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Chronic diseases : impact European priorities – Belgian presidency 1.07 - 31.12.2010 Bukarest 23.09.2010. Dr Jan Van Emelen (MLOZ, Independant Health Insurance Funds - Belgium ). Agenda. Chapter 1 : chronic diseases - impact & management Introduction The global problem

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dr jan van emelen mloz independant health insurance funds belgium

Chronic diseases : impact

European priorities – Belgian presidency 1.07 - 31.12.2010

Bukarest 23.09.2010

Dr Jan Van Emelen (MLOZ, Independant Health Insurance Funds - Belgium)

  • Chapter 1 : chronicdiseases - impact & management
    • Introduction
    • The globalproblem
    • Chronicdiseases : impact & management
    • Belgiancas of DMC
  • Chapter 2 : Eu prioritiesBelgianpresidency

1. Introduction : AIM : international association

An international association

for universal principles



41 national federations

27 countries worldwide

Europe, Middle-East, Africa, Latin-America


Healthcare financing

Healthcare provision

Social services, pensions

For 240 mln citizens

Values and principles

Health and well-being

Autonomous management

Not-for-profit orientation



Interest representation

Knowledge exchange



the new role of healthcare mutuals
The New Role of Healthcare Mutuals

Director of healthcare

Director of care

Steering capacity


and Provider

Payer and provider

Pay office

Engagement in healthcare management

decentralize towards personal health
Decentralize towards personal health


Independent, Healthy Living

Community Clinic

Chronic DiseaseManagement

Doctor’s Office


Assisted Living

Acute Care

Skilled Nursing Facility

Specialty Clinic

Community Hospital


Qualityof Life






Cost of Care / Day

Cost of Care / Day


Source: Freely adapted from Intel (2007)

reimbursement principles
Reimbursement principles

Criteria of choice:

the quality of care

safety/risk management (risk of malpractice)

collaborative health care processes

improved time/healthcare

the access to care

the economic efficiency of care.

  • Founded in 1999, EHTEL (the European Health Telematics Association) is a pan European multi-stakeholder forum providing a leadership and networking platform for European corporate, institutional and individual actors dedicated to the betterment of healthcare delivery through eHealth.
2 the global problem
2. The Global Problem

Econoshock (G. Noels) - 6 events at the same moment




Energy crisis

Financial Crisis

Climate crisis

Result : dramatic change needed

lnnovation is a duty

in health
…in health

Chronic conditions leading cause of mortality and not well « managed»

Long Term care

Labor shortage

Budget restrictions

Quality and safety

More homecare instead of hospitalisation

Lack of coordination

IT is a catastrophe

Complementary insurances

Disease Management


Cost and longevity

UC Atlas of Global Inequality

3 chronic diseases impact
3. Chronic diseases : impact

Literature : European Observatory on Health Systems and Policies


Tackling chronic disease in Europe. Strategies, interventions and challenges - Reinhard Busse, Miriam Blümel, David Scheller-Kreinsen, Annette Zentner

Managing chronic conditions: Experience in eight countries - Ellen Nolte, Cécile Knai, Martin McKee


burden of chronic diseases r busse 2009 berlin tu
Burden of chronic diseases(R. Busse 2009 Berlin TU)

Chronic conditions and diseases are the leading cause of mortality and morbidity in Europe, and research suggests that complex conditions such as diabetesand depression will impose an even greater health burden in the future. It has been estimated that in 2005 77%of all Disabiliy-Adjusted-Life-Years (DALYs) and 86% of premature deaths in the WHO European region are related to non-communicable diseases. The condition expected to increase most dramatically is dementia.

Worldwide share of deaths by causes and countries within different World Bank income categories (2002)

Chronic diseaseis the major causeof death in allbut the poorestcountries!

