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

KCE Reports 133 Special Solidarity Fund 173
For most respondents the existence of the SSF as such is positive. They see it as one of
the only possibilities to have treatments, drugs or medical devices that are not
reimbursed under the regular health insurance system, accessible for patient use. In this
perspective many respondent expressed the opinion there is a need for the SSF (or
another system with similar objectives) as a complement to the general insurance
system. All of them are convinced it is impossible to have every situation regulated in
the general health insurance system.
9.12.4 The SSF: meeting its objectives?
Most respondents judge the achievement of objectives by the SSF from their own direct
experience. Some of them had a positive experience regarding the reimbursement of
the drugs or medical devices for which they introduced an application. A solution for
the practical issue they were facing was provided: the SSF reimbursed the costs.
However the difficulties to obtain that reimbursement are judged as rather important.
The other respondents got mixed feelings regarding their experience with the SSF.
The SSF is sometimes perceived as an adequate and fully satisfying solution for the
introduction of the innovative medical treatment he learned abroad (in the US) and
wanted to apply on his patients in Belgium. The acceptance by the SSF of this new
technique (colon stent) took about 6 months and since a few years the technique is part
of the general health insurance system. In this case the SSF fully met the objectives on
reimbursement of new innovative techniques as well as the objective to function as a
kind of waiting room for general coverage of the costs of new medical treatments.
In another mentioned, the drug is already reimbursed by the SSF for a very long period
(13 years), causing a side effect regarding the price of this drug. The price has never
been subject of negotiation with the pharmaceutical company and as a consequence
there has never been any ‘regulation’ on the price. The conclusion is, there is a solution
for the patient (reimbursement) but it’s a bad situation for the public health insurance
system. For this type of reimbursed drugs the objective of the SSF as a “temporary”
waiting room is clearly not met.
Respondents identified the following gaps in achieving the SSF objectives:
• Reimbursement is often limited to a percentage of the cost leaving a non
solved problem for the hospital and the patient. Theoretically the patient
is accountable for the part that was not reimbursed by the SSF. The
hospital gets an invoice from the pharmaceutical firm for the full cost. The
invoice is addressed to the patient but often the patient is not asked to
pay the amount (the part that was not reimbursed by the SSF) till the
moment the NIHDI and the pharmaceutical company reach an agreement
on a fixed price and the drug is transferred to the regular health insurance
system. In the meantime the hospital is in a difficult situation towards the
pharmaceutical company (open invoice that can reach very important
levels) and the patient still is in a very uncertain position not knowing
what the final outcome of the SSF application will be. Some respondents
see this situation as very problematic and see the patient and the hospital
as a kind of hostage of both other parties. The NIHDI is judged as
negligent towards as well the patient as to the hospital. The position of
the prescribing doctor towards the hospital and the patient is not
comfortable either.
• Patients are the ultimate victims of conflicts of interests between the
NIHDI and pharmaceutical companies. The fact the procedure for
acceptance (registration) of a new drug is complicated and time
consuming results in non availability of new and necessary drugs for
specific treatments. This is not acceptable from a medical point of view.
Belgium is seen as one of the countries were the introduction of new
drugs last the longest in Western Europe.