. A shortage of nurses has led Belgium to import EU-trained staff, but assistance companies say these shortages are yet to affect services provided.
Generally, international assistance companies have very good relationships with local hospitals. The only issue raised has been over guarantee of payment (GOP). As Ivo Bonte, network co-ordinator for Belgian assistance company VAB, told ITIJ: “In general, hospitals accept GOPs from Belgian assistance companies without any problems. However, I’ve seen an evolution over the last 10 years – in Belgium as well as many other countries around the world – where there’s less trust. This started even before the financial crisis. If a hospital doesn’t have a GOP from someone they ‘know and trust’, immediate payment is being more frequently demanded by the hospital.”
All for one
Unlike tax-based healthcare systems, the Belgian health system is based on social insurance, a system dependent on employment infrastructure and separate from health facilities, such as hospitals and clinics. In exchange for social security payments, which are directly deducted from wages, Belgian citizens become insured against the risks of illness, accident or hospitalisation. Mutual insurance organisations, or sickness funds, provide this insurance to citizens. They are financed not only by earnings – generally, every employed person pays 13.07 per cent of his gross remuneration to the federal state for social security – but other sources, including employers’ contributions.
It is compulsory for all employees to join a sickness fund. By 2008, 99 per cent of the Belgian population belonged to one of these funds. Over 9.4 million people were insured under a so-called general scheme and over one million under the scheme for the self-employed.
There are six private non-profit-making sickness funds. The National Alliance of Christian Mutualities is the largest and manages around 45 per cent of the population. There is one public sickness fund. Essentially, they are politically oriented, each having a Flemish, Walloon or German community identity. The funds have a long history, starting in the late 19th Century, when workers organised societies to protect members against the risk of disease, unemployment and incapacity for work. Today, they are highly politicised and powerful, says Filip Declercq, business manager at Expat & Co, a start-up health insurer.
Essentially, sickness funds exist to reimburse citizens for health services they may use. The main insured members are entitled to health insurance based on their current or previous profession. Their dependants, defined as a member of the family of the entitled person living in the same main place of residence, are covered under their contribution too. However, the rate of reimbursement and method by which reimbursement takes place differs depending on the intervention. That means Belgian citizens are expected to co-pay to some extent for their health services. Most Belgians purchase additional coverage from their mutual insurer on top of the compulsory insurance, however, which ensures most out-of-pocket healthcare expenditure is kept to a minimum.
Tourists with a European Health Insurance Card are subject to the same co-payment system as Belgian citizens
The level of reimbursement is independent of the job the patient does, unless their disorder is the result of an occupational accident. In that case, all medical costs are covered. Generally, the rule of thumb is that for Belgian citizens, about 80 to 90 per cent of the cost of healthcare is covered by the sickness funds. The rest is paid by the patient through official co-payments, supplements (such as private rooms in hospitals) and other non-reimbursable services, drugs and devices.
Essentially, rates of reimbursement for treatment are set out in a rather complex document called the nomenclature. The difference between the actual charge and the reimbursement is the user fee or co-payment rate. A visit to a GP will elicit one rate, and a visit to a cardiologist will elicit another. Co-payment rates are about 25 per cent for GP consultations, 35 per cent for GP home visits, and 40 per cent for specialist consultations, physiotherapy or speech therapy. (Rates of reimbursement are the same for everyone except those with special reimbursement status). However, doctors and hospitals are at liberty to increase prices, which means reimbursement amounts can be lower. Specialist fees can vary by a factor of four, says Filip Declercq.
Most inpatient services require co-payments of no more than 20 per cent of the cost. A hip replacement will cost about €1,000 to the patient, as an example. Dr Jan Christiaen says: “Indeed, the rule is mostly that if you are seriously ill, and need hospitalisation, most costs will be covered. If you are ‘ambulatory ill’, the non refundable part gets higher.”
Inpatient services are charged on the basis of set flat-rate user fees. Furthermore, patients do not have to pay the entire cost of services upfront and wait for reimbursement. The sickness funds have agreements with hospitals for the direct payment of hospitalisation costs, but ambulant medical treatment is paid for by the patient and then reimbursed. The set rates can comprise a flat rate per day for hospitalisation; a room supplement when the patient has requested a single or double room; a flat rate charge for pharmaceuticals (around €0.62/day); an inpatient stay for biological tests (€7.44/stay); and for radiology (€6.20/stay). Room supplements are usually taken up by private patients who have top-up health insurance in addition to basic sickness fund coverage.
“All costs are invoiced. On the invoice you can see what has been charged to the health insurance and what is not covered or how much the personal cost is,” says Dr Jan Christiaen. Different drugs are reimbursed at different rates too. Drugs issued at normal pharmacies for non-life-threatening diseases such as antibiotics, anti-asthmatic and anti-hypertensive medicines incur a co-payment rate of 25 per cent, to a maximum of €10.80.
Tourists with a European Health Insurance Card are subject to the same co-payment system as Belgian citizens. Citizens of some countries, including the UK, are able to seek reimbursement for some co-payments – such as for seeing a doctor – once they return home, but only if the doctor isregistered with the national health service (conventionné/geconventioneerd). Doctors offering private healthcare are not usually reimbursed under this system.
The sickness funds have agreements with hospitals for the direct payment of hospitalisation costs, but ambulant medical treatment is paid for by the patient and then reimbursed
Expats living and working in Belgium are able to join sickness funds. Some are able to get reimbursements for co-payments. If that is the case, the sickness fund does the work of settling bills with the home country institute to ensure co-payments are covered. For those without medical insurance or who do not belong to a sickness fund, health services are generally expensive. Drugs are also expensive compared to other countries.