cost benefits of chronic conditions
Cost & benefits of chronic conditions
  • A lot of uncertainty : further research needed
  • How to measure? Cost dimensions:
    • Cost of illness : direct, indirect, intangible costs
    • Micro economic level : income and spending, labour productivity and supply
    • Macro economic level : economic growth : quantifying negative impact of CD
  • Marc Suhrcke, Rachel A. Nugent, David Stuckler and Lorenzo Rocco for OxHA, (Oxford Health Alliance)
  • Ellen Nolte, Cécile Knai, Martin Mc Kee,
cost of illness
Cost of illness
  • Cost-of-illness: quantity of resources (in monetary terms) used to treat a disease as well as the size of the negative economic consequences of illness in terms of lost productivity to society or to a specific sector:
    • Direct : medical care
    • Indirect : loss of income
    • Intangible : pain, sickness
cost of chronic diseases
Cost of chronic diseases
  • The cost of chronic diseases and their risk factors – as measured by cost-of-illness studies – is significant and sizeable, ranging from 0.02% to 6.77% of a country’s GDP.
  • Relevant?
  • What about solutions? Integrated care needed : Disease management
integrated care
Integrated care
  • At patient level :
    • Empowerment of patient
    • Guaranteed service from birth to grave
  • At professional level :
    • continuity of care model : prevention, early detection, early treatment, treatment, palliative care.
    • Real implication in decisions
  • At organizational level : new financing, new organization
disease management programs
Disease Management Programs

Expected RESULTS :

  • Improving quality of life cost-effectively.
  • Cost containment

Expected COSTS :

  • Set up costs
  • Operating costs
  • Adverse selection costs
disease management key elements
Disease management: key elements
  • Comprehensive care: multidisciplinary care for entire disease cycle
  • Integrated care, care continuum, coordination of the different components
  • Population orientation (defined by a specific condition)
  • Active client–patient management tools (health education, empowerment, self-care)
  • Evidence-based guidelines, protocols, care pathways
  • Information technology, system solutions
  • Continuous quality improvement

Source: Velasco-Garrido, Busse and Hisashige 2003.

lessons learned nolte knai and mc kee
Lessons learned (Nolte, Knai and Mc Kee)
  • Coordination: in countries with multidisciplinar primary care : increasing role of nurses
  • Incentives: Independant primary care - DMP with financial and legal conditions, with incentives for insurers and providers.
how effective are disease management programmes
How effective are Disease Management Programmes?

Mattke et al. Am J Manag Care. 2007; 13: 670-676

methods for paying service provision
Methods for paying service provision
  • Fee for service
  • Pay for performance
  • Flat fee
  • Capitation system for chronic diseases

Payment systems can hinder implementation of new services.

costs of illness in belgium
Costs of illness in Belgium
  • Belgium : 10.4% of GDP spending on health care = 65% chronic diseases
  • Cardiac diseases : 8% of total health care costs
  • Fee for service
  • No coordination incentives
  • No incentives for DMP
change possible telemonitoring net benefit 2007
Change possible : Telemonitoring Net Benefit (2007)

NB! Based on pessimistic assumption: readmission avoidance = 0%

Readmission avoidance =10%

Break-even is achieved by

Readmission avoidance rate = 13%, or

Reduction in hospitalization by 2 days

IM3 Project (Irina Odnoletkova)


4 belgian case disease managament developed by mloz
4. Belgian case Disease Managamentdeveloped by MLOZ
  • Fee for service system, independant and competitive health care providers
  • Budgets: Vertical silos – co cooperation
  • 5 competitive Health Insurance Funds
  • Budget policy, no health policy
  • 4000 $ per caput
dm history in mloz independant health insurance funds
DM History in MLOZ Independant Health Insurance Funds
  • Complementary insurance : in 2005 platforms launched for chronic diseases (diabetes, obesitas) with specific reimbursements
  • Experiences :
    • HIF is not the optimal structure
    • Healthcare providers not involved
new initiative creation of dmc
New initiative : creation of DMC

New elements of care:

  • Enrolment system based on the risk stratification and the Evidence Based Practice Guidelines
  • Patient self management support tools
  • Providers support tools (IT based)
  • Process and outcomes measurement
  • Care plans development – integration/relation other initiatives
  • Individual Care plan management
  • Education/coaching/monitoring for each pathology and combined pathologies
  • Care plans IT support and maintenance
  • Promotion of care plans and IT support with physicians
  • Training of physicians in system use
  • Facilitating of medical telephone support to patients outsourcing with Home Care/Call centre’s
  • Data processing and analysis
  • System quality monitoring and care plans upgrading
  • Communication
how to start
How to start?
  • Creating trust with stakeholders – pilot project Care Television : implication of all partners : doctors, pharmacists, hospitals, nurses
  • Political consensus between 4 stakeholders on concept of DM : private governance, equal rights (50% HIF, 50% healthcare providers)
  • Support by IT companies
how to start1
How to start?
  • Financial incentives for stakeholders
  • Open and large consultation and large tenders
  • Concrete services :
    • Tele-education/coaching of chronic patients
    • Hospital service : pre- and post intervention management (coronary interventions)
    • PHR & Datamanagment
temporary consortium
Temporary Consortium
  • 4 founding partners : Independant and Neutral HIF, BVAS - Belgian Doctors association, Belgian Pharmacist Association
  • 4 supporting IT companies, financing consortium
ch 2 priorities in eu
Cross Border Care

