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

186 Special Solidarity Fund KCE Reports 133
The time between the moment where the medication is needed for the treatment of
the patient and the moment where a decision on reimbursement is taken, is judged as
unacceptably long. The internal procedures of the SSF as well as the preliminary steps at
sickness fund level are not clear to the respondents.
The pharmaceutical companies are not involved in the SSF procedures, even if they have
to deliver expensive drugs at the start of a patients’ medical treatment. Indeed, when
asked for, the pharmaceutical company has to deliver the drug to the patient via the
hospital at the moment the drug is needed for the treatment of the patient. In most
cases the need for the drug is urgent and the drugs have a high cost. Ethically the
company cannot refuse to provide the drug, even if at this stage the company has no
guarantee at all the product will be paid for.
In most cases the pharmaceutical company will make an invoice to the hospital for the
drugs that have been provided. In reality the invoice will not be paid for as long as there
is no decision from the SSF and payment is effectively received by the hospital. If the SSF
only refunds a percentage (mostly 60%) of the price of the medication, the hospital will
only pay that part of the invoice to the pharmaceutical company. The rest of the
amount stays ‘open’. The laps of time between the provision of the drug and the partial
payment by the hospital in general exceeds the period of one year. It can take several
years before the additional 40% is paid. In most of the cases the 40 % will be limited to
the price that finally is accepted by the SSF. The company does not know when the
additional reimbursement is executed.
The pharmaceutical company has no knowledge or control at all on the introduction of
an SSF application since the application is initiated by the patient (via the medical doctor
that prescribed the drug). No information is given on the fact if an application is
submitted to the SSF or on the progress of the decision-making process. The
pharmaceutical company does not know if the prescription of the drug meets the
criteria as applicable for SSF files. They can not verify if the patient’s medical condition
meets the criteria of the SSF and if or when a decision by the SSF has been taken. The
outcome is not known to them. They fully depend on the information that is given by
the hospital. Contacts with the SSF itself are not allowed. For the pharmaceutical
companies it is clear the actual system leads to many discussions between the company,
the hospital and the patient. Uncertainty for all is very important and not acceptable.
The administrative follow-up of the invoices for the medication to the hospitals is
judged as very time consuming. It can take several years. In some cases the total amount
of these invoices that are waiting for payment can be very important. One company
mentioned the amount of €4,5 M for one type of drugs over a period of two years. If
the SSF takes a negative decision and the reimbursement is refused, the pharmaceutical
companies say they mostly will not be paid. They find it unreasonable that they have to
bear the risk in such cases; even if they understand these (mostly very high) costs
cannot be charged of the patient.
The SSF procedure normally foresees the reimbursement will be done to the patient. If
the patient agrees, the payment will be executed directly to the hospital (the hospital
pharmacy that delivered the drug to the patient). As mentioned, the pharmaceutical
company is not informed of the status of an SSF application and gets no notification of a
decision taken by the SSF. They also don not know if the patient agreed to have a direct
payment to the hospital. The pharmaceutical companies ask to have a more transparent
procedure where, if they delivered the drugs and have not been paid for it, the SSF
would keep them informed on the decision and the payment procedure. It must be
possible to organize such notification in full respect of the patients’ privacy by making it
completely anonymous.