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

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174 Special Solidarity Fund KCE Reports 133 • The time to obtain a decision by the SSF (initiation to final decision) is in general too long. For some treatments it is ethically or medically not acceptable to postpone the start of the treatment till after having a decision. In some cases the patient is not prepared to take a risk of non acceptance by the SSF, leading to a real dilemma and leading to non adequate medical care. Medical needs are not fulfilled and no optimal medical treatment is provided. One respondent mentioned a medical treatment had to be interrupted for a 3 months period because a decision lasted too long. In this specific case the treating physician had to substitute the drug by another less effective one. • The outcome of an SSF application is not predictable. Several respondents said they obtained different decisions on similar cases, or new colleagues that had a different outcome on quasi identical cases. • Decisions are not motivated. The only information that is disseminated is that the application is not accepted for reimbursement since a criterion is not met (pure administrative motivation based on the SSF regulation). No specific medical motivation is provided. For all respondents the motivation is clearly not satisfying. • Some respondents mentioned they are not convinced a case is examined on medical grounds. The individual medical background of the patient is, at their opinion, not taken into account. • Since SSF criteria for reimbursement are rather unclear (not clear or not enough specified, not known by the interested parties) several respondents are convinced all theoretically acceptable cases for reimbursement do not lead to final applications. The number of cases where no file is introduced is not calculable. There is a general feeling of ‘under-use’ of the SSF and all potential SSF cases do not result in submitted cases. • The function of the SSF as a waiting room is not met. Drugs and treatments are kept too long within the SSF reimbursement and are not transferred to the regular health insurance system in due time. In general the procedures to have new drugs accepted into the regular health insurance system are judged as being too long and complicated. • Acceptance of reimbursement at one time is no guarantee for later acceptance, leading to uncertainty for both patients and treating specialist doctors. There is no guarantee for the patient that the SSF will continue to finance the treatment, even in situations where the interruption of the treatment is life threatening. As such the patient is facing an uncertainty • The name of the SSF “special solidarity fund” is not fully appropriate since the SFF only intervenes in very specific situations linked to the rareness of a disease or an indication or the innovative character of a medical technique. The fact the reimbursement or the level of the reimbursement does not depend from the patients’ personal financial situation is not completely in line with the term ‘solidarity’. The doctors did however not plead to have personal income of patients determining SSF reimbursement. The main reasons why the SSF doesn’t reach her objectives mentioned are: • Too long time laps to obtain a decision from the SSF: The main reason given for this is the long duration time before a SSF file is transferred from the sickness fund to the SSF itself. Once a file is handled at SSF level, most respondents see a rather quick decision by the SSF. The bottle neck is situated at the level of the sickness funds (local sickness funds). • Lack of knowledge and transparency on the exact definition of the SSF criteria used to judge on reimbursement. The unclearness of the interpretation by the SSF on these criteria and the unfamiliarity with the
KCE Reports 133 Special Solidarity Fund 175 SSF, as well within the group of medical doctors as in the group of social workers. • The approach by the social services of the local sickness funds of SSF applications is not uniform and not transparent. The attention given to an application differs between the sickness funds and is often determined by the quality of the individual contact of the patient and his interaction with the social worker from the local sickness fund. • Differences in treatment of SSF applications by the medical advisors of the local sickness funds creating unequal treatment of patients. The level of detailed knowledge at local sickness fund level on the SSF procedures differs substantially leading to unequal results. • The approach by the SSF is very administrative oriented. The medical situation of the patient is rarely taken into account. The SSF decisions focus on the administrative elements of an application. • The SFF does not start from an acceptance of the professional judgment of the treating medical doctor nor his expertise. The treating physician has too limited impact on the decision-making process of the SSF. He is not seen as an objective partner that proposes the most adequate treatment for his patient. • The grounds, on which decisions for partial reimbursement are taken, are not known and not clear to the treating medical doctor or the patients. • Extensive motivation of decisions is not available; there is no canvas on all decisions taken by the SSF. • The fact a treatment has to be scientifically proven (have a scientific value and generally accepted as effective) limits the action field of the SSF. In some cases evidence based medicine is not possible since no scientific studies are or can be performed due to the rareness of the disease or the indication. 9.12.5 Alternatives for the SSF In fact medical doctors interviewed see no real existing alternative to the SSF. However the functioning of the actual SSF is very much criticized. In general nearly all respondents suggest a maximal integration of actual SSF reimbursement within the regular insurance system. A supplementary system as the SSF should be restrained to the ultimate minimum. Such complementary system is seen as necessary to cope with extreme unique medical situations. Other options to respond to the needs that ‘should’ be met by the SSF, do not exist at this time. Next to the SSF, different additional systems are mentioned. These are used to complement SSF reimbursement or, if no SSF reimbursement was granted to get at least maximal alternative financial support for the patient. • Public centers for social welfare: only for patients without a minimum level of income; • Private health insurances; • Studies by pharmaceutical firms; • Free samples provided by the pharmaceutical firms; • Charitable organisations; • The hospital (not charging the patient); • Compassionate use of drugs; • The cancer fund (only for small expenses). All respondents indicated that none of these channels are a really valid and sustainable alternative to the SSF.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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