what future for belgian healthcare breaking the budgetary autism

8/14/2019 What Future for Belgian Healthcare Breaking the Budgetary Autism

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Breaking the deadlock o budgetary

autism: what paradigms or uturehealthcare organisation in Belgium?

1. Major trends in Belgian healthcare provision

1.1. Budgetary explosion combined with budgetary austerityIn healthcare organisation contrary to perhaps some popular and nave belie about ree andaccessible healthcare everything comes down to numbers. And the numbers are impressivewhen you take a look at the evolution o the budget or public health care in Belgium. In1970, public healthcare expenditures were still under the billion euro mark. Ten years later,they accounted or more than 3 billion. By the end o the millennium, public health careexpenditures had reached 12 billion and it is very likely this gure will again be doubled by

2010. In 2005, the public healthcare budget already equalled 17 250 358 000, in 2006 17 735292 000 and in 2007 18 873 404 000. The objective is to spend approximately 21,5 billionin 2008(3) and 23 billion in 2009. Compare this gure with the 850 million in 1970 and themetaphor with the universe seems straightorward: always expanding and expanding. Ocourse, these are absolute gures. We have seen in over 30 years an average annual growth oclose to 5 percent in real terms, i.e. on top o ination. This is way aster than average economicgrowth in this country. From the perspective o public budget control, thereore, the growth ohealthcare spending is simply unsustainable.

We have nonetheless managed to survive such an expenditure explosion by giving everincreased weight to the relative importance o healthcare in the total social security budget.In 2008, the share o public health care expenditures in the total social security budget will

be close to 32%(4). In 1980, it was a mere 22%. It is thereore air to say that healthcareis gradually cannibalizing social security(5). The victims o this budgetary evolution are therst pillar pensions, the unemployment insurance benets and child allowances, all o whichhave seen their relative levels reduced because o increased healthcare expenditure. Thissituation is untenable in the long run and has already led to a series o healthcare policiesthat are perhaps necessary or inevitable, but that share a common characteristic in that theyrestrict the oer o, or access to healthcare in this country.

1.2. Healthcare policy vs. budgetary policyGiven the enormous and ever increasing budgetary importance o healthcare, it is normaland predictable that government should impose a budgetary discipline to avoid decitspending. This necessary awareness, however, has turned into somewhat o an obsession.Since about a quarter o a century, Belgiums governmental policies in healthcare have

indeed been dominated by budgetary concerns, rather than by public health concerns(6).When one looks at the picture rom a distance, one can easily come to the conclusion thathealthcare policy in Belgium has essentially become budgetary policy. On the one hand,a lot o time and eort is spent on an almost yearly basis in determining growth norms orthe public healthcare budget. On the other hand a number o reorm measures, althoughnot directly o a budgetary nature, have been developed under the growing pressure obudgetary austerity. In just the past couple o years, we have observed tightened budgets orhospitals and new technology, mergers o hospitals, and the concentration o some medicalservices in certain hospitals. The doctors and other healthcare providers have seen theirtherapeutic reedom restricted or the sake o eciency. The reedom o choice in accessto doctors is partially eroding and the doctors have seen the prescription o generic drugsimposed. More bureaucratic rules streamline the medical proession, the inow o new

medicines has been more strictly managed, reimbursed care is increasingly controlled, theinow o doctors managed, etc.

MEMO

2

The objective iso spend approxi-

mately 21,5 bil-on on healthcare

n 2008 and 23illion in 2009.

Compare this g-

re with the 850million in 1970 andhe metaphor withhe universe seemstraightorward:lways expandingnd expanding.


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What the neutral observer notices, thereore, is a gradual streamlining and sot restriction onhealthcare supply, and a gradual streamlining and sot restriction on healthcare demand.Some o these evolutions are highly contentious and debated. Many, indeed perhaps even all,may be necessary or desirable rom a pubic governance perspective. But it goes without sayingthat they all have tradeos. Our oten trumpeted model o reely available and accessiblehealthcare in an open market that guarantees competition and choice is gradually eroding.What are widely considered as key components o the Belgian healthcare model are thusbegin gradually undermined. We can illustrate this trend by ocussing on two key parties: themedical proession and the patients/citizens.

