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

152 Special Solidarity Fund KCE Reports 133
9.10.4 The SSF: meeting its objectives?
Some respondents reported the SSF achieves its objective of reimbursement of medical
costs not covered by the compulsory health insurance at least for the SSF cases related
to their hospital. The other respondents identified the following gaps in achieving the
proposed objectives:
• Reimbursement is often limited to a percentage of the cost (varying from
product to product- 50%, 60% and 70% were mentioned). The
consequence is the patients still have to pay a sometimes very substantial
amount themselves. Social services indicated that sickness funds are not
always eager to submit a file to the SSF. No reasons were cited explaining
this sense of hesitation.
• The throughput time (initiation to final decision) is sometimes long and
demotivates patients/medical doctors to submit a file. It creates
uncertainty about the outcome in a situation where the patient is
confronted with a serious illness and is facing important medical expenses.
• The decision of the SSF is not send to the social service, only to the
patient. The lack of a clear motivation of a negative decision to the social
services is sometimes disappointing because social services have the
objective to help their patients.
• Not all potential SSF cases actually result in submitted SSF files, as the SSF
is not widely known among medical doctors or patients. As a
consequence the SSF doesn’t reach all her potential beneficiaries.
• For the same pathology and treatment, they noticed different
reimbursement amounts in 2002. Similar SSF files can result in different
reimbursement amounts. Similar cases result in different decisions.
• Some patients want certainty about the acceptance of their case before
they give their consent to start up the treatment, due to a lack of financial
resources. In these cases there is no invoice to submit to the SFF and
decision times are long. If the decision is negative, patients as a
consequence won’t receive the optimal medical treatment.
• The premise of the SSF is not that the treating medical doctor, as an
expert, is the right person to determine which therapy is the best for
his/her particular patient and condition. The treating medical doctor is
responsible that the most appropriate therapy is followed. His/her opinion
and responsibility are central. The SSF doesn’t start from a medical
necessity of a particular treatment but rather from an administrative
perspective and fixed limited budget.
• The term SSF “special solidarity fund” is confusing because the SSF
doesn’t intervene in all cases where there is no reimbursement in the
regulatory health insurance system. Solidarity within the SSF is restricted
and limited to very specific financial costs for very specific indications and
pathologies, for which a whole set of criteria, must be met.
• Local sickness funds do not always treat the SSF applications objectively.
Differences in treatment and advice from the advising doctor at local level
are mentioned creating unequal treatment. Knowledge on the SSF at local
sickness level differs substantially.
• The function of the SSF as a waiting room and a system for detection of
new treatments or devices implicates the “waiting room” has to be
emptied on time. Transfer of reimbursement from the SSF to the regular
health insurance system takes too long.
• Patients are sometimes victims of conflicts of interests between the
NIHDI and pharmaceutical companies. The fact there is no agreement on
the price of a drug or a drug has is not registered in Belgium, or is not
registered for a specific indication, may not have consequences for the
individual patient or the hospital. Patients and hospitals are sometime seen
as a hostage in such conflicts of interest.