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

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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.
KCE Reports 133 Special Solidarity Fund 187 9.14 INTERNATIONAL COMPARISON: FRANCE 9.14.1 Sources • Telephone interview with Mrs. Marie-Claude Hittinger, Rare diseases Expert of the Haute Autorité de Santé • Telephone interview with Mrs. Isabelle Cheiney, Direction de la Sécurité Sociale of the French Ministry of Health • Telephone interview with Mrs. Anna-Marie Bouchard, Comité Economique des produits de Santé (CEPS) • Circulaire Assurance Maladie – Caisse nationale regarding the conditions for reimbursements of costs, related to rare diseases. . • Website: o Comité Economique des produits de Santé (CEPS) : 9.14.2 http://www.sante.gouv.fr/ceps o Assurance Maladie : http://www.ameli.fr/ Short introduction to the French healthcare system 9.14.2.1 Who is covered? In France, one should distinguish between: Basic, public health care insurance, providing a standard benefits package for all residents (assurance maladie obligatoire). There is a universal, basic health care insurance providing a standard benefits package for all residents, through large occupation-based funds. One can distinguish between different public insurance schemes: • The General National Health Insurance Scheme (le régime général de la Sécurité sociale) covers about 83% of French workers, as well as their families, and is the most important one. Other occupational specific schemes cover the remainder: • La Mutualité sociale agricole (MSA) covers agricultural workers and their families - about 9% of the population. • La Caisse nationale d’assurance maladie des professions indépendants (CANAM) covers artists, entrepreneurs and other self-employed – about 6 of the population. Following the introduction of Couverture Maladie Universelle (CMU) in 2000, the state finances coverage for those residents that are not eligible for coverage by the public health insurance scheme (0.4% of the population). The state also finances health services for illegal residents (L’Aide Médicale d’Etat; AME). Complementary private health insurance: in order to cover the difference between what the state pays and the cost of treatment (complément), most French residents purchase a complementary health insurance policy to cover the difference. This is called a police complémentaire or mutuelle and is provided by about 80 insurance companies, 20 welfare institutions (institutions de prévoyance, managed by both employers and syndicates) and 6500 mutual societies (mutualités). Often, complementary health insurance is occupation-based. Complementary private health insurance covers over 92% of the population. In 2005 out-of-pocket payments and private health insurance accounted for 7.4% and 12.8% of total health expenditure respectively. 45
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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