Belgian Former Minister of Social Affairs, Public Health and Asylum & Migration Maggie de Block outlines some of the key reforms her Ministry has rolled out since she took office in 2014 and the urgent changes to Belgian healthcare that still need to take place.
Along with the Netherlands, Luxembourg, Austria, and Ireland, we collaborate in the four topics of health technology assessment, information exchange, joint negotiations with the industry, and horizon scanning
In 2015 healthcare spending accounted for 10.5 percent of Belgium’s GDP – above the EU average of 9.9 percent – making sustainability a critical topic of discussion. What do you see as the necessary steps which must be taken to ensure the system remains sustainable?
Sustainability is absolutely a big challenge which is why we made a priority for much-needed structural reforms such as in hospitals. However, I would first like to stress that this challenge is actually a positive development which we owe to better technologies, diagnosis, and treatment options that have become available. While these innovations are expensive, no one would want to turn back the clock. As healthcare stakeholders, if we can help a patient, we must do it, and it is up to all those involved to do so sustainably.
In the meantime, we are taking steps to keep healthcare affordable for both the government and the patient. For example, the reorganization of the hospital landscape and the modernization of the partnership model between the government and the pharmaceutical industry with the 2015 Pact for the Future have been essential tools in creating a more sustainable system. Additionally, we took structural measures in the off-patent segment to keep the medicine budget under control through a patent cliff, ceiling prices, volume cliff, incentives to improve the uptake of biosimilars, and promotion of cheap prescribing.
Furthermore, another important action was the BeNeLuxA initiative, an international cooperation that aims to ensure sustainable access to innovative medicine at an affordable cost for our patients. Along with the Netherlands, Luxembourg, Austria, and Ireland, we collaborate in the four topics of health technology assessment, information exchange, joint negotiations with the industry, and horizon scanning. Through this last pillar we are taking a joint look towards the future and looking out for developments that could have a major impact on a country’s healthcare policy. This collaboration element resulted in a ‘spin-off’ International Horizon Scanning Initiative, in which currently nine countries are participating.
What have been the major implications of the program to reorganize the Belgian hospital landscape and reform the financing of hospitals that you first enacted in 2014?
Care in close vicinity does not always equate to quality. Good care means care in the right place, at the right time, and by the right care providers. How can we guarantee that to the patient? Not by offering every possible treatment in every hospital. On the contrary, this can even be detrimental to quality.
By law we have determined there will be a maximum of 25 hospital networks in Belgium. A majority are already formed, others are now choosing their definitive partners and need to agree on the governance of the network and set up a legal entity. In addition to the hospital networks, we concentrated certain uncommon and complex medical procedures like oesophageal and pancreatic surgery. These are life-saving measures, yet patients were twice as likely to die from complications in a centre with little expertise than in a centre that performs 20 or more operations per year. Similarly, we have concentrated interventional stroke care in 15 hospitals that act as centres of excellence. Moreover, pilot projects on home hospitalization and shorter maternity unit stays have been completed and received positive reactions. The next step is now to transform these experiences into structural measures.
Since the beginning of 2019, 54 standard hospital interventions are being reimbursed in the same way throughout Belgium. This makes the financing more predictable and therefore more manageable. At the same time, patients receive a transparent invoice and undergo fewer unnecessary examinations.
We have taken crucial steps but of course, it cannot stop here. We must continue moving further down that road as such major reforms don’t happen overnight. Each step requires consultation with numerous stakeholders. Many components required extra study work by the Belgian Healthcare Knowledge Centre. For example, clustering patient groups in low, medium and high-variable care groups, organization of maternities, emergency care, and an ongoing organization of paediatrics.
The hospitals come from a period in which many activities made them stronger, more attractive to their patients and provided them with a larger share of the budgets. Their former competitors now become their partners in their network, with whom they decide together who will offer which care. Everyone is realizing that the traditional competitive model is no longer tenable and that we have to make decisions based on hard facts.
