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

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158 Special Solidarity Fund KCE Reports 133 9.10.9.5 Scientific value and effectiveness: This criterion is seen as clear, specific enough and relevant by most of the respondents. It is obvious to them the medical treatment or the drugs and medical devices or techniques have to be effective and must have a scientific value. Several respondents clarify this opinion by adding it is the treating medical specialist that has to argument his/her proposed treatment on scientific grounds, taking into account the individual medical situation of the patient concerned. Judgment on this criterion should be made by experts on the concrete disease. 9.10.9.6 Experimental stage The criterion is clear, specific enough and relevant by some respondents. The remarks that were made on relevance are that in very special situations, it should be possible to use treatments or drugs for which classical studies have not been performed since it might be possible the disease is too rare to have these studies performed. 9.10.9.7 No therapeutic alternative in the regular health insurance system The criterion is clear, specific enough and relevant. The only remarks on this criterion are one the alternative in the regular system has to be “equal” and guarantee the same medical outcome for the patient. 9.10.9.8 Medical treatment abroad This category is clear, relevant and sufficiently specific to nearly all respondents. The non- acceptance of cost for a second accompanying parent has been mentioned as problematic in cases concerning children. 9.10.9.9 Chronically ill children The criterion is clear and judged by some as formulated specific enough. Most comments regarding unclarity are related to the type of costs that are eligible for reimbursement. Some respondents see the category as relevant for the SSF. Others express the opinion it is questionable why this category is limited to children and why these costs cannot be integrated in the regular health insurance system. 9.10.9.10 Innovative medical techniques The category is clear; however some respondents perceive the criterion as formulated not specific enough. The appropriateness of the prescribed assistive devices and medical treatments must be assessed correctly and the term innovative may not be equal to new. The treating medical doctor has to be enabled to make use of existing devices or treatments (medical techniques) that are not reimbursed under the regular health insurance system on specific non common indications or diseases.
KCE Reports 133 Special Solidarity Fund 159 9.10.10 The internal SSF procedure within the hospital 9.10.10.1 The initiator and final responsible for SSF applications • The medical doctor was indicated in all interviews as the initiator of SSF files submission. The social service was sometimes mentioned as additional/complementary initiator. They intervene as an initiator when contacted by a patient on financial problems but also anticipate when they are aware of a situation (medical treatment) where an application for reimbursement by the SSF could be envisaged. The fact the social workers are operationally linked to the medical service of the hospital enhances the possibility for detection of such cases. Patients can play an active role in the initiation when they know the SSF or when communicating their financial problems with the hospital staff (nurses, medical doctors). The pharmacy department and invoice department were both mentioned twice as an initiator. They have a signal function when they detect the ordering of very expensive drugs or identify invoices for very expensive materials. • The final decision to submit a file to the SSF is clearly a medical decision. In all interviews the treating medical doctor is indicated as the ultimate responsible and decider. Structural involvement of the social service has been mentioned; as well as the invoice department and the pharmacy department. • In the hospitals where there is structural involvement of the social /financial or pharmacy department in the final decision, these departments advice the treating medical doctor on the SSF procedure. If they are convinced SSF criteria aren’t met, the social services stop the procedure of submission to the SSF. In the other hospitals, the social services don’t take up such a role since it’s not their competency and responsibility or because the situation has not yet occurred. • None of the social workers gives a specific prognosis on the changes of success for SSF files to patients in order not to create false expectations. This is a generalized hospital policy that counts for every intervention of the social services. 9.10.10.2 More or less involvement of the social services in the internal procedure Many respondents ask for more involvement in SSF files. The request for more involvement is situated at two levels: the SSF and the hospital • Towards the SSF, the main requests are related to having information regarding the final decision and more specifically the reasons/motivation why a file is approved/denied. Some interviewees would also appreciate more information on the status of a file (which step in the procedure? practical planning) and more transparency on SSF criteria and global decisions. • Internally, at hospital level there is the aim to be more involved in the initiation of SSF files to avoid potential SSF applications not being detected and as a consequence prevent situations where patients don’t get reimbursement, provide more support on content and finally more internal administrative coordination of SSF files.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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