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

KCE Reports 133 Special Solidarity Fund 157
9.10.9.1 Rare indication/rare disease
Both criteria on the rareness of the disease or the indication are definitely not clear to
the social services interviewed. Since clearness of these criteria is poor, it is evident
most of the respondents see the criteria as not specific enough.
For both criteria the relevance is not obvious at all for several people, as well for SSF
intervention as for the rare disease One respondent did not express an opinion because
the criterion was too unclear to judge the relevance.
Most of the interviewees stated the SFF reimbursement should not be limited to rare
indications or rare diseases. They suggest expanding the action field of the SSF to special
medical situations where the most appropriate medical treatment of the patient is not
possible within the limits of the regular public health insurance regulation.
(nomenclature codes). The fact a patient is not responding to a regulated drug or
treatment for which prescription is possible under the regular health insurance
regulation, the SSF should intervene in the costs and as such allow the prescription and
the reimbursed use of the most adequate drug or treatment.
They find it is an individual right to have the most appropriate medical care, and if the
regular health insurance system is not providing this, individual decisions on individual
medical cases should fill this gap. There is a general consensus such situations must be
assessed and decisions have to be taken on medical grounds only enabling the treating
medical specialist to motivate his choice of treatment.
9.10.9.2 Expensive
The criterion expensive is not clear and not formulated sufficiently specific. For most of
the respondents the criterion is relevant. A minimal cost as a criterion is largely
accepted.
The unclearness is linked to the SSF decisions known and the lack of specific motivation
of these decisions. It is not clear at all which specific internal criteria the SSF uses to
determine the “expensiveness” of a drug, a medical device or a treatment. The specific
internal criteria used by the SSF have to be known and to be fully transparent.
Most respondents stated that the meaning of ‘expensive’ depends from the individual
social and financial situation of the patient. For some patients a yearly cost of 500 € is
seen as expensive. Opinions on the question if the SSF reimbursement should be
variable linked to the patients’ income or financial situation differ. As the regular health
insurance system does not link the right to reimbursement on individual income, most
of them suggest the right to SSF reimbursement should not depend on personal income
either. For the lowest income categories, the same protection as foreseen under the
regular health insurance could be applied. (full reimbursement if the reimbursement for
example is limited to a certain percentage, integration of the costs that are not
reimbursed in the system of the MAB).
9.10.9.3 Vital functions
The criterion of vital function seems to be clear to respondents but it is not always
judged as formulated sufficiently specific. One can conclude this criterion is not clear
enough in its use in the SSF decision-making process. The relevancy of the criterion is
widely accepted since seen relevant.
When asked to specify what the term vital means, we noticed confusion. Some see vital
as related to vital organs and directly linked to a life threatening medical condition;
others see vital as a condition were a patient cannot have a acceptable level of ‘normal
quality of life, mobility, functioning..).
9.10.9.4 Medical – social perspective
This criterion is definitely judged as unclear and not formulated specific enough.
However it is seen by some as a relevant criterion. A few respondents did not express
an opinion on relevance because of the unclearness of the criterion.