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

KCE Reports 133 Special Solidarity Fund 87
8.1.3 Threatening the vital functions of the patient
In the preparatory documents of the law of 2005 the Minister explicited that a vital
function is “an essential function such as the sight, even if the disease the patient is
suffering from is not life threatening”. A point of discussion is if the concept “vital” only
refers to a primordial interest for living or also for functioning, allowing psychosocial
diseases and quality of life to be taken into account. It was not possible to derive the
interpretation of this notion from the sample.
8.1.4 Rare indication/disease
According to the interviewed medical directors of the College, the rareness of a disease
is regarded in perspective to the orphaned criterion of a prevalence of 1/2000. This
criterion is not included in legislation.
8.2 INFORMATION CHANNELS ON THE EXISTENCE OF THE
SSF
As mentioned before, it was impossible to assess whether there is a lack of knowledge
on the existence of the SSF among the potential target group of the SSF. Most of the
interviewed stakeholders perceive the existence of the SSF as poorly known by the
parties (potentially) concerned. The interviewed stakeholders are informed on the
existence of the SSF through diverse channels. In 2007 the SSF sent information
brochures to the patients, the hospitals, the specialists, the pharmacists and the patient
organizations. We observed, however, that the SSF brochure or information initiatives
by the SSF itself were hardly mentioned by the interviewed stakeholders.
8.3 APPRAISAL BY STAKEHOLDERS OF THE APPLICATION
PROCEDURE AND DECISION-MAKING PROCESS
8.3.1 Clarity of the eligibility criteria
There is consensus between the interviewees that the legal criteria and requirements
for eligibility are open for interpretation. Particularly, “expensive treatment”, “rare
disease”, “experimental phase” and “vital functions” are terms that might cause
confusion and discussion. Some respondents consider the broadness and vagueness of
the criteria as an obstacle for coherent decision-making. However, most of them
welcome the possibility of interpretation, given the role of the SSF as an additional
safety net.
8.3.2 Duration
The duration of the procedure (throughput time from initiation to decision) is judged by
many respondents as problematic. Yet, the time aspect is of an utmost importance since
patients often wait for the decision to start the treatment. The bottleneck is seen at the
level of the sickness funds since an application, once it is send to the SSF, is quickly
decided upon at SSF level. Indeed, results from the sample data analysis indicate that
today about 90% of the cases are handled at the SSF level within one month. It was
impossible however to quantify the overall throughput time because the available data
solely concern the assessment at the SSF. There were no data available on the reason(s)
for the probable bottleneck in the pre-trajectory of the SSF. Yet it is reasonable to
assume that passing through the different stages implies a repetitive administrative
burden at each level and paves the way to delays. Indeed, the administrative check on
the completeness of the file as well as a medical assessment happens at each level.
Other possible underlying clarifying factors are: the non timely introduction of the
required documents by the patient to the local sickness fund, delays at the financial
service level of the hospital responsible for delivering the invoice, etc…
Another problematic issue is the lack of a rapid procedure for individuals in urgent need
of a particular medical treatment, device or drug. Moreover renewals follow the same
procedure as new applications.