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

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.