Healthcare workforce in EU

Pharmaceutical package

Ageing and chronic diseases

Service Directive (Bolkestein) and social services of general importance

Europe 2020-strategy

A digital agenda for Europe

CH 2 . Priorities in EU
1 cross border care directive
1. Cross Border Care Directive
  • Aim: more legal support for mobile patient + more cooperation Member states
  • Content :
    • New rules for reimbursement
    • Responsabilities of each Member State : information on quality, safety and accessebility of services, procedure medical error
    • Creation National point of contact
    • Recognition of prescription
    • Creation of Reference network
    • Cooperation chronic diseases and HTA
texte of directive
Texte of Directive
  • 3 versions of Directive :
      • European Commission July 2008
      • Europ.Parliament: 1st reading April 2009
      • European Council : compromis June 2010
  • Belgian presidency : consensustext
  • Application : 2014
2 healtcare workforce
2. Healtcare Workforce
  • Common problem EU: shortage nurses
  • End 2008: Green book : public consultation
    • Need for EU initiative
    • Need ethical rules
    • Need HRM
  • Aim : concrete initiatives EU commission and member states.
3 pharmaceutical package
3. Pharmaceutical Package
  • 3 directives (propositions)
    • Information topatients
      • Direct toconsumer information
      • Critics : ethical? validation?
    • Pharmaceutical control
      • Falsifications
    • Pharmacovigilance
      • monitoring pharmaceuticals
      • Simplification of existingregulation
pharmaceutical package
Pharmaceutical Package
  • Change of competency
    • Before: DG industry
    • Now: DG SANCO (health)
  • Belgian Presidency:
    • Pharmacovigilance: vote EP on 22/09
    • Pharmaceutical control : BE compromise Parliament and council
    • Patient information: discussion continues
pharmaceutical package1
Pharmaceutical Package
  • Events:
    • Ministerial Conference « Innovation and solidarity on pharmaceuticals »
    • Conference «generics for sustainable health
      • 17/11, Brussels
    • European mobilisation day for correct use of antibiotics
      • 18/11, Brussels
4 ageing and chronic diseases
4. Ageing and chronic diseases
  • Priorities
    • Employment : keepingolderpeople at work : Europe 2020-strategy.
    • Chronicdiseases : prevention, special attention for Alzheimer anddemency. Strategic actionplan “Togetherfor health: a strategic approach for the EU 2008-2013”.
    • EU partnership Action against Cancer : Research, treatment andpalliative care, prevention.
    • Program AmbientAssisted Living : improvingquality of life of care dependentelderly (fall prevention, demention support)
    • Action plan againstsocialexclusionandpoverty.
    • Pensions :howtoguarantee pension system in silver EU. Green bookjuly 2010.

2012 = EU year of ageing

ageing chronic diseases
Ageing& chronic diseases
  • Belgianpresidency : 3 themestobehighlighted
      • Emplyomentolderworkers
      • Sustainability pension systems
      • Chronicdiseases – special Alzheimer

« workandageing society pact » - conclusions

      • new types of carrier planning
      • New white job creation
ageing and chronic diseases
Ageing and chronic diseases
  • Events:
    • ‘Innovative approaches forchronicillness in Public Health and Health care systems”

Interministerial conference 19 en 20/10, Brussels

    • Conference on demency ( MLOZ supported film – “Lost in the memory palace”.) Neurodegenerative diseases such as dementia will be back on the European agenda during the Belgian Presidency of the EU. The conference will follow on from the formal commitments made at European level to improve the treatment of these conditions.