Insuring a healthy future
Because the public hospital system is generally quite good, private profit-making health insurance companies account for only a small part of the non-compulsory health insurance market, say experts. According to Truus Andries, some patients use the private system to provide top-up payments over and above those paid out by sickness funds to cover costs the funds do not reimburse. Expats without any form of social security tend to use private insurance as their primary health insurance.
The social insurance infrastructure is just one of a distinct set of principles to which the Belgian health system abides. Others include therapeutic freedom for physicians and freedom of choice for patients. So, unlike some countries in Europe, citizens are able to approach specialists directly rather than go through a GP gatekeeper system. “It is very easy to find a specialist if you go to the website of any hospital on the Internet, and you can make an appointment directly,” says Andries. The advantage of such a system, say experts, is that citizens can seek a second opinion if they do not trust the first. The disadvantage is that health spending is higher (especially as some doctors can sometimes raise their prices).
That said, some sickness funds prefer clients to first consult a GP before seeing a specialist. “Sometimes, the GP can solve the problem and the patient doesn't have to go to the specialist and in that way it costs less for the sickness fund,” adds Andries. In recent years, the government has introduced a series of measures to try and strengthen the role of GPs and prevent so many patients relying on hospital emergency services for less urgent problems. For instance, it has raised the reimbursement rate for the first visit to a specialist if referred by a GP. In addition, hospitals must now charge ambulatory patients a fixed amount for using a hospital A&E unit for non-urgent visits. The fees have varied over the years but are now about €9.50, according to a review of the Belgian health system published by the World Health Organization this year.
GP services are undergoing a revamp too. GP federations, or circles, have been created so that local GPs work together to provide out-of-hours shifts, improve emergency care and arrange locums for colleagues who are ill or on holiday. In addition, primary care outposts, providing permanent on-call GP services with facilities to treat minor urgencies are in pilot too. Patients with minor emergency needs can therefore call the GP out-of-hours service and either receive a GP visit or call in at the practice. The GP can make a diagnosis, decide to treat the patient or refer them to the nearest A&E department at a hospital.
Filip Declercq says some measures are having the desired effect amongst Belgians. “There was a time when patients went directly to the hospital with all their complaints,” he says. “Then the government introduced an extra cost for non-emergency treatments which could be done by a GP. Now we see local people more often going to the GP.”
For Belgians venturing abroad, personal travel medical assistance is usually provided through the additional insurance taken out by the majority of the population with their mutual insurer or sickness fund
But while Belgians have started to use GPs more, foreigners, particularly expats, tend to head for the prestigious Brussels hospitals, and students to the university hospitals. The longer they stay in the country, however, the more likely they are to call on GPs. In addition, there are a few doctors practices that specialise in treating expats, providing services in different languages.
Already covered
For Belgians venturing abroad, personal travel medical assistance is usually provided through the additional insurance taken out by the majority of the population with their mutual insurer or sickness fund. This extra coverage provides insurance for travel abroad for recreational purposes only – not business travel or expatriate travel. In general, it covers the insured while abroad for up to between three and six months, with covered amounts for travel within Europe generally being more comprehensive than for those venturing out of Europe. The cover is strictly limited to medical costs and does not include car-related assistance.
Considering that the sickness funds offer travel assistance to members who pay for additional cover, and that the majority of Belgian people opt for the additional coverage, it is perhaps not surprising that stand-alone travel insurers ‘have a challenge selling their products’, as Ivo Bonte explained to ITIJ. Naturally, the cover provided by independent insurers is much more comprehensive – providing reimbursement for baggage, natural disasters, liability, and so on. In fact, the one major selling point of independent travel insurance is that it covers for car-related assistance (breakdown and recovery) – a very important element for Belgians. Furthermore, the Belgian tax regime is favourable towards company cars, so the long-term leasing market in the country is huge. As these leasing companies want to care for their customers when they have a breakdown or accident in Belgium or abroad, they want to confide the assistance to a reliable provider.
On the flip side, for those visiting Belgium and requiring immediate emergency assistance, the number to call is 112, or 100 for an ambulance. Emergency medical care is provided by 17 ‘aid centres’, which inform the nearest ambulance service and make sure the patient is transported to the most suitable hospital (or, in some cases, a GP). Aid centres can also call on one of 79 ‘mobile urgency groups’, 24-hour crack-teams that specialise in providing emergency services at the scene.
Three regional air ambulance services provide emergency primary, and in some cases secondary, transfers to hospital for those needing such a mode of transport, explains Dr Laurent Taymans, an emergency physician with iMedevac. Between them, they cover the whole country, but are run very independently of each other, with separate funding, membership schemes, and operating policies.
For the repatriation of patients out of Belgium, there are a handful of local air ambulance providers such as Skylifeguard and ASL, but nearby foreign companies are also used. Furthermore, the Dutch airline KLM and Group partner Air France both have good reputations for repatriating international patients, especially to Amsterdam and Paris (respectively), but their stretcher pricing policy is considered by some to be relatively expensive. In addition, SN Brussels Airlines also has a good reputation for providing swift medical clearance, and is lauded for its clear pricing policies. It reportedly flies to many of the destinations favoured by Belgian tourists, including a number in Africa, so is also used frequently by local assistance companies.