1.3. The medical and paramedical proession under pressureAs almost any practitioner will tell you when questioned upon the state o his/her proession,doctors are acing less therapeutic reedom and more bureaucracy. Moreover, as hospitalshave been rationalized, ewer have remained in the non-private sector, thereby decreasing thepersonal social security o the aliated medical corps as compared to the previous generationdoctors with public servant status. Furthermore, the income growth o the medical proessionhas diminished in relative size: between 1996 and 2008, the share o the doctors honorariain the public budget went rom 33,6% to 28,4% - a 5 points decline(7). This trend is urtherexacerbated by the systematic underunding o hospitals, which has led hospitals to increasethe overhead deducted rom the doctors ees.

The growing pressures on the medical proession and its correspondingly diminishedattractiveness should be a source o grave concern. For at the end o the day, the quality oa healthcare system depends on the quality o its human capital. This goes or the medicalproession as it goes or the paramedical proession. Human resources will be a key challengeor the uture wellbeing o Belgiums healthcare system. I we are to continue to thrive, weneed to be able to attract and motivate the requisite human capital at home and, increasingly,abroad as well.

1.4. Private expenditures are on the riseAlthough our healthcare expenditures are nanced by an ever expanding public budget,the patients themselves have to carry some o the burden. The OECD computed that 27,7%

o the total healthcare expenditures in Belgium are paid by the patient-citizen (or his/heremployer), either as out o the pocket expenses or through private insurance(8). Only ourOECD countries have an even more important share o private expenditure: the US, Canada,Spain and Switzerland (Figure 1).

MEMO

3

Belgiums gov-rnmental poli-es in healthcareave indeed beenominated byudgetary con-erns, rather thany public healthoncerns.


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Figure 1: Health expenditure per capita, public and private, 2005

Source: Health at a Glance 2007, OECD Indicators.

This already considerable share o private expenditures has been growing over the past ewyears, as can be seen rom gure 2 below.

Figure 2: Evolution o the private share o healthcare expenditures in Belgium

20

21

22

23

24

25

26

27

28

29

1997 1998 1999 2000 2001 2002 2003 2004 2005

Source: Health at a Glance 2007, OECD Indicators.

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What is more, the share o private expenditure is likely to continue to increase in the yearsto come. O course, this in itsel is not necessarily a problem. Research learns that, while themarginal utility o consumption goods decreases rapidly with the number o purchases, thisis not true or healthcare expenditures. In act, as people get richer and consumption rises,the marginal utility o consumption alls rapidly. Spending on health to extend lie allowsindividuals to purchase additional periods o utility. The marginal utility o lie extension doesnot decline(9). In other words, people are willing to pay or healthcare and or a wholebunch o health related goods and services, simply because they value them. This is one o thereasons why an increasing number o people are willing to pay or private health insurance.According to the European insurance and reinsurance ederation, the amount o privately

insured individuals in Belgium has almost doubled in ten years: rom 2 667 thousand in 1996to 4 913 thousand in 2006(10).

The growth o private expenditure signals the evolution o our economy towards a healtheconomy. This is in itsel a good and desirable thing and heralds the next phase in oureconomic development. On the other hand, however, and this is where our reection kicksin, the growing share o private expenditure underscores the growing inability or publicsector unding to match private healthcare demand. It underscores that the one size ts allapproach to healthcare provision ts less and less. As we shall see, this trend is not goingto disappear and thereore the policy debate should conront ully and squarely the questiono choice and limits in public unding. The alternative is a continued slow erosion o publiclyunded healthcare, with an American style prolieration o private insurance in a chaotic

market context on the side. All this will be to the detriment o the poorest and sickest and isthereore not an attractive perspective and, we venture to claim, not a perspective the publicwould support i ully inormed o the choice we ace.

