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

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150 Special Solidarity Fund KCE Reports 133 Critères de décisions pour intervention du FSS Voici la liste des critères d’éligibilité annoncés par le FSS. MONTRER LA GRILLE 23. Quelle est votre appréciation pour chacun d’entre eux en termes de relevance (répond à un besoin réel), de clarté et de formulation? Evaluation générale du FSS 24. Finalement, quels points positifs identifiez-vous dans l’existence et le fonctionnement du FSS? 25. Quels points négatifs identifiez-vous? 26. Quelles modifications ou améliorations suggèreriez vous? Uniformité : contradictions dans les décisions? - Dans le système tel qu’il existe - Changement de système - Comment augmenter l’utilisation?
KCE Reports 133 Special Solidarity Fund 151 9.10 RESULTS OF THE INTERVIEWS WITH THE REPRESENTATIVES OF THE SOCIAL SERVICES 9.10.1 Knowledge on the existence of the SSF The interviewed social workers have gained knowledge on the existence of the SSF trough the following channels: colleagues from the hospital’s social service , the sickness funds, during their bachelor degree “social work”, via the medical doctors of the hospital, via the cancer league, via a previous work experience in a sickness fund and finally via the SSF brochure. One notices the majority of social workers got this information from inside the hospital. 9.10.2 General information on SSF cases The number of cases yearly submitted to the SSF by the social workers interviewed ranges between 40 (university hospital – big applicant) and 1 or 2 cases. This number can vary substantially over the years, depending on the patient’s profiles, the evolution of the regulatory health insurance coverage and the criteria set by the SSF. Respondents indicated that the number of cases has decreased substantially over the years due to inclusion (and reimbursement) of previous SSF cases into the regular health insurance system. The social services stipulated they don’t have the requisite medical knowledge to assess the SSF files on content. Only when they know that one or more SSF criteria aren’t met, they inform the medical doctor of the possible non eligibility for reimbursement of the case by the SSF. This action can lead to the decision to stop the procedure on preparing or entering a SFF file. None of the respondents could inform us on the exact number of applying medical doctors within their hospital (at hospital level) as the social services are not necessarily involved in the submission of all the SSF files (medical doctors can submit a SSF file on their own or patients can go directly to their local sickness fund to apply for SSF intervention). All respondents reported they have contact with a limited number of applying medical doctors, some respondents reported an exact number, ranging between 1 and 5. Since social workers are linked to medical services or hospital wards, this number does not represent the total number of medical doctors concerned. The data on SSF applications are not consolidated at hospital level. The global number of medical doctors involved in SSF cases clearly depends of the size of the hospital and the grade of specialization within the medical services and disciplines, but even in big university hospitals the global number of staff members implicated in SSF applications is limited. The following medical disciplines were linked to SSF cases: (pediatric) oncology, cardiology, (pediatric) neurology, metabolic diseases, nephrology, urology, hematology, gastroenterology and digestive surgery, radiotherapy and pulmonary diseases. 9.10.3 Need for a safety net/relevance of the SSF/effectiveness of the SSF On the question “Why has a safety net as the SSF been established next to the regular health insurance system?” the respondents gave two major reasons which they see as major objectives for the SSF: • To cover the costs of necessary and expensive medical treatments which are not (yet) included and reimbursed in the regular health insurance system. As such the SSF should be a real safety net and provide financial support to patients facing such situations. The objective mentioned is clearly based on the solidarity principle. • To identify expensive medical treatments, drugs or medical devices which are not included in the regular health insurance system in order to gain knowledge on the use and the effectiveness of them and to document a later decision on eventual transfer to reimbursement by the regular health insurance system. As a consequence, the SSF assures access to medical care through financial support (solidarity principle) in a kind of “waiting room” modus.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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