25 en 26/11, Brussels



  • European Strategy for Chronic Conditions workshop (9 December 2010) One day open event will focus on the challenges faced by patients with chronic diseases. It will point out the specific burdens that chronics conditions put on patients, in comparison with other acute diseases; these burdens go beyond the commonly mentioned one financial impact.
  • 08-12-10 High Level Conference on monitoring and evalution of EU and MS strategies on nutrition, overweight and obesity
5 bolkestein directive services
5. Bolkestein Directive (Services)
  • Voted in 2006 – aim : free circulation of services The member states have to tackle the hurdles before December 2009.
  • 12 Member states not OK (tranposition)
  • Scope:
    • Excluded: healthcare, social security and justice. : de gezondheidszorg, niet economische diensten zoals sociale zekerheid en justitie.
    • Social services of general interest can be excluded is member state authority gives specific mandate..
    • HIF services and complementary insurances.
  • Evaluation of the application at the end of 2010
  • Events:
    • 3e Forum of social services of general interest
      • 26 and 27/10, Brussels
      • 2 themes :
        • Legal EU framework
        • Quality of services
    • Conference socialeconomy
      • 27 and 28/10, Brussels
      • Socialeconomy = 10 % of companies – 2 mio – 6% of total EU employment.
6 strategy 2020 after lisbon
6. Strategy 2020 (after Lisbon)
  • 5 stategic goals :
    • 75% of population 20-64 jaar at work;
    • 3% of EU GDP to invest in R&D in 2020;
    • "20/20/20"-climate and energy objectives.
    • Less than 10% premature school leavers and 40% of young population graduated at high school level.
    • Reduction poor population with 20 mio.
  • 3 axes:
    • Smart growth: accent on knowledge, innovation, education and digital society
    • Sustainable growth: improving competition, whith energy reduction in production processes
    • Growth for all: increase labour participation, better education, poverty reduction.
europe 2020
Europe 2020
  • Europe 2020 approaved top June 2010
  • In autumn 2010 member states should translate startegic objectives in national initiatives.
  • Methodology
    • Member States should review national (and regional) R&D and innovation systems, ensuring adequate and effective public investment, and orienting them towards higher growth while addressing major societal challenges (for example energy, resource efficiency, climate, change, social cohesion, ageing, health, and security).

Member States should also remove barriers to labour market entry for newcomers, support self-employment and job creation in areas including green employment and care and promote social innovation.

Social security and pension systems must be modernised to ensure that they can be fully deployed to ensure adequate income support and access to healthcare — thus providing social cohesion — whilst at the same time remaining financially sustainable.

Member States should also actively promote the social economy and social innovation in support of the most vulnerable.

strategy 2020
Strategy 2020
  • DG SANCO : this strategy has to reali!ze :
      • Innovative health services : e-prescription, tele-medecine, self-monitoring by patients, commonh health technology assessment.
      • Labour market: voldoende gezondheidswerkers en een betere werkomgeving voor deze beroepen
      • Sociale inclusion: new services supporting autonomous living elderly
7 a digital agenda for eu
7. A digital agenda for EU
  • A “digital revolution” before 2020.
  • Commissioner Kroes:
    • “We must speed up : our budgets and patients call for it. If we do not embrace e-Health, our healthcare systems will not stand the test of time.”
digital agenda for eu
Digital agenda for EU
  • 4 action lines for healthcare
    • Before 2015: safe acces to medical data and before 2020 generalized telemedecine.
    • Publication of a recommendation fixing minimal interoperabel medical data of health electronic record, accessible electronically between member states before 2012.
    • Before 2015 standards for EU, tests for interoperability and quality certification of e-healthcare systems.
    • Enhance the Ambient Assisted Living program in aiming autonomous living in society of elderly and handicapped
  • Safe and fast broadband connection, more efficient investments in R&D, improving e literacy..
digital agenda
Digital agenda
  • The Digital agenda is the first action plan that started in 2010.
  • Before end 2011 first evaluation on progress.
  • Increasing influence and impact of EU on healthcare systems
  • High consistency of several initiatives.
  • Not only social, also economic drives
    • Healthcare is a sector with innovation, growth and job creation.
  • New partnerships needed for cooperation

Foreign affairs specialist MLOZ

Christian Horemans


Innovation Director MLOZ

Dr. Jan Van Emelen