2. The budgetary challenge: how the problem can become (part o) thesolutionHealthcares place in society will be increasingly predominant in the 21st century, not onlybecause o well-known demographic developments, but also because o socio-economic,scientic and technological changes. The key challenge will increasingly be to providehealthcare that is both aordable and accessible, while being o high quality. The trendshighlighted in the previous paragraph are thereore worrying. I we do not succeed in reversingthem, these trends risk becoming real and structural weaknesses as the ollowing decadesunold.

2.1. The challenge o ageingIn almost every country, the proportion o people aged over 60 years is growing asterthan any other age group, as a result o both longer lie expectancy and declining ertilityrates. This population ageing can be seen as a success story or public health policies andor socioeconomic development, but it also challenges society to adapt, in order to maximizethe health and unctional capacity o older people as well as their social participation andsecurity(11). As we progress through the 21st century, global ageing will put increasedeconomic and social demands on many countries. Belgium is no exception to that. As can beseen rom gure 3 below, the dependency ratio o the elder compared to the population atworking age is about to double in 50 years. In 2050 there will be 2.27 people at workingage, or 1 elder (65+), which is about hal o the ratio at the end o the 20th century.

MEMO

5

The growth orivate expendi-

ure signals thevolution o ourconomy towardshealth economy.ut it also under-cores the growingnability or pub-c sector undingo match privateealthcare de-

mand.


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The dramatic decline in the number o (potentially) economically active people as comparedto the number o (potentially) economically inactive is o major concern in countries where as in Belgium social security (including healthcare) is nanced through the so calledrepartition system. In such a system, the social security expenses or the old and the sick arepaid or by the current working generation, who themselves hope that the ollowing generationwill do them the same avour in the uture. However, with ageing and the retirement o theBaby Boomers the equilibrium between succeeding generations disappears and our societyis consequently aced with a real budgetary challenge which will be inevitable. Needless tosay this is going to put a tremendous pressure on our social security system and thus on thetaxpayers contributions.

Figure 3: Dependency ratio o the elder(ratio o the population o 65 years or older on the population at working age)

Source: National Bank o Belgium (11)

Moreover, the ageing o the population as such is also estimated to increase healthcareexpenses by 3 percentage points by 2049, as can be seen rom gure 4 below. Roughly,this represents 10 billion more expenses. This rise in expenditure comes on top o thedramatic doubling o the dependency ratio. Less and less younger workers will have tonance ever more healthcare expenses or ever more older retirees.

MEMO

6

The key challengeill increasingly be

o provide health-are that is both a-ordable and acces-ble, while being high quality.


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Figure 4: The budgetary cost o ageing(percentage points change o GNP, compared to 2007)

Source: National Bank o Belgium (12)

2.2. More health and the rise o the health economyFor Belgium, it is estimated that the phenomenon o ageing by itsel will only increase healthcareexpenses by 0,7% on an annual basis(13). The expected larger share o healthcare in oureconomy can thereore not be explained by demographic actors alone. Ageing is just the tipo the iceberg o growing health and healthcare expenditure. It is widely acknowledged that

several drivers will be responsible or an inexorable push in healthcare expenditures in thedecades to come, besides demographics(14):- Changing liestyles and the consequent explosion o liestyle diseases, e.g. related toobesity.- Continued increased specialisation in the medical proession, as the scientic evolutioncreates ever more avenues and branches.- Innovation in technology and medicines, opening up new treatments and narrowing downthe target group to eventually the level o individual and genetic treatment, where the costsaving eects o blockbuster treatments with huge markets will disappear. The treatments willcontinue to improve, but their relative cost will rise.- Consumerism, as people become ever more demanding and willing to improve their healthand wellbeing, urther blurring the line between medicine and consumption.

