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Table of Contents
                            KCE reports 80A
	Evaluatie van de effecten vande maximumfactuur op deconsumptie en financiëletoegankelijkheid vangezondheidszorg
		VOORWOORD
		Samenvatting
			INLEIDING
			DE WERKING VAN DE MAF ALS SOCIAALBESCHERMINGSMECHANISME: DE TOESTAND IN2004
			VERANDERT DE MAF HET GEDRAG VANPATIËNTEN EN ZORGVERLENERS?
			DE EFFECTEN VAN DE BELEIDSMAATREGELENSINDS 2004
			MOGELIJKE WIJZIGINGEN IN DE STRUCTUUR VANDE MAF: KEUZES EN MOGELIJKHEDEN
			AANBEVELINGEN
		Scientific Summary
			Table of contents
			1 INTRODUCTION
			2 THE MAB IN THE CONTEXT OF THEBELGIAN HEALTH INSURANCE SYSTEM
			3 DESCRIPTION OF THE DATA
			4 EFFECTIVENESS OF THE MAB AS A SOCIALPROTECTION MECHANISM: A DESCRIPTIVEANALYSIS
			5 DOES THE MAB CHANGE CONSUMPTIONBEHAVIOUR?
			6 IMPROVING THE SYSTEM? THE EFFECTS OFTHE POLICY MEASURES SINCE 2004
			7 THE MAB AND THE STRUCTURE OFSOCIAL PROTECTION
			8 GENERAL CONCLUSION
			9 REFERENCES
                        
Document Text Contents
Page 1

Evaluatie van de effecten van de
maximumfactuur op de consumptie en

financiële toegankelijkheid van
gezondheidszorg




KCE reports 80A

















Federaal Kenniscentrum voor de Gezondheidszorg
Centre fédéral d’expertise des soins de santé

2008

Page 2

Het Federaal Kenniscentrum voor de Gezondheidszorg

Voorstelling : Het Federaal Kenniscentrum voor de Gezondheidszorg is een
parastatale, opgericht door de programma-wet van 24 december 2002
(artikelen 262 tot 266) die onder de bevoegdheid valt van de Minister
van Volksgezondheid en Sociale Zaken. Het Centrum is belast met het
realiseren van beleidsondersteunende studies binnen de sector van de
gezondheidszorg en de ziekteverzekering.

Raad van Bestuur

Effectieve leden : Gillet Pierre (Voorzitter), Cuypers Dirk (Ondervoorzitter),
Avontroodt Yolande, De Cock Jo (Ondervoorzitter), De Meyere
Frank, De Ridder Henri, Gillet Jean-Bernard, Godin Jean-Noël, Goyens
Floris, Kesteloot Katrien, Maes Jef, Mertens Pascal, Mertens Raf,
Moens Marc, Perl François, Smiets Pierre, Van Massenhove Frank,
Vandermeeren Philippe, Verertbruggen Patrick, Vermeyen Karel.

Plaatsvervangers : Annemans Lieven, Bertels Jan, Collin Benoît, Cuypers Rita, Decoster
Christiaan, Dercq Jean-Paul, Désir Daniel, Laasman Jean-Marc, Lemye
Roland, Morel Amanda, Palsterman Paul, Ponce Annick, Remacle Anne,
Schrooten Renaat, Vanderstappen Anne.

Regeringscommissaris : Roger Yves

Directie

Algemeen Directeur : Dirk Ramaekers

Adjunct-Algemeen Directeur : Jean-Pierre Closon

Contact

Federaal Kenniscentrum voor de Gezondheidszorg (KCE)
Wetstraat 62
B-1040 Brussel
Belgium

Tel: +32 [0]2 287 33 88
Fax: +32 [0]2 287 33 85

Email : [email protected]
Web : http://www.kce.fgov.be

Page 96

80 Maximum Billing KCE reports 80

On the one hand, as argued before, Figure 21 can only be a rough approximation, since
it seems unrealistic to assume that the individual patients are fully aware of the amount
of co-payments they have paid in the past. On the other hand, applying the date of
notification is probably an exaggeration in the other direction, as it implies that patients
are totally ignorant about the magnitude of their co-payments unless they are informed
by their mutuality. In fact, if we favour the latter option and we apply the estimated
delay of 4-5 months to the distribution sketched in Figure 21 (as is acceptable when the
reporting errors are indeed random), the scope for myopic behaviour in 2004 would be
extremely small indeed. In the next subsection, we will combine the information from
both approaches.mmm

5.2 TRACING SIGNS OF MYOPIC OR RATIONAL BEHAVIOUR?
Let us now see whether there is a change in consumption after reaching the (social or
income) MAB-ceilings. By way of introduction, Table 17 gives yearly spending in the
different categories for different groups of households.nnn Not surprisingly (and almost
by definition), households that exceed the MAB-ceiling during the year have larger
expenditures. Those who exceed the MAB-ceiling and are notified about that within
2004 have even larger expenditures. In fact, given the delay between exceeding and
notification, these are households that have reached the MAB-ceiling earlier in the
year.ooo A simple comparison of expenditures as in Table 17 therefore does not teach
us anything about possible behavioural effects.

