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

More documents

Recommendations

Info

154 Special Solidarity Fund KCE Reports 133 • The category of “chronically ill children” should be extended to “all chronically ill patients”. • The off label use of drugs. • The social and financial situation of the patient should be taken into account in the reimbursement amount. Otherwise the SSF doesn’t cover what the term suggests. • For some “social” categories no limitation in the reimbursement may be applied. • The restriction to “one parent guidance” to other countries is problematic and emotionally unacceptable. 9.10.6.2 Limitation of the SSF intervention domains On the question “Which elements should to your opinion be excluded from the current SSF system?” all respondents answered that there was no reason to reduce the existing intervention domains of the SSF. On the contrary, the suggestion was given to include current SSF cases as much as possible into the regular health insurance system and to look for solutions for all medical treatments not covered by the current system. The SSF has a role to play in the identification, the communication and formulation of suggestions for inclusion of treatments into the regular health system. Five respondents explicitly suggested including the category of “chronically ill children” into the regular health insurance coverage. The inclusion of costs for medical treatment abroad was mentioned once. 9.10.7 Experience with the SSF/knowledge of the SSF procedure The respondents described their view on the different steps and parties involved in the SSF procedure. • Many respondents reported that the complete file (declaration on honor, scientific articles, medical information, invoice, …) is submitted to the local sickness fund of the patient. One interviewee reported that the SSF files are submitted directly to the national level (medical director) of the sickness funds. One social worker indicated the possibility to send the SSF file directly to the SSF. • Among respondents knowing that files are submitted in a first step to the local sickness funds, some reported the internal transfer from the local sickness funds (advisory physician) to the national level (medical director). Consequently, many respondents believe that the local advisory physicians submit the files directly to the SSF and are not aware of the intermediate step within the sickness funds. • It is not clear who the deciding authority is for SSF files: the advisory physician of the local sickness fund decides, or a committee of advisory physicians that meets once every two to three months; Some respondents refer also to a committee without further specification. • Almost all respondents indicate that they are not involved or informed on the outcome and further follow-up of a SSF file. There is only feedback and communication with the local sickness funds when documents are missing. Contacts with the SSF or the sickness funds at national level (medical directors) don’t exist. • Social services are not informed about the final outcome of a SSF file unless the patient informs them that the SSF file is rejected and the patient is still confronted with the financial problem linked to the cost of the medical treatment. • One respondent received the information from the sickness funds that the financial cost needs to exceed €2000 before a SSF reimbursement can be accepted.
KCE Reports 133 Special Solidarity Fund 155 • Many respondents are aware that an appeal procedure exists: Some of them know the “labour court” procedure. The procedure is perceived as complex, not really supported by the sickness funds. It increases the throughput time to a final decision and prolongs the uncertainty for the patients. 9.10.8 Communication and information dissemination On the question “How do you get informed regarding evolutions/changes in the SSF regulation/procedure?” all respondents indicated that they are not systematically informed on these topics. Some respondents know the SSF brochure as source of information, one hospital has developed an internal brochure on the functioning of the SSF, and one hospital organizes internal training on the functioning of the SSF. Other “ad hoc” channels are: the cancer league, centers for social welfare, sickness funds and contacts with the NIHDI. None of the respondents indicated there were informed directly by the SSF on changes in regulation/procedure. The quality of the available information about the SSF is judged as “too limited”. • Respondents indicate that the limited information in itself creates a huge quality problem. Direct feedback from the SSF regarding the files (decision and motivation) could improve the knowledge of the SSF enormously. The annual report is difficult to find and the information included is to general to realize “in depth knowledge” on the SSF. Two respondents suggested SSF decisions should be fully transparent and accessible. One respondent suggested the decisions of the labour courts on SSF cases should systematically be accessible. • The SSF is described by three respondents as "surrounded by a haze of fog" or “a black box” because it acts very isolated, is not accessible and provides no transparency on its decisions. As additional problem, the remark was made several times that smaller sickness funds at their local level hardly know the procedures and functioning of the SSF. The comparison with the cancer fund has been made. This institution gives on an annual basis a presentation on their functioning and the most recent changes. A similar initiative from the SSF would improve the relation with the SSF and eliminate current unclearness. • The available information is sufficient for some people: via the social services of the sickness funds we receive all necessary information. The SSF brochure has been described as handy and user friendly but it is not available at all campuses of the hospital. 9.10.9 Knowledge and appreciation of the SSF criteria The criteria, necessary for approval of SSF cases that were reported spontaneously during the 12 interviews (without any support tool – grid) are listed below: • Expensive : with the remarks that the term “expensive” is very depending on the individual financial situation of patients, rare diseases, serious diseases, beyond the experimental phase, not reimbursement within the regular health insurance system, essential care, appropriate treatment, exceptional situation, life threatening situation, no other reimbursement channels, added value must be proved, exceptional costs, exceptional high costs for drugs, administrative requirements including the submission of an invoice and declaration on honour, for chronically ill children more then € 650 of financial costs. • As shown above, respondents could only report a limited number of criteria without the help of the criteria grid, often in more general terms. When asked for the definition of each criterion, respondents said they were not aware of the exact definition, used by the SSF to decide on the SSF cases.
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:
Page 122 and 123: 104 Special Solidarity Fund KCE Rep
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?