- Greater wealth in both the western world and the now rapidly expanding developed world,eeding urther the desire and willingness to pay or health and healthcare.

MEMO

7

Less and lessounger workers

will have to nancever more health-are expenses or

ver more olderetirees.


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The link between wealth and health in the shape o healthcare expenditures is borne outby economic research, also in Belgium. The Federal Plan Bureau ound that the elasticity ohealth expenses per capita and GDP per capita this is the extent to which health expenditurereacts to increased economic growth is superior to one(15). This means two things: (1) thewealthier people become, the more they are willing to spend on healthcare, and (2) peopleare prepared to spend proportionally more on health compared to the extra wealth they haveacquired. The relationship between GDP per capita and health expenditures is also illustratedin gure 5 below: the wealthier a country, the healthier a country.

Figure 5: Health expenses per capita and GDP per capita, 2005

Source: Health at a Glance 2007, OECD

All o this indicates that the citizen-patient is consciously choosing or health. Citizens areno longer mere patients who swallow whatever the doctor prescribes. They are becomingmore and more conscious healthcare buyers and consumers, urther stimulated by increasedaccess to healthcare inormation via a variety o sources, including the internet. According tosome long term estimates, up to one third o a developed countrys GDP will thus be spent on

healthcare by the end o our century(16) . This signals the evolution o our economy towardsa health economy, a new stage in economic progress in post-industrial societies.

Economically speaking, it makes no sense to deprive people rom something that createsvalue or them. The bottom line is: rather than being satised with the landscape as we knowit now, which is characterized by ever more rationing, more trade-os and more multi-speedmedicine under an ever tighter public budget, we should allow ourselves to invest more andmore consciously in healthcare. We should put our traditional budgetary autism aside andstart grasping the economic opportunities that arise rom the shit to a health economy. Inthis perspective, the growing private expenditure on healthcare is not so much the problemas it is part o the solution. For that to be the case, however, the necessary but narrow ocuson budgetary control in public sector unding needs to be lited and an open debate on the

limits and choices in public healthcare provision must be recognized as both inevitable anddesirable.

MEMO

8

Our economy isvolving towards aealth economy, aew stage in eco-omic progress

n post-industrialocieties.


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3. The necessary quest or new paradigms or uture healthcare organisationin Belgium

3.1. Moving beyond the Brussels consensusTo anticipate the budgetary impact o ageing and to discipline governments in the short runor this long term challenge, Belgium has established a virtual savings strategy (the Silver Fund)and an annual rite o uture ageing cost estimation, in the shape o reports rom the HighCouncil o Finances Commission on Ageing. The purpose o these reports is to estimate andthe estimates have never ceased to increase with each annual report the expected uture

cost o demographic ageing, based on a number o parameters o uture scal, social, andeconomic perormance.

These parameters can be summed up as ollows below. We contrast the premise with the past/current perormance:

1,75% labour productivity growth per year till 2030 (average 1,45% between 1980-2005).Total unemployment rate o 8% in 2030 (12,6% in 2007).Activity rate o 70% in 2030 (62% in 2008, or a dierence o roughly 500.000 jobs).Average annual economic growth 2,2% till 2030 (1,8% between 1990-2005).State debt 60% GDP in 2014 (81,4% in 2008).

Annual average real term growth o public health care budget restricted to 3% till 2030 (near5% between 1970-2006).

As the list shows, the estimates assume a systematic and marked improvement o Belgiumsscal, social, and economic perormance. We have argued elsewhere that such animprovement is very unlikely and in act amounts to wishul thinking without prior undamentalpolicy reorm(17). Indeed, ceteris paribus, population ageing is likely to impede and sloweconomic perormance, not improve it(18). The High Council o Finance itsel recognizesthe limits o a purely budgetary strategy and advocates reorms that stimulate growth andemployment in order to meet the nancial challenge o ageing(19).

