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

10 Special Solidarity Fund KCE Reports 133
2.1.3 Position of the SSF in the Belgian Health System
2.1.3.1 The SSF position in practice: unique but complex
Although the SSF is fully embedded in the NIHDI, the SSF complements the Belgian
compulsory health insurance system and reimburses certain medical expenses for rare
diseases, rare indications and innovative techniques which are not (yet) refunded by the
compulsory health insurance. This situation creates a strange and unique positioning of
the SSF within the national health system. The SSF belongs structurally to the
compulsory health care insurance system (NIHDI) but performs activities
2.1.3.2
(reimbursement) which fall outside the regular system.
Secondly, the SSF only intervenes when all other options/channels for reimbursement
have been exhausted including reimbursement from private health insurance companies.
This condition emphasizes that the scope of the SSF is outside the compulsory health
insurance system but it is on the other hand confusing as the SSF belongs to the
compulsory health insurance structure. The SSF is the last additional safety net to
“ordinary” insurance coverage for medical care.
This unique position makes the SSF heavily dependent on the functioning of the various
councils, committees or colleges and the evolution of the benefit package as a whole
within the regular health insurance system. The services that are covered by the
compulsory health insurance are described in the nationally established fee schedule
(the “nomenclature”), which is extremely detailed and lists more than 8000 procedures
and types of products. For each service, the identification number, contractual fee and
reimbursement rate are specified. Services not included in the fee schedule are not
reimbursable. At regular intervals, new treatments or products are introduced into the
benefits package and treatments that have become obsolete are removed. When the fee
schedule/nomenclature is adapted too slowly to evolutions in the general medical
practice, this will affect the SSF by keeping the reimbursement of these services and
medical acts in the scope of action of the SSF instead of inclusion into the regular
reimbursement system (compulsory health insurance).
On the other hand decisions taken by the SSF can also influence negotiations and
activities of the committees, councils and colleges of the compulsory health insurance
system. This could be the case for the negotiations with the pharmaceutical companies
on the reimbursement level for new drugs led by the Drug Reimbursement Commission
(DRC/CTG/CRM). In order not to influence these negotiations, the SSF, if it decides to
reimburse a drug before acceptance in the compulsory health insurance, can decide to
accept only a part (mostly a percentage) of the cost that is charged by the
pharmaceutical company.
One can notice that the relation between the SSF and other compulsory health
insurance committees is bidirectional.
Other protection mechanisms and the relation to the SSF
Regulation on orphan drugs
For orphan drugs the Belgian compulsory health insurance system introduced a specific
reimbursement framework. The “College of medical directors on orphan drugs”
(CMDOD) assesses the individual right of the patient to the reimbursement of an
orphan drug, as far as the reimbursement conditions require such an assessment and as
far as the advising physician of the patient’s sickness fund requested the advice of the
College. The action field of the College interacts with the action field of the SSF. If the
CMDOD decides on the reimbursement of an “orphan drug” for a particular indication
for an individual patient, the SSF will no longer decide on the reimbursement of this
drug, not even for indications the CMOD did not decide on (off label use of the
respective orphan drug). This implies that patients potentially benefiting from SSF
reimbursement of a drug for a specific indication before the respective drug was
accepted as an orphan drug, will no longer be reimbursed if the CMDOD did not
include that particular indication in its decision 2 .