The Belgian chess game: Will the rules be modified?
The last 12 months have been punctuated by many political statements about cardiac medical care in Belgium.
Moreover, some of these allegations have created confusion in public opinion about the practice of cardiologists and cardiac surgeons. It has been necessary to inform officially politicians and the media that cardiac surgery requires more than just 15 minutes and to remind them that our rewards are justified by financing of wider technical and staff structures. We have also had to introduce cardiac surgeons into many professional committees and several national advisory boards to defend our interests. So, nowadays, little by little authorities are accepting the vision of a “homo cardio chirurgicus” technically independent of cardiologists, but so much dependent on them for patients.
For many years, private cardiologist lobbies driven by scientific arguments have been struggling for PCI agreement anywhere in Belgium allowing the population fast and equal access to revascularization in acute coronary syndromes.
Nevertheless, in December 2004 both BACTS and the Belgian Cardiology Association informed the authorities that legal links between surgery and interventional cardiology must be maintained in future new requirements. Today we are still stressing that this prevents any risk of over consumption leading to reduced quality and increased cost. This option has always been criticized in our country and even abroad, but today, many of us admit that Belgian laws anticipated the world scientific community’s position. Indeed an STS - AATS - American Heart Association joint statement was published in JTCS last May. It formulated guidelines for the development of percutaneous heart valve technology. Close collaboration between surgeons and cardiologists is required for indications, procedures and follow up.
Currently, several rumors are circulating about new law proposals on cardiac centers in Belgium. Today, the situation seems confused because of numerous conflicts of interest between practitioners’ common sense and hospital managers’ objectives. Furthermore, local opportunist considerations often exceed scientific or economic grounds. The government, mainly concerned about the health care economy and worried by some community pressure, is studying a logical plan and will soon promulgate a new Royal Decree.
The Health Minister’s view on this sticky issue is clear.
He appears very motivated to achieve his aims for the organization of high technology medicine. His laudable strategy is as follows:
- To maintain or improve quality of care.
- To ensure the population “social” and “geographic” access to modern health care.
- To provide on the same site the complete range of technology for any kind of treatment thus preventing useless or dangerous transfers.
- To stop hospitals racing for high tech medical structures allowing them to acquire additional equipment.
- To take decisions for durable and sustainable options.
- To convince the population to go further for better and more complete treatment.
In other words, all B1 centers will be closed in the near future.
Subgroups B2 and B3 will not exist anymore. Only restricted and approved cardiac centers will exist in which assessment, interventional cardiology and surgery will be performed in an integrated structure. Therefore, these new centers will be spread over Belgium allowing the entire population fast access to cath lab in less than 90 minutes, according to international guidelines. Since the introduction of our welfare state policy, health care has had to remain accessible regardless of social conditions, but new additional laws on financial sources for hospitals must be voted.
New minimal and controversial criteria for centers are still being debated and some new logical proposals were formulated last June. They guarantee sufficient workload, high quality and enhanced cost effectiveness:
- Diagnostic, interventional therapy and surgery located on the same site.
- A total of 650 cases must be treated every year: these will be made up of 400 angioplasties and 250 operative cases.
The support provided by more active hospitals to less active remote structures will no longer be allowed, and extra regional or extra community coverage for new centers is recommended. - These procedures must be performed by three cath lab cardiologists and by two approved surgeons.
Only one surgeon must be full time in the new structure. - However, any new center implantation needs prior approval from neighbouring partners.
- A new concept of specific health care areas is appearing and will soon modify the law on hospital mergers.
They are defined as workload zones where every high tech medicine must be combined on same approved centers. According to Minister’s staff simulations, the target population for each center could be of 375.000, 350.000 and 250.000 inhabitants respectively in the North, in the south and in Brussels.
This is an ongoing process and under special executive power, time is now running out for authorities. The pending question is not HOW or WHY it must be applied but WHEN! Probably within the next 3 years for complete application and in the forthcoming months for the B1 closure announcement. This last proposal is currently under State Council examination and it’s seems to be nearly approved.
As president of a scientific association, I tend to support these new proposals so long as there are no additional centers. On the other hand, I strongly believe that we have to promote association between less active hospitals and so create new structures regardless of political or philosophical considerations. We also have to accept potential repositioning on the Belgian chessboard.
From our specific point of view, it’s obvious that our specialty could be threatened by PCI progress and by lack of multidisciplinary discussion in cardiac health care. We are not the gate keepers! We have to struggle for integrated cardio-surgical structures sharing means, expenses and incomes.
The current depressive atmosphere in many cardio surgical circles forces us to re-evaluate our position in hospitals. It’s now time to learn how to deal with less invasive techniques or to share our inestimable skills for new cardio surgical perspectives in operating theatres or in cath labs.
Thoracic surgeons will also in the near future undergo the same revolution and, today, they have to prepare themselves for upcoming pulmonary oncology programs.
The time for corporatism is gone. Now begins an era of friendly collaboration and partnership respecting each other with our own specificities.
Yes, dear members, the rules will change, but it will also be another game!
Get ready!
Thank you for your attention.
Brussels, 19 November 2005