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

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