For example, must every hospital be equipped with every – and often very expensive – kind – of equipment. But is not just a matter of efficiency, the patient must get access to the best possible care. And as mentioned before: complex care requires expertise. That is why we need to concentrate on certain procedures
Each hospital will retain its identity. It is not intended to create 25 mega-hospitals. The networks that have a bright future will be those that evolve into collaborations between hospitals that trust each other, having a common goal of offering quality care to the citizens of the region and are able to develop the right strategy for this. We must continue to think about how we can better use the resources deployed. We must strive for better care with more hands around the bed. That is the ultimate goal of my reform plan: to give every Belgian patient the guarantee of even better care.
Five years ago, a Pact for the Future with the pharmaceutical industry was signed to address the factors of accessibility, growth and innovation, deontology and budgetary sustainability and predictability. To what extent was the pact successful in reaching its initial goals and what other possibilities exist for collaboration with the industry to ensure continued access in the face of rising innovation costs?
First of all, the pact was successful in the sense that we initiated the dialogue with the industry through a way of working that proved to be much more constructive than confrontations in the media. We realized many important achievements thanks to the pact and there are countries taking Belgium as an example to make their own pact for the future in the interest of their citizens. Thanks in part to the pact, we were able to save EUR 1.1 billion on medicines, especially in the off-patent market. This has allowed us to make additional investments in new treatments for patients.
Furthermore, Belgian patients have quicker access to innovative treatments like immunotherapy, pediatric indications, and Hepatitis C medications thanks to regulatory fast-tracking. We developed a more predictable manner to reimburse an extension of indication with a transparent decision tree. We promoted the prescription of cheap drugs with ceiling price and by increasing the quota for physicians. Finally, I want to highlight the improved environment for innovation and growth by making the Belgian healthcare environment more attractive for clinical trials as they are the earliest access for patients to innovation.
Concerning the budget, in addition to the number of measures in the off-patent segment to creating savings, we agreed with the sector on a yearly average budget growth of 0.5 percent to deliver stability and predictability. However, this does not cover all needs. Many innovations reached the market faster than we expected which required an additional investment of approximately EUR 200 million in the medicines budget in 2019, specifically in oncology.
This brings me to a next pact as we are confronted with more advanced treatment options high price tags while our resources are limited. This is a responsibility of all stakeholders to examine how to align innovative medicines with real unmet medical needs of our patients, hence the importance of horizon scanning. Additionally, the National Institute for Health and Disability Insurance (NIHDI) is examining new ways to reimburse expensive innovative treatments and the uptake of biosimilar medicines. Finally, we should also reflect on how our country can keep attracting biotech companies.
One of the main principles in my policy is ‘evidence-based’, comparable to the principle of value-based healthcare. It should be the main decision-making criterium in healthcare, together with patient centricity. However, we will continue to be confronted with rising costs in healthcare as the share of the population contributing to our social security system is decreasing while the group that benefits from our social security is expanding due to ageing. Therefore, we need to reinforce the economic basis of our social security system and that means jobs, jobs, and jobs.
Healthcare systems around the world, including in Belgium, have begun a major push forward to embrace the digitalization wave. What major challenges is Belgium facing in the implementation of eHealth programs and what solutions do you see as necessary for a strong adoption of capabilities in this area?
Belgium has an enormous wealth of digital data: general data, data about reimbursements, genetic databanks, diagnostic data and so on. The possibilities and ideas exist to become a new “mining” country. Unfortunately, all the data is very decentralized. If we could combine all this data, we could find new solutions and improve current ones. We need to unlock our health data in a streamlined fashion in order to optimize our healthcare.
Obviously, it is not desirable that all existing real-world evidence data collected in health organisations are used for such smart systems. With privacy being the top concern of citizens, it is necessary to explain the added value of data for our society and how it is a form of responsible citizenship. However, we should never collect real-world evidence data without informed consent for scientific research or optimal screening programs.
What is the scope of the eHealth 2019-2021 Action Plan initiated last year?