More importantly or our exercise is the last o the aorementioned premises, which seeksto reduce the annual growth rate o public expenditure on healthcare to 3% per year, i.e.

a bafing reduction o almost 40% as compared to the average growth in the previous 35years. Given the powerul vectors that will increase rather than decrease healthcare needs inthe uture, as listed above, this estimate is simply unbelievable. In the absence o undamentalreorm in both healthcare organisation and in healthcare nancing it can only mean a growingsovietisation o Belgian healthcare or the general public, with an increasingly importantprivate market or the ortunate. This is a proposition too undesirable even to entertain.

Given these stark realities, the Belgian healthcare system both in its organisation and in itsnancing has no option but to reorm and improve. Without such reorms we will simply notbe able to maintain anything near the quality and accessibility we now enjoy. This article isnot the place or developing a comprehensive and balanced list o undamental proposals.We will, however, indicate some directions with potential, in the hope o broadening mindsets

and starting a pragmatic debate on the paradigms o uture healthcare organisation in thiscountry.

MEMO

9

The Brusselsonsensus seekso reduce thennual growthate o publicxpendituren healthcare

o 3% per year,e. a bafingeduction olmost 40% asompared to theverage growth

n the previous5 years. This es-mate is simply

nbelievable.


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3.2. The promise o ICTInormation and communication technologies (ICT) have already had a signicant impact oneconomic growth, but also on healthcare and the delivery o health services in a number ocountries. From telemedicine to electronic health records to RFID to embedded sensors, avariety o health ICTs have been shown to improve operational and administrative eciencies,clinical outcomes, documentation and inormation ow in a variety o global settings. Chaudhryet al. (2006)(22) have scrutinized 257 empirical studies to analyze the impact o healthinormation technology on quality, eciency and costs o medical care. The analyzed studiesunanimously reported positive results on the quality o care through an increasing adherence

to guideline- or protocol-based care, clinical monitoring based on large-scale screening andaggregation, transparency, and the reduction o medical errors. ICT was also ound to improvehealthcares eciency thanks to more accurate diagnosis and thus less unnecessary treatmentsand medication consumption. One examined study reported eciency gains up to no lessthan 24%. Chaudry et al. were not able to nd relevant studies they were either too old ormethodologically questionable that showed ICT to be cost reducing in healthcare. Hillestadet al. (2005)(23), on the other hand, computed a cautious estimate not a proo o howmuch money could be saved in the US thanks to the generalised application o the electronichealth record(24). The estimation yielded an impressive gure o $513 billion by 2020.

What the above demonstrates and illustrates is the potential o inormation and communicationtechnology to improve the organisation o healthcare, to improve the delivery o health care

services, to improve health outcomes and to rationalize healthcare spending without restrictingthe supply o healthcare services. In view o the current pressures and uture challenges acingthe Belgian healthcare system, it is clear that these benets represent both an opportunity anda necessity. ICT should be and will be central to the uture o Belgian healthcare organisation,much more so than it is today and than current government programmes envisage.

3.3. Horizontal v. vertical integration o healthcare services The Belgian healthcare system is essentially vertically integrated. From the top down, thegovernment decide on budgets, the RIZIV/INAMI allocates budgets, the mutual unds (or privateinsurers) assure reimbursement, the hospitals organize and centralize care, the specialistsprovide specialist care, and the general practitioners provide general care. This slicing up othe healthcare cake induces tur wars and causes mutual isolation between dierent levels inhealthcare provision. From the perspective o health outcomes this is a suboptimal situation,

especially since a large percentage o healthcare expenditures is linked to a limited groupo pathologies. It would be more logical, and indeed more productive, to adopt a horizontalapproach where the main pathologies would be targeted in a succession o stages: rominormation and sensitisation (prevention), to screening, early diagnosis, and eventually teamtreatment with various health care proessionals involved in the particular disease on a platormbasis. Health care providers, with the right government support and structure, could thus workmore closely together to improve the coordination and access to health, and to ensure betterhealth outcomes. Todays parcelled out approach could thus make room or a continuum ocare which integrates the whole healthcare chain.

