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

More documents

Recommendations

Info

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.
KCE Reports 133 Special Solidarity Fund 153 • Patients living close to the Belgian border, have the possibility to get medical treatment and medication in the neighbour country and can as such have cost of treatments or medication reimbursed that is not reimbursed in Belgium. The main reasons why the SSF doesn’t reach her objectives mentioned were: • The unfamiliarity with the SSF, as well within the group of medical doctors as in the group of social workers. • The long duration time before a final decision is taken for some cases. • Lack of knowledge concerning the exact definition of the SSF criteria and how these are interpreted in practice. • The administrative focus of the SSF instead of a medical viewpoint. • The fact drugs and medical devices are kept within the SSF reimbursement system for too long (several years) instead of transferring them to the regular health insurance system. • The highly defined and very limited field of action of the SSF. 9.10.5 Alternatives for the SSF On the question “What other options do you see to respond to this type of need?” the following answers were provided: • The cancer fund (oncology focus): reimbursement of limited amounts • Public centres for social welfare (OCMW/CPAS): focuses on persons with a particular social profile • Private health insurances • The social funds of the sickness funds • Studies by pharmaceutical firms • The fund for occupational diseases • Organisation of charity event • Parents associations, grants, charity institutions, non profit initiatives, … • Caritas funds • Support/social funds of the hospital • MAB All respondents indicated that none of the channels mentioned are a valid alternative to the SSF. These channels are “emergency solutions”, no structural solutions responding to a need. The reimbursement of exceptional medical costs is seen as a responsibility to be covered by the health insurance system and can not rely on charity initiatives. The SSF is actually the only institution responding to the needs of patients who are confronted with high medical costs of necessary medical treatments, not reimbursed within the regular health insurance system. 9.10.6 The intervention domains of the SSF 9.10.6.1 Enlargement of the SSF intervention domains On the question “Which other elements should to your opinion be covered by the SSF”, respondents reported the following recommendations: • The criterion on “experimental phase” needs to be widened. • The criterion “rare disease and rare indication” limits the action field of the SSF. High medical expenses due to an exceptional medical treatment that is judged as appropriate by the treating medical doctor should be reimbursed regardless of the fact the disease or the indication is rare. • The criterion on “vital function” is very restrictive. Hair transplantation for children is not a treatment of life-threatening nature but does offer a solution to a serious psychological/emotional problem.
Page 1 and 2:
Optimalisatie van de werkingsproces
Page 3 and 4:
Optimalisatie van de werkingsproces
Page 5 and 6:
KCE reports 133A Bijzonder Solidari
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17:
Page 20 and 21:
2 Special Solidarity Fund KCE Repor
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
10 Special Solidarity Fund KCE Repo
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
100 Special Solidarity Fund KCE Rep
Page 120 and 121: 102 Special Solidarity Fund KCE Rep
Page 220 and 221:
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Wettelijk depot : D/2010/10.273/44
Page 232 and 233:
37. HTA Magnetische Resonantie Beel
Page 234:
108. Tiotropium in de behandeling v
show all

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

Create successful ePaper yourself

Delete template?

Save as template?