Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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82 Special Solidarity Fund KCE Reports 133 Netherlands Spain France Name Activ sustance Reimbursement Reimbursement Reimbursement Adagen Pegademase bovine Vidaza Azacitidine Kuvan Cellcept sapropterin dihydrochloride Mycophenolate mofetil Mabthera Rituximab Avastin Bevacizumab US‐registered orphan drugs (non‐EU): not reimbursed intra muros, nor extra muros. Today, adagen could possibly be paid by pharmacist's, pharma company or the hospital through ad hoc‐ reimbursement systems (however not by the health insurers) GREY ZONE. Received recently a positive advice to be recognized as 'Expensive Drugs' (intra muros) ‐ 100% reimbursable ‐ prescribed by specialists in Hospital use Financed NHS without all hospitals any co‐payment of the patient Received recently a positive advice to be adopted in the Drug Reimbursement System (GVS‐extra muros) ‐ 100% reimbursable Reimbursed under GVS ‐ Schedule 2 (advies CVZ, 2007) Recognized as 'Expensive Drugs' (intra muros) ‐ 100% reimbursable ‐ prescribed by specialists in all hospitals Hospital use Financed NHS without any co‐payment of the patient Diagnose by medical specialist Co‐payment of the patient 10% max.2,64€ Hospital use Financed NHS without any co‐payment of the patient Recognized as 'Expensive Drugs' (intra muros) ‐ 100% reimbursable ‐ prescribed by specialists in Hospital use Financed NHS without all hospitals any co‐payment of the patient glucamylase & inver‐ Bi‐myconase and/or sucraid tase (saccharase) Ointmenst, disinfectants, pain‐ killers, tape, food supplements Implantable cardiac valves (aortic valves) In hospital's budget Not found= not reimbursed under the statutory health insurance (l'Assurance Maladie obligatoire) When prescribed in the hospital 100% financed also for ambulatory patients When prescribed in the hospital 100% financed also for ambulatory patients 60% CIP: depending on the product; Homologation Assurés Sociaux (A) ‐ 100% ‐ since 10/01/2006 (re‐examined in 2013) + Homologation Collectivité C: since 10/01/2006 CIP: Médicament NON Remboursable aux Assurés Sociaux (A) / Agrées aux collectivités C: since 1998 When used in the hospital 100% financed not for ambulatory patients Not found in the nomenclature Not found in the nomenclature Not found in the nomenclature Implantable pulmonary valves In hospital's budget Not found in the nomenclature Brainstem implant Probably not reimbursed under GVS ‐ Advies CVZ In hospital's budget Neuro stimulator of the stomach Flolan époprosténol Remodulin tréprostinil Viagra/revatio Reimbursed under GVS ‐ listed under Schedule 2 + Hospital use Financed NHS without Paid on the hospital budget (intra muros) any co‐payment of the patient Reimbursed under GVS ‐ listed under Schedule 2 + Paid on the hospital budget (intra muros) Reimbursed under GVS ‐ listed under Schedule 2 + Hospital use Financed NHS without Paid on the hospital budget (intra muros) any co‐payment of the patient Not found in the nomenclature Not found= not reimbursed under the statutory health insurance (l'Assurance Maladie obligatoire) When used in the hospital 100% financed also for ambulatory patients When used in the hospital 100% financed also for ambulatory patients When used in the hospital 100% financed also for ambulatory patients Reimbursed under GVS ‐ listed under Schedule 2 + Hospital use Financed NHS without Ilomedine iloprost Paid on the hospital budget (intra muros) any co‐payment of the patient When used in the hospital 100% financed Elvorine Not found in the nomenclature Calcort déflazacort Myozine alglucosidase alfa Sovrima idebenone Paid on the hospital budget (intra muros): adopted on the list of 'Orphan Drugs' ‐ 80 % reimbursed ‐ only prescribed by specialists in Probably not reimbursed under GVS ‐ Still in clinical trial process Other product ‐ on prescription for long time treatment co‐payment of 40% Hospital use Financed NHS without any co‐payment of the patient Ditropan for intravesical application oxybutynin chloride In hospital's budget implant cochléaire contralétéral (in fact bilatéral) In hospital's budget Not found= not reimbursed under the statutory health insurance (l'Assurance Maladie obligatoire) Not found= not reimbursed under the statutory health insurance (l'Assurance Maladie obligatoire) Not found in the nomenclature CIP: depending on the product; Homologation Assurés Sociaux (A) ‐ 100% ‐ sinds 10/01/2006 (reexamen in 2013) / Agrées aux collectivités: sinds 06/2006 Not found in the nomenclature Cranial implant on messure In hospital's budget Not found in the nomenclature corticale electrodes In hospital's budget Not found in the nomenclature intégra Not found in the nomenclature implant in mid ear In hospital's budget Not found in the nomenclature diafragmatic pacemaker In hospital's budget Not found in the nomenclature contrathion When used in the hospital 100% financed cystadane Reimbursed under GVS ‐ listed under Schedule 1B ‐ 100% reimbursable Hospital use Financed NHS without any co‐payment of the patient When prescribed in the hospital 100% financed also for ambulatory patients 60%
KCE Reports 133 Special Solidarity Fund 83 7.5 CONCLUSIONS OF THE CHAPTER ON THE INTERNATIONAL APPROACH No mirror systems or comparable safety networks to the SSF exist in the countries studied. 7.5.1 Costs of drugs at secondary care level (hospital care) As in Belgium the health care system differentiates primary care and secondary care (hospital care). Looking at the health care systems in the other countries that were part of the international approach in this study, one notices a major difference with the Belgian health care system on how costs of drugs and medical treatments are covered at hospital level. In Belgium there a third-party payer system for inpatient care and drugs, for which the sickness fund directly pays the provider while the patient only pays co-payments. If there is no coverage of the costs by the health insurance system, the costs are fully charged to the patient. There are some exceptions on these principles were hospitals are not allowed to charge specific costs to the patients. For example some antibiotics are paid at a flat rate to the hospitals and are not charged to the individual patient. In all countries studied, medicines are included in the overall hospital budget. They are globally financed to the hospitals. In the Netherlands supplementary compensation (extra budget) for the hospital can be granted for expensive or orphan drugs. In Spain the hospital budget will be influenced by regional priorities (Autonomous regions) with possible differences between the regions. Such a system of (closed or semi closed) hospital budgets including costs of drugs and medical devices leads to a different approach. It’s the hospitals’ responsibility to decide on the use of (authorized) drugs and medical devices. The costs are not charged to the patients. This could however lead to different approaches between hospitals and as such to different outcomes for patients. The specialist doctors have a joint responsibility at hospital level. Hospital care is not restricted to hospitalized patients but includes care to extra muros patients that are treated by medical specialist doctors in the hospital facilities. 7.5.2 Costs of drugs at primary care level For primary care, costs of drugs delivered through the local pharmacies in the countries studied, are subject to (differentiated) co-payment. This is the same as in Belgium. Only drugs that are listed on the nomenclature code are reimbursed. In France there is no co-payment for patients with chronic disease if their disease has been recognized (ALD). In Spain the costs of drugs provided at the primary health care centers are not charged to the patients, only drugs delivered by the local pharmacies are subject to copayment. 7.5.3 Reference centers for rare diseases In both France as Spain health authorities foresee reference centers for treatment of rare and chronic diseases. Costs of treatments and drugs are included in the reference centers’ budgets. In the Netherlands some hospitals are specialized in treating rare diseases. The health insurance companies contract these hospitals and as such influence concentration of patients in specialized hospitals. In Belgium till now every medical specialist can treat rare diseases and prescribe drugs or innovative treatments. The results from the SSF sample however reveal that a small number of hospitals present a large number of applications, which implies that “de facto” there is a kind of reference centre system for rare diseases in Belgium. There is however no regulation with regard to the systematic financing of the treatment in those particular hospitals.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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