The eHealth 2019-2021 Action Plan pays particular attention to infrastructure and support. We want to keep improving the accessibility and user-friendliness of eHealth for healthcare providers and patients. With the “MyHealth” portal, we have already reached many citizens and thanks to the openness and transparency of the platform, various areas for improvement have come to light. This ultimately leads to a high quality-awareness of all partners and stakeholders; involving citizens always leads to better personal healthcare.
When you spoke at the European Cancer Form at the end of January, you delivered a powerful message of hope regarding the European-wide Beating Cancer Plan. What expectations do you have for this initiative and what will be the key factors that will define success for the Beating Cancer Plan?
The European Cancer Plan needs to take into account that some member states already made important investments. France implemented two nationwide cancer plans. And our country has also invested substantially in its cancer plan over the past decade. The measures with the highest added value are those that immediately impact patients and improve quality of life. This is what we need to focus on: investing in access to new therapies, offering patients a cardio-oncology rehabilitation plan, supporting initiatives to return to work, cost-free onco-freezing, providing high expertise reference centres, etc.
Claiming that we will exterminate cancer as a disease would be too populist. Nevertheless, we must strive to cure as many cancers as possible in a sustainable way. Therefore, it is essential that the plan be realistic, tangible and pragmatic. As a first step, we should reinforce screening as the earlier a cancer is detected, the better the chance of cure and survival. Now that more people are surviving cancer, we should focus on survivorship and quality of life after cancer as well. We need to do whatever we reasonably can in order to guarantee the highest quality of life possible.
What do you see as the areas of expertise or best practices that Belgium can share with its fellow member states?
Firstly, it was important, and I believe Belgium should be proud of this, to give the patient access to immunotherapy. Our country’s healthcare policy and scientists were pioneers in making this therapeutic option accessible to the patient. Moreover, we decided to speed up the reimbursement procedure, meaning authorization by the European Medicines Agency (EMA) equals reimbursement and the results are overwhelming. Calculations by professor Lieven Annemans of Ghent University demonstrated that fast-tracking resulted in more than 9.700 quality-adjusted life years (QALY) gained, whereas the classic procedure would have gained only 5.900 QALY. In other words, patients live longer, and they have a better quality of life.
As previously discussed, our innovative pharmaceutical policy with the Pact for the Future led to the reimbursement of 33 new orphan drugs in the last five years, more than half involving cancer treatment.
Finally and equally important, is the reimbursement of next-generation sequencing (NGS) diagnostic tests. By detecting tumour mutations, we can determine which drugs will work, leading to more effective use of drugs. Similar is the reimbursement of gene expression profiling tests like Mammaprint or Oncotype Dx that rule out whether women can benefit from chemotherapy, avoiding side effects of a needless therapy. An extra benefit is that the corresponding healthcare budget can be spent in a more useful way.
You have held ministerial responsibility for health and social affairs for nearly six years. What do you hope your legacy will be as Belgium’s Minister of Social Affairs, Public Health and Asylum & Migration?
I feel that I have implemented policies that have been spoken about for the last 20 years since I first entered parliament in 1999. At this time the conversation was already being had about finding new ways to treat our patients, creating more hospital collaboration, foster prevention and early diagnosis, embracing digitalization, and other many topics. I have been working on not only accessibility, but the quality of care for our citizens, and affordability and accountability.
As a general practitioner myself, I understand we are working with the money of citizens who are contributing through taxes. Therefore, we have a responsibility to act strategically and not create waste. This was faced with resistance as many professionals were not used to this mindset, but for the future of patients, we must keep sustainability in mind.
When I look at my career up until now, it has been a bit of a tornado in our healthcare system – something I am very proud of. In politics, there is only one opportunity to make the major reforms which are necessary but not always met with such ease. This was my window of opportunity and I wanted to take it full force. To sit idle and happy with just the title of Minister is not enough for me – I wanted to step up to make the changes that Belgium needs.