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

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178 Special Solidarity Fund KCE Reports 133 but several respondents pointed out this can be problematic when a decision is negative. It can cause an unnecessary panic from the patient in a condition that is not very comfortable; • Many respondents are aware a patient can appeal a decision by the SSF before the “labour courts” but the idea that no appeal was possible and that the only solution is to submit a new application to the SSF exist also. All respondents argument a procedure before the labour courts is totally inadequate. For patients such a procedure is heavy since in most cases they will be subject of a medical expertise ordered by the judge. Mostly the patient will also have to advance the costs of the expertise. The sickness funds are reluctant to have these procedures since at the end they would appeal a decision that was taken by their own medical director (within the SSF College of medical doctors). For nearly all respondents an appeal procedure has to be foreseen within the health system framework. Some said an appeal before a court is a total disgrace. The ruling of the courts on SSF matters should be public and accessible for doctors and patients systematically. The fact the SSF does not change its future decisions according to the courts judgments (case law) is totally unacceptable. 9.12.8 Communication and information dissemination On the question “How do you get informed regarding evolutions/changes in the SSF regulation/procedure?” all respondents indicated that they are not systematically informed on these topics. Not all respondents received the SSF brochure. Some respondents said the only information they have is the form they have to use for SSF files. Another said he got information from the NIHDI. Most respondents have the social service of the hospital as administrative support and rely on the social workers for the information. The quality of the information about the SSF is judged as difficult to access and unclear. The website where the information can be found and the documents on it are difficult to find; the website has a too complicated structure. Several respondents said medical doctors have to treat patients and do not have the time to look for information on administrative procedures. • Most respondents indicated that the information is unclear or simply of bad quality. • When the information was judged as “good”, asking upon the SSF criteria revealed that these were totally unknown by the respective respondent. • Several respondents expect a feedback from the SSF before a final decision is taken. 9.12.9 Knowledge and appreciation of the SSF criteria The criteria, to be fulfilled for reimbursement of SSF applications that were reported spontaneously during the 13 interviews (without any support tool – grid) are listed below. In general spontaneous knowledge of the criteria is poor. When quoted, most respondents knew the element is used to determine reimbursement by the SSF. • Expensive with the observation by most of the respondents that “expensive” is a very relative criterion. The level of income of the patient makes a treatment expensive or not expensive. Whether personal income should be a determinant factor for the amount or the fraction that is reimbursed by the SSF is judged very differently. Most respondents see it as irrelevant for reimbursement of medical expenses. They refer to the general health insurance system where income is not a major item for determination of the level or the amount that is being reimbursed. Several respondents made the observation that patients that are confronted with serious diseases have a lot of costs on top of the strictly medical
KCE Reports 133 Special Solidarity Fund 179 expenses. Most of them are not able to work and have additional expenses for mobility and housekeeping. They expect the health insurance system to fully reimburse the costs linked to the disease to the patients. Two respondents stress the opinion that reimbursement must be variable on the income status of the patient; the others don’t see a need for such an approach. • The criterion serious diseases is mentioned by five respondents, rare diseases by 4 respondents, not reimbursement within the regular health insurance system, effectiveness of the treatment, beyond the experimental phase, no other reimbursement channels, life threatening situation , added value (cost effectiveness) must be proved, scientifically proven. • As demonstrated above, respondents could only report a limited number of criteria without the help of the criteria grid. Most respondents knew a treatment has to be expensive. One interviewee is convinced that when a treatment is very expensive, chances on reimbursement are higher. The other respondents could not agree with this at all. The respondents were asked to formulate their appreciation of each criterion in terms of relevance (answering to a real need), clearness and formulation. On this question a grid in which all criteria were listed was shown to the respondent. One respondent said all elements were too unclear in order to give an opinion on the relevancy or the specificity of the formulation. One respondent did not complete the grid. As a consequence the overview below is based on eleven responses. Table 21: evaluation of SSF criteria by the physicians Clearness Relevant Formulated sufficiently specific Yes Neutral No Yes Neutral No Yes Neutral No Rare indications 7 4 7 1 3 4 2 5 Rare diseases 9 2 8 0 3 6 3 2 Expensive 4 1 6 9 0 2 1 0 10 Related to a rare disease harming vital functions Responding to an 8 1 2 6 2 3 6 2 3 indication necessary on medical – social perspective 4 1 6 6 2 3 3 2 6 Scientific value and effectiveness 9 1 1 9 0 2 6 1 4 Passes the experimental stage No therapeutic alternative in the regular health insurance system 10 0 1 10 0 1 7 0 4 11 0 0 10 0 1 8 0 3 Medical treatments abroad 10 0 1 9 1 1 8 0 3 Chronically ill children Costs medical aids en treatments that are 9 0 3 6 0 5 2 3 6 innovative medical techniques 7 1 2 9 1 1 6 1 4 NB: the occurrence of the answers is given as an indication but have no statistical signification. No inference can be done with these results due to the theoretical purposive sample, i.e. not representative in the statistical acception
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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