MEMO

10

CT shoulde and will beentral to theuture o Bel-ian healthcarerganisation,uch more so

han it is todaynd than currentovernmentrogrammesnvisage.


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According to the World Health Organization, the continuum o care oers a complete servicearray, rom hospital to home care, and requires all medical and social services within thecommunity to be brought together. The connection o all healthcare initiatives on all levels othe healthcare system is also part o the continuum o care. The patient thereore stands in thecentre o the health supply chain. For every patient and or every type o pathology, the mostadequate and available treatment is suggested. Not the protability or anyone level or actor,but the patients needs are the most important selection criterion when treatment is oered.Obviously, this implies more coordination and integration between the dierent healthcarelevels and healthcare services.

The distinction between a vertical and a horizontal approach to healthcare is not sacrosanct. There are, or instance, certainly issues o organisational complexity in raming a horizontal,disease and patient oriented approach. But what the above illustrates is the need or theBelgian healthcare organisation to reconsider both the individual role o the respective levelsor actors in healthcare organisation and the way they collaborate or ensuring optimal healthoutcomes with improved eciency. Is the division between GPs and specialists useul? Whatroles do mutual unds have to assume going orward? Should not the patient or the disease becentral to the process, rather than the institutional structure o health care? The current verticaldivision o healthcare organisation does not easily allow such reconsiderations, but on thecontrary reinorces conservative and interest group style reections (sot corporatism) at theexpense o eciency or health outcome. We need the reedom to reconsider the relevance

and purpose o the current institutional actors in the healthcare system i we are to preserve itshealthcare perormance or the uture.

3.4. Towards a real debate on a multiple pillar structure in healthcare?We have seen that:-While even today a large percentage o Belgian healthcare expenditure is already private;-Public healthcare expenditure in the uture will increasingly suer rom the gul between whatis required and what is aordable, as the Belgian repartition system meets the combinedchallenge o ageing and the exponential growth o healthcare demand.

This sober reality should orce us to recognize what is already a reality today and what willincreasingly become a necessity tomorrow, i.e. that healthcare unding is both a public and a

private aair. The solid policy approach is not to deny this combination but to conront it andhave a societal debate about the combination and organisation o both. The policy o denial,which is oten practiced today, oers no respite but instead allows private unding to developorganically in an unregulated market. This results in limited transparency, unlimited priceincreases, and a real two-speed society between those who can and those who cannot aordprivate insurance o some kind. I you are looking or the USA, do not look any urther.

The very sensitive debate about the limits o public health care provision needs to be broughtinto the open. It is currently hidden behind the closed doors o administration and a mass oad hoc decisions on public unding. It will, o course, be a very dicult and sensitive debate.

The limits o public health care provision will have to be determined, not on ad hoc basis buton a undamental and principled societal basis. The role and responsibility o various actors

will have to be (re-)dened, since we would have to organize additional pillars o healthcare unding by recalibrating the responsibilities o citizens, employers, insurers and mutualunds. In the same vein, patient responsibility would have to be constructed and organized,implying a variety o ethical questions on the limits o solidarity and the scope o personalresponsibility.

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The debate will thus undoubtedly be dicult, but at the same time cathartic. It will allow usto rationalize and democratize the vagaries o currently ad hoc budgetary decisions. It willallow us to streamline and organize a market or private insurance, ensuring due attention tocoverage o the poor and the ill. It will allow us to set ethical rules o personal conduct andresponsibility, making the residual solidarity airer and more deensible. And, as emphasizedabove, it will allow us to liberate the unds necessary or our inexorable and ortunate evolutiontowards a healthcare economy. The alternative is political meandering, ethical distortion, andbudgetary scarcity. Multiple pillars o healthcare nancing will be inevitable and necessaryi Belgium wants to maintain, not only a high level healthcare system but also a air and just

healthcare system.

