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

More documents

Recommendations

Info

182 Special Solidarity Fund KCE Reports 133 9.12.10 The internal procedure within the hospital 9.12.10.1 The initiator and final responsible for SSF applications • The medical doctor is reported as the principal initiator of SSF files as well as the social service as additional/complementary initiator. More, the social service of the hospital drew the attention on the existence of the SSF. The pharmacy department, the invoice department from the hospital and a pharmaceutical company were also mentioned as an initiator. In some cases patient organizations can influence indirectly by attending the medical doctor on specific costs he is not completely aware of. Most medical doctors treating patients with rare diseases have contacts with patient organizations. • The final decision to submit a file to the SSF is definitely a medical one. All respondents said they take the ultimate decision to introduce an application for reimbursement at the local sickness fund (SSF procedure). Several respondents explicitly mentioned they start the treatment at the same time and do not wait for a decision by the SSF while one respondent said he never starts the treatment before the patient obtains a decision because the costs are too high to be supported by the patient. • Most medical doctors give information on the possibility of acceptance of the application by the SSF. No respondent gives full assurance the application will be accepted. They mostly tell the patient they will try but that decisions of the SSF are difficult to predict. In some cases the respondents give a probability based on earlier experiences but always add there is no guarantee at all the SSF will grant reimbursement. Several respondents said they had contradictory ruling by the SSF in the past. Most respondents inform the patient he will receive a bill from the hospital for sometime very high amounts. They warn the patient that they do not have to pay instantly and that the bill is needed to be able to introduce an application at the SSF. Most hospitals grant a delay of payment to the patients. Even if the SSF refuses the petition for reimbursement, the hospitals try to help patients to overcome that situation (payment plan). All respondents say this is a very annoying situation where the patient is put in a very stressful situation. • If a patient does not want to take the financial risk, even if that risk is theoretical, the medical treatment has to be postponed. This is seen as not acceptable at all. Three respondents mentioned they were confronted with such situations. • It is not always possible to inform the patient on the financial consequences of a medical treatment. The patient can be in a very critical condition where dialoguing is not possible or not convenient. This poses ethical dilemmas for the treating doctor. 9.12.10.2 More or less involvement in the procedural steps All but one respondent want to have more involvement in the decision-making process. They want to be seen as an objective partner and even they deem it necessary to be contacted by the SSF if a negative decision is envisaged. Some respondents said they want to be able to meet with the College of medical directors to argument the case. Most doctors see this as not feasible since they do not have the time to do this. They must treat patients, not act as a counselor. It is clear the decision-making process of the SSF is very much questioned by the treating medical doctors. They see no added value from the advice of the advisory doctor at local sickness fund level. The medical expertise needed to judge on such complicated cases as these introduced for reimbursement by the SSF, just is not present at this level. This is very well understandable since one cannot be an expert for all diseases.
KCE Reports 133 Special Solidarity Fund 183 The respondents have no contact with the medical directors of the sickness funds at federal level. They also have no contact at all with the medical staff at SSF level. Nearly all respondents are convinced the needed medical expertise to judge on very specific patient files, is simply not present at the decision table. All respondents agree to have a review of the treatment, the drugs or the devices they prescribe but want this review to be processed by making use of other means than the actual SSF decision-making council. They propose to have experts (national or international) involved or a second opinion process. The expertise on the diseases or the indications is often very limited in Belgium. They all consider themselves as experts and have great difficulties that their medical judgment is questioned by non-peers. For routine SSF files, this may not cause major problems, but for very complicated cases, a system of peer review and peer decision has to be put in place. They however do not want to have a similar procedure as the procedure on orphan drugs. This procedure is judged as too heavy and too restricted. The fact every year a petition for renewal has to be entered is seen as unnecessary complication of the procedure. The paperwork for the orphan drugs is seen as even more heavy as for the SSF applications. Several respondents referred to the French system where new drugs, which are not generally accepted in the health insurance system (yet), can be prescribed to certain groups of patients, or for other indications without heavy procedures. Decisions are taken very quickly and they can make use of the ATU procedure to have access to drugs that are not registered yet in France. The one respondent that did not want further involvement argued his statement saying for him the SSF applications in fact are routine files where acceptance is evident and needs no further argumentation. There is enough paperwork already. Respondents want to decrease their involvement in SSF files, and formulated the following suggestions/remarks in order to increase efficiency and simplify the current procedure: • The administrative burden is judged to be high by many respondents. Most responders understand there is a minimum of paperwork that has to be done for every application for specific reimbursement of medical costs, but it has to be limited to the strict minimum. Medical doctors are overwhelmed with paperwork when their first task is to treat patients, not filling out all sorts of formularies; • Duplication of scientific articles and literature on the SSF cases is seen as an unnecessary waste of time. The SSF can easily keep track of all elements provided on similar previous cases and as such avoid unnecessary duplication. Respondents do not see the need to have these provided on each separate application; • The fact prices have to be given and costs have to be calculated each time is also seen as unnecessary complication. It creates an unproductive administrative burden. Prices can be provided by the NIHDI and cost calculation could be performed by the SSF administrative services. It should be sufficient if the prescribing doctor gives the dose that has to be administrated to the patient. Documents have to be regularly re-entered to the sickness funds when lost. Several respondents mentioned this fact. In Belgium no financial compensation at all is given to medical doctors for all the paperwork on patients’ files. In other countries as Luxembourg it is. • The administrative step of the local sickness funds is completely unnecessary and gives no added value for the SSF process at all. Most respondents prefer to have SSF files entered at the SSF services directly. It would be much easier to have one single point of contact. Several respondents judge the intermediate step of the local sickness fund as completely unnecessary. It only consumes more time and resources and
Page 1 and 2:
Optimalisatie van de werkingsproces
Page 3 and 4:
Optimalisatie van de werkingsproces
Page 5 and 6:
KCE reports 133A Bijzonder Solidari
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17:
Page 20 and 21:
2 Special Solidarity Fund KCE Repor
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
10 Special Solidarity Fund KCE Repo
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
100 Special Solidarity Fund KCE Rep
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151: 132 Special Solidarity Fund KCE Rep
Page 230 and 231: Wettelijk depot : D/2010/10.273/44
Page 232 and 233: 37. HTA Magnetische Resonantie Beel
Page 234: 108. Tiotropium in de behandeling v
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?