Table 17. Average yearly household expenditures (€)
full sample MAB not

exceeded
MAB
exceeded

exceeded,
not notified

exceeded,
notified

N 255 497


228 390


27 107


19 478


7 629


ZIV-expenditures 2 922.04 2 190.25 10 600.06 9 962.9 12 316.19
co-payments 366.34 302.25 1 038.78 959.54 1 252.21

co-payments in MAB 337.19 276.32 975.92 898.29 1 185.01
co-payments not in MAB 29.52 25.93 67.15 61.63 82.04
supplements 146.93 113.88 493.64 487.40 510.46
OOP-payments after
MAB

473.53 414.10 1 097.12 1 094.62 1 103.84

A better insight into the relevancy of the hypothesis of myopic behaviour can be gained
by comparing the consumption behaviour of the households before and after they have
reached the MAB-ceiling. We will discuss such an exercise in the first subsection. As
described before, however, there can be an effect of the MAB on behaviour, even if we
do not observe a clear difference between consumption before and after reaching the
ceiling. This is possible if “rational” households anticipate that they might reach the
ceiling in the course of the year. To get some idea about the relevancy of this
assumption, we focus in the second subsection on the group of the chronically ill.


mmm As the number of patients for which the date of knowing comes before the date of exceeding

on the basis of summing co-payments, is limited, we did not delete them from the sample.
nnn The numbers of observations in this and the following tables are unweighted. This gives a better idea

about the size of the sample on which we base our conclusions. The amounts are weighted, however.
ooo This is not in contradiction with our finding of random reporting errors. That involved a comparison

between the group of patients that had been informed (at whatever moment) and the group that had not
been informed. In Table 17, however, we focus on the group that has been notified in 2004.

Page 97

KCE Reports 80 Maximum Billing 81

5.2.1 Myopic adjustment of behaviour?
In Table 18, we draw a comparison between the average monthly per capita
expenditures before and after reaching the MAB-ceiling.ppp In the light of the discussion
in the previous section, we calculated four different versions. First, we consider all the
households that exceeded the MAB-ceiling through summing co-payments – “before”
and “after” then refer to the moment of exceeding the ceiling. Second, we split the first
sample in two groups: (1) those families that already know in 2004 that the MAB has
been exceeded; and (2) those that do not know within 2004 that the MAB is exceeded.
Again, “before” and “after” refer to the moment of exceeding the ceiling. Lastly, we
calculate average per capita expenses before and after the month in which the MAB-
household knows that it exceeded the MAB-ceiling. In each case, “before” and “after”
average per capita expenditures have been calculated through summing co-payments.

Table 18. Average monthly (per capita) expenditures before and after
reaching the MAB-ceiling

Variable N Mean (€) 95% Confidence limit

Exceeded MAB (all)
co-payments before 26 707 51.58 50.79 52.36
co-payments after 24 311 53.15 52.24 54.06
ZIV-expenditures before 26 707 564.67 551.04 578.29
ZIV-expenditures after 24 311 523.50 512.42 534.58
supplements before 26 707 28.07 26.31 29.83
supplements after 24 311 23.86 22.36 25.36
Exceeded MAB + knowing in 2004
co-payments before 7 459 67.95 66.07 69.82
co-payments after 7 549 55.68 54.13 57.23
ZIV-expenditures before 7 459 675.12 647.21 703.03
ZIV-expenditures after 7 549 543.16 524.75 561.57
supplements before 7 459 36.25 31.72 40.79
supplements after 7 549 18.68 16.86 20.51
Exceeded MAB + not knowing
co-payments before 19 248 45.60 44.80 46.39
co-payments after 16 762 52.08 50.97 53.18
ZIV-expenditures before 19 248 524.34 508.85 539.83
ZIV-expenditures after 16 762 515.14 501.43 528.86
supplements before 19 248 25.08 23.34 26.83
supplements after 16 762 26.05 24.06 28.05
Exceeded MAB + knowing in 2004; means before/after being notified
co-payments before being notified 7 627 69.08 67.47 70.70
co-payments after being notified 6 134 51.18 49.25 53.11
ZIV-expenditures before being notified 7 627 650.89 630.56 671.23
ZIV-expenditures after being notified 6 134 493.52 470.28 516.76
supplements before being notified 7 627 31.79 29.34 34.24
supplements after being notified 6 134 16.54 13.30 19.77

The picture that comes out of the Table is clear. Co-payments after having reached the
ceiling are significantly higher for only one subgroup, namely those that exceeded the
MAB-ceiling but are not notified within 2004.


ppp We show per capita expenditures, because it turns out that households exceeding the MAB are larger on

average. The conclusions do not change when using total household expenditures. The expenditures
made in the month of exceeding the MAB are not counted in the calculations, as we do not know the
exact date of exceeding. The “before” and “after” expenditures cannot be calculated if the moment of
exceeding (or being notified) is January or December. Leaving out these months does not change the
results.

Page 191

76. Kwaliteitsbevordering in de huisartsenpraktijk in België: status quo of quo vadis?
D/2008/10.273/18.

77. Orthodontie bij kinderen en adolescenten. D/2008/10.273/20.
78. Richtlijnen voor farmaco-economische evaluaties in België. D/2008/10.273/23.
79. Terugbetaling van radioisotopen in België. D/2008/10.273/26
80. Evaluatie van de effecten van de maximumfactuur op de consumptie en financiële

toegankelijkheid van gezondheidszorg. D/2008/10.273/35.

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