ConclusionThe traditional public rhetoric leads Belgians to believe that theirs is one o the best healthcaresystems in the world. The accolade may or may not be true. What is certainly alse, however, isthe common political conclusion that the only debate should be about how much public moneyis poured into the system. This political mantra, which has dominated Belgian healthcarepolicy or the past quarter o a century, is untenable i we are to successully conront the twinchallenges o ageing and increased healthcare demand in the 21st century. These challengeswill be inevitably upon us or the coming decades. How can we meet them while maintainingthe real ortes o the Belgian healthcare system, i.e. quality and accessibility?

This short paper argues that we will certainly not meet the impending challenges i we ollowthe wholly unrealistic Brussels Consensus on the impact o ageing. We will nd ourselvesin a very uncomortable dead-end street i we do not succeed in adopting reorm policiesthat improve both health care unding and its perormance. The oundations o the Belgianhealthcare model quality combined with accessibility and choice are already graduallyeroding. Only by considering new avenues or its organisation and nancing will we be ableto sustain or uture generations the type o healthcare perormance we enjoy today.

We suggest three lines o thinking: increasing investments in ICT, improving coordinationand integration between the stakeholders o the healthcare system, and a real debate on amulti-pillar structure or the nancing o healthcare. These are nothing more than openings ordebate. The question is whether the political and institutional healthcare community in thiscountry, which is so mobilized by the day-to-day constraints and challenges, will be able to

entertain creative and undamental thinking in time. A healthcare system is like the proverbialtanker which turns ever so slowly but which consequently is equally hard to correct once it hasturned. Let us hope, or all our sakes, that the Belgian actors will turn in time.

MEMO

12

Multiple pillars healthcarenancing wille inevitablend necessary ielgium wantso maintain,

ot only a highvel healthcare

ystem but alsoair and justealthcare sys-m.


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REFERENCES

(1) Marc De Vos (Lic., LLM, Phd) is the Director o the Itinera Institute and a Proessor o labour and employment law

at Ghent University. Brieuc Van Damme (MA) is a ellow at the Itinera Institute and an independent consultant. The

Itinera Institute is an independent think-tank and do-tank or sustainable economic growth and social protection, or

Belgium and its regions: www.itinerainstitute.org

The authors thank Ivan Van de Cloot, chie economist o the Itinera Institute, or his input and constructive remarks.

However, the opinions expressed in this article engage only the authors.

(2) Daue, F. and Crainich, D., (2008). Hoe Gezond is de Gezondheidszorg in Belgi?, Itinera Institute Report, on-

line: http://www.itinerainstitute.org/upl/1/deault/doc/20080421_SWOT%20Deel%201%20NL_FVH_0.6.pd

(3) RIZIV/INAMI, (2007). Statistieken van de geneeskundige verzorging, online: http://www.inami.gov.be/inormation/nl/statistics/health/2007/pd/statisticshealth2007all.pd

(4) This calculus includes under also social security the public sector pensions, early retirements, and other social

expenditure. From a more restrictive perspective, the share o healthcare is thus even bigger.

(5) Studiecommissie voor de Vergrijzing, (2008). Jaarlijks Verslag, online: http://docun.gov.be/intersalgnl/

hrcs/adviezen/PDF/vergrijzing_2008_06.pd.

Studiecommissie voor de Vergrijzing, (2002). Jaarlijks Verslag, online: http://www.plan.be/admin/

uploaded/200605091448049.OPVERG200201r.pd

(6) F. Daue and D. Crainich, Hoe gezond is de Belgische gezondheidszorg?, supra, note 3.

(7) RIZIV/INAMI, (2007). Statistieken van de geneeskundige verzorging, online: http://www.inami.gov.be/

inormation/nl/statistics/health/2007/pd/statisticshealth2007all.pd

(8) RIZIV/INAMI, (1999). Statistieken van de geneeskundige verzorging, online: http://www.riziv.gov.be/

inormation/nl/statistics/health/1999/pd/statisticshealth1999.pd OESO, (2007). Health at a Glance 2007,OECD Indicators.

