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

KCE Reports 133 Special Solidarity Fund 55
6 EVALUATION OF THE FUNCTIONING OF
THE SSF
A high level description of the perceived positive and negative elements regarding the
functioning of the SSF and some suggestions is listed in the current chapter. It should be
stressed that these statements represent the perception and the experiences of the
interviewed stakeholders. An overview of the detailed answers on the following topics
is included in annex 9.10., 9.11. and 9.12. Annex 9.13. reflects the statements of
Pharma.be and the representatives of the pharmaceutical industry.
• Knowledge on the existence of the SSF
• Need for a safety net
• The SSF: meeting its objectives
• Alternatives for the SSF
• The intervention domains of the SSG
• The limitations of the SSF intervention domains
• Experiences with the SSF and knowledge of the SFF procedure
• Communication and information dissemination
• Knowledge and appreciation of the SSF criteria
6.1 THE MEMBERS OF THE ‘COLLEGE OF MEDICAL
DIRECTORS’
As mentioned above, the College of Medical directors is composed out of the medical
directors of the sickness funds and some medical doctors from the NIHDI. They meet
on a weekly base to decide upon the SSF applications that have been introduced to the
SSF services.
6.1.1 Primary objectives of the SSF
According to the medical directors interviewed, the primary objective of the SFF is to
act as a social safety net for patients who are confronted with high, non-reimbursable
costs following an expensive medical treatment. The SSF reimburses the expenses of a
very small target population for rare treatments that are not reimbursed under the
compulsory health care insurance system.
Some respondents consider the SSF as a contemporary solution (‘waiting room’) for
specific and complex situations (treatments, devices or drugs) for which there has not
been arranged a framework for reimbursement yet. Diseases, indications or medical
situations that cannot be categorized based on a first analysis, risk to fall as a residual
under the SSF umbrella. Some members of the ‘College’ are slightly worried about this
evolution and stress that it would be better to speed up the inclusion of a number of
expenses for medical treatments or medicines in the compulsory health care insurance
framework.
There is a general concern among the respondents about the SSF refunding expenses
for medical treatment or medicines that could easily be covered by the compulsory
sickness insurance system especially for drugs and medical devices. However,
pharmaceutical companies are not always eager to introduce a request at the “Drug
Reimbursement Commission” (Commissie Tegemoetkomingen
Geneesmiddelen/Commission Remboursement des Médicaments), deciding on what
drugs, products or treatments are refundable within the compulsory health care
insurance system. Since the introduction of such a request is costly procedure,
commercial or financial arguments could explain the identified hesitation especially
among pharmaceutical companies to start up the process. Entering an application for
reimbursement of a drug in the compulsory health system also includes a discussion on
price setting.