Belgium: €4.2B in Doctor Fees Could Go Directly to Hospitals

Belgian Health Minister Frank Vandenbroucke (Vooruit) is pushing forward with a major overhaul of hospital financing following the publication of a new report from the National Institute for Health and Disability Insurance (RIZIV). The report concludes that approximately €4.2 billion of the €12 billion in annual doctor honoraria currently serves to finance hospital practice costs—and could be redirected directly to hospitals, untangling what experts describe as a “complete tangle” of opaque financial flows.

The 35% Solution

The RIZIV report, published on June 29, proposes splitting doctor honoraria into two distinct components: 65% for intellectual and medical performance, and 35% for practice costs. Based on 2019 data—the last complete year before COVID-19—total practice costs were estimated at €4.797 billion. After accounting for €1.424 billion already covered by other financing channels, the remaining €3.373 billion (35%) is currently funded through doctor fees. Applied to today’s figures, that amounts to €4.2 billion, as HLN reported.

Crucially, the RIZIV note emphasizes that the 65/35 ratio is a macro-analysis of the total honorarium mass and does not apply uniformly to every medical discipline or procedure. Cost structures vary significantly—consultations involve primarily intellectual work with limited practice costs, while surgical and technical procedures require heavy equipment, operating theaters, and multidisciplinary support. The final split will be calculated per nomenclature code, not per discipline.

Untangling a Complex System

Belgian hospital financing has been described as a “complete tangle” for years. The system evolved such that doctors’ honoraria serve a dual purpose: compensating medical performance while simultaneously funding hospital infrastructure, personnel, and equipment through “afdrachten” (transfers) that doctors pay to hospitals from their fees. The amounts vary greatly between hospitals, creating incentives for over-performance, including unnecessary medical scans.

The De Wever government (Arizona coalition) committed to creating clarity by moving toward a “pure honorarium” for doctors, eliminating these opaque transfers. As De Morgen reported, the RIZIV’s 67-page methodological note is the first of three documents on reforming the medical nomenclature, aiming to split honoraria into intellectual and cost components, value intellectual performance separately, and make healthcare financing more comprehensible.

Political Momentum and Opposition

Vandenbroucke’s cabinet emphasizes that the studies are an important starting signal. “We expect the first reactions very quickly, so that we can take the next step after the summer,” the minister said, as quoted by multiple Belgian outlets.

The largest doctors’ union, BVAS (Belgian Association of Medical Unions), calls the 35% figure a “logical starting point” but views Vandenbroucke’s next steps with suspicion. The union demands hard guarantees that hospital transfers will actually disappear and opposes the speed of implementation, according to HLN.

The reform takes place against a backdrop of significant tension between the medical community and the minister. In July 2025, doctors and dentists held their first strike in nearly 25 years against Vandenbroucke’s healthcare reforms, as documented by VRT NWS. Key concerns include loss of professional autonomy, fear that mandatory conventioning will reduce incomes, and worries that hospital management—not doctors—will control practice cost budgets.

What the Reform Would Change

If implemented, the reform would fundamentally restructure the relationship between doctors and hospitals in Belgium. Doctors would lose significant control over how their fee income is allocated to hospital infrastructure, while hospital management would gain direct control over practice cost budgets. The reform could reduce incentives for over-performance—such as unnecessary scans and procedures—but might also reduce incomes in high-earning specialties.

Patients could benefit from more transparent pricing and potentially lower out-of-pocket costs. The RIZIV’s detailed methodological note, analyzed extensively by Medi-Sfeer, was developed in collaboration with FOD Volksgezondheid, KCE (Federal Knowledge Centre for Healthcare), and university research teams from KU Leuven and ULB.

Looking Ahead

Several outstanding questions remain. How will the per-code split be calculated for the thousands of nomenclature codes? Will the 65/35 ratio change when updated with post-COVID data? Can the government provide the guarantees BVAS demands? And how will the reform affect the ongoing tension between conventioned (tariff-bound) and non-conventioned doctors?

Vandenbroucke plans to take the “next step” after the summer, following initial stakeholder reactions. The coming months will be critical in determining whether this ambitious reform can navigate the complex political and professional landscape of Belgian healthcare.