(9) Hall, R. and Jones, C., (2007). The Value o Lie and the Rise in Health Spending, The Quarterly Journal

o Economics, Vol. 122, nr. 1, p. 39 72, online: http://www.mitpressjournals.org/doi/pd/10.1162/

qjec.122.1.39

(10) CEA Insurers o Europe, (2008). The European Health Insurance Market in 2006, CEA Statistics, nr. 35,

online:http://www.cea.assur.org/uploads/DocumentsLibrary/documents/1218202930_european-health-

insurance-2006.pd

(11) Gro Harlem Brundtland, Director-General, World Health Organization, 1999, cited in WHO, (2002). Active

Ageing, a policy ramework, A contribution o the World Health Organization to the Second United Nations World

Assembly on Ageing, Madrid, Spain, April 2002, online: http://whqlibdoc.who.int/hq/2002/WHO_NMH_

NPH_02.8.pd

(12) Presented by Jan Smets, Director o the NBB, on the CEDER study day Aan de slag (blijven),

05/09/2008.(13) Van de Cloot, I., (2003). De Beheersbare Gezondheidszorg, Financile Berichten ING, Nr. 2390, p. 1 10; NBB, Jaarverslag 2003, p. 94-97. http://www.nbb.be/NR/rdonlyres/9C708875-6591-41C2-AFF0-

2E40BC1E1F33/0/JV2003T1_volledig.pd

(14) See, inter alia, Boston Consulting Croup, (2007). Health Care Regulation Across Europe, From Funding Crisis

to Productivity Imperative, on-line:

http://www.bcg.com/impact_expertise/publications/les/HealthCare_Regulation_Europe_Sept_2007.pd

(15) Studiecommissie voor de Vergrijzing, (2002). Jaarlijks Verslag, online: http://www.plan.be/admin/

uploaded/200605091448049.OPVERG200201r.pd

(16) Getzen, T., (2008). Modeling Long Term Healthcare Cost Trends, Research Projects in Health, the Society o

Actuaries, online: http://www.soa.org/research/health/research-hlthcare-trends.aspx

(17) De Vos, M., (2008). Doorbreek de cijerban van de vergrijzing, Itinera Institute Nota, on-line: http://

www.itinerainstitute.org/upl/1/deault/doc/20080708%20-%20Nota%2028%20-%20Doorbreek%20de%20cijerban%20van%20de%20vergrijzing%20-%20MDV.pd

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(18) Gruescu, S., (2007). Population Ageing and Economic Growth, Contributions to Economics, Springer

publishing.

(19) In Federal Public Service Finance, (2008). Belgiums Stability Programme (2008 2011), online: http://

stabiliteitsprogramma.be/en/Stabilityprogramme_2008_2011_Belgium_Cabinet_Finances_20080418_EN.pd

(20) The interested reader can nd ood or thought on these in F. Daue and D. Crainich, Hoe gezond is de

Belgische gezondheidszorg, note 3 above.

(21) Radio Frequency Identication, is an automatic identication method, relying on storing and remotely retrieving

data using devices called RFID tags or transponders.

(22) Chaudry, P. et al., (2006). Systematic Review: Impact o Health Inormation Technology on Quality, Eciency,

and Costs o Medical Care, Annals o Internal Medicine, Vol. 144, Nr. 10, p. E12 E22.

(23) Hillestad, R., et al., (2005). Can electronic medical record systems transorm health care? Potential healthbenets, savings, and costs, Health Aairs, Vol. 24, nr. 5, p. 1103 1117.

(24) An electronic health record (EHR) reers to an individual patients medical record in digital ormat. Electronic

health record systems co-ordinate the storage and retrieval o individual records with the aid o computers.

MEMO

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