Belgium, or the Kingdom of Belgium, is a federal monarchy in Western Europe. Together with The Netherlands and Luxemburg, the area used to be known as "the low countries" until Belgium seperated from The Netherlands in 1830. Linguistically speaking, Belgium forms the border of Germanic and Latin Europe and is home to three official languages; Dutch in the Nothern region Flanders, French in the Southern region Walloon and German in small parts of the country. Belgium is one of the co-founders of the European Union and its capital Brussels hosts the EU headquarters. Other major cities in Belgium include Antwerp, Liege, Gent and Brugge. Belgium covers an area of 30,528 square kilometres (11,787 sq mi) and has a population of about 11 million people.
Healthcare in Belgium
Healthcare in Belgium is best depicted as a 3 legged table-like structure standing over the patient. The table-top is a primarily publicly funded healthcare and social security service, run by the federal government, which organizes and regulates healthcare. The first leg provides healthcare in the form of independent private practitioners and public, university and semi-private hospitals and care institutions, there are a few (commercially run for profit) private hospitals. The second leg is the insurance cover provided to patients and the third leg is formed by the industry which covers production and distribution of healthcare products, and research and development, although an important part of the research effort is done in universities and hospitals.
Health insurance is only one of the pillars of the system of social security provided for every Belgian citizen. Every Belgian citizen has access to the social security system—it is compulsory—but there are gaps in the system where people can drop out: not paying contributions is one such exit, another is homelessness (social security is only available to people with an address).
Financing the system : compulsory social security
Every wage-earning worker or employee: in a factory, an office, working as house personnel (maids, chauffeurs etc) working in Belgium is registered to a central system, also the unemployed. The self-employed, such as shopkeepers, innkeepers, lawyers, and doctors, are also registered.
Workers are paid a daily or monthly wage : their gross salary. From that gross salary their employer has to deduct a certain amount (approx 13%) for social security and another (approx 20%) for taxes. The employer has to pay these amounts directly to the Social Security Services and the Inland Revenue Service (employers are making these payments for the employee and from his wage). On top of the gross salary the employer has to pay an employers contribution for social security of approx 15%-22% to the Social Security Services. Failing to make these payments regularly and on-time is closely monitored and often causes failing businesses to be taken to court for failing to comply with their social security and fiscal obligations for their workers, Reducing the risk for workers the they remain unpaid or that their contributions are not paid for them.
The Self-employed have a system in which they have to declare their earnings and based on that a contribution is calculated which is roughly 20%-22%, but they are not covered like workers. People can opt-in to the system through this self-employed scheme. The government form its tax earnings finances in part the social security system. This is a wealth re-distribution mechanism, because the contributions are incremental : meaning that the more someone earns the more that person will contribute. Moreover for health services the compulsory health insurance the refund system is the same for everybody (corrected for the lowest incomes) : i.e. for a consultation at the GP everybody pays the same and get the same refund (irrespective of their income).
Financing the system: complementary systems
There a complementary system of health insurance offered by the mutualities (extended hospital cover and travel cover), available to all mutuality members, and there is private insurance with commercial insurance companies for extended care (hospital and aftercare) and for travel care.
These systems are pure premium based insurance system.
Covering healthcare costs
1. Consultations with GP's or specialists in their private practise
- patients pay a fee for the consultation (approx 20-25€ for a GP) and for any medical acts (e.g. dental care at the dentist) (s)he may perform directly to the doctor, in return the patient gets a receipt that lists all the medical acts performed, and if necessary a prescription for medication.
- the patient gives this receipt to his mutuality, and they refund the patient in part (depending on the patients status), average patients get about 75% refunded
- some patients have a special social security code; they pay only 1€ to the doctor, and do not receive a refund receipt. The doctor is paid directly by the mutuality (3rd payer system)
- the patient takes his prescription to a pharmacist, paying only part of its price; for each medication dispensed the supplier is paid a supplement by the social security services. In some cases the medication requires extra checks and such medication is often free to the patient, although very expensive. Each sale of the medication is tracked, and the supplier paid by the social security services directly.
2. Consultations at hospitals (polyclinic)
- patients see a doctor at the hospital polyclinic just link in their private practise.
- some patients pay the hospital as they leave and get a receipt for their mutuality, just like in a private practise; however many patient come in for follow-up consultations after a medical intervention or hospitalisation. The hospitals send the bill to the mutuality (3rd payer system) and patients get invoiced for their personal part.
3. Hospitalisations and medical interventions
- patients are hospitalised and they have to pay weekly advances for their medical expenses (usually 50-100€ per week).
- all consultations and interventions, medications etc are directly invoiced to the mutuality and to and insurance cover the patient may have (3rd payer system)
- they receive an invoice for their personal part, which is often in part refundable by their complementary insurance.
- patients who suffer accidents might never have to pay any medical expenses, as accident insurers are often charged immediately, once responsibility is established.
Managing healthcare money streams
- Private insurance : private insurance companies collect premiums and provide cover, when an "insured risk" is realised the insurance company pays.
- Legal systems protect patients, doctors and hospitals from abusive denials of refunds by insurers a governmental complaints authority keeps an eye on policy conditions and execution.
- Access to private insurance is of course free, however an independent ombudsman service (not an individual) oversees refusals to ensure or termination (by the insurers) due to changes in medical condition of the patient. A governmental arbitration service reviews patient cases referred to it by the ombudsman and determines fair conditions/premiums for refuses / terminated patients
- Mutuality complementary insurance : the mutuality collects premiums and pays according to the selected cover.
- Mutualities compulsory health insurance:
- The mutualities front-office workers evaluate any refund claims superficially : is the medical act refundable and what rate, and refunds the patient nearly immediately (used to be in cash, now directly to the patients bank account)
- The receipt is the controlled through the mutuality backoffice system such that you don't get double refunds and other abuses
- Some claims, (based on the patients status) incur supplemental refunds, which are send by the mutuality back office to the patients bank account
- The mutuality gets paid by the social security services
- the amounts they pay as refund
- a fee for operating cost : mutualities have en extensive network of offices and significant numbers of staff runs in the thousands, they also have large computer networks and difficult software programs that are often tailor-made (because apart form the 6 ot 7 mutualities no-one else needs that software, and the amount of data treated is so extensive it requires a lot of effort)
the patients key to system
In the 80'ies an "SIS-card" (plastic creditcard-size chipcard like bank card) was introduced, the social security card. With it the Federal Government introduced a "national number", that identifies each individual uniquely based on his/her birthday. Every individual had such an SIS card, and it established their entitlement to social security.
In 2014 that system was superseded by the plastic ID card (Belgium EID card) with social security information on the card chip, readable with a simple card-reader.