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

56 Special Solidarity Fund KCE Reports 133
Some respondents state that the SSF may not result in inequalities between patients
with a disease – indication versus a rare disease indication. The rare character may not
lead to the situation that costs that have to paid out of pocket by patients with a nonrare
disease/indication are reimbursed to patients with a rare disease/indication.
6.1.2 Relevance of the SSF
All respondents are convinced that the activities of the SSF correspond to real,
identified needs. The relevance of the SSF becomes clear in a small number of rare,
extraordinary situations for which the compulsory insurance system is not providing a
solution yet.
Some respondents warn for the danger that the SSF might be used by the
pharmaceutical industry as a fund for studies during phase 2 and phase 3 in the
development process of a medicine. Today, the share of drugs in the total
reimbursements by the SSF is already extremely high.
6.1.3 Familiarity of the SSF
According to our respondents, the SSF is still insufficiently known among health
practitioners and health providers. Target populations might not be entirely reached
because of the relatively limited knowledge of the SSF. To their opinion reaching the
target populations in a more effective way is considered as a true challenge for the
coming years.
Some respondents support the idea to shift the reimbursement of costs for ‘chronically
ill children’ to the compulsory health system. They do not see this group of patients as a
specific target population for the SSF and would prefer to have a regular reimbursement
for the costs the SSF is reimbursing now on a case to case basis. The costs and the
medical acts can easily be integrated in the standard nomenclature used in the
compulsory system.
6.1.4 Procedure
6.1.4.1 Local Sickness Fund level
6.1.4.2 SSF level
According to the interviewees, the local advising doctor should play a more active role
during the first step of the procedure and examine eligibility to reimbursement more in
detail instead of focusing on the administrative’ aspects of the request.
The involvement of the ‘medical director’ of the sickness fund at the SSF level in the SSF
files is judged as relatively low due to a lack of time.
The preparation of the College meetings by its members is mostly limited to their
individual files (belonging to their health insurance fund). Files of other members are
available only two to one day before the meeting of the College, which is considered as
a very short notice for preparation. This observation is corroborated indirectly by the
SSF sample data. Of all applications, 95.5% is scheduled on a SSF College meeting within
7 days of reception. Applications delegated to the sickness fund are all scheduled within
5 days of reception.
The members of the College agree the leading officer is consequent in the policy to
submit all cases to the plenary session of the College where there could be any doubt
whether the application meets the criteria for reimbursement.
The fact there is no formal and systematic control on the decisions taken ‘by delegation’
is not judged as a problem. The contra signature of one other member of the College in
the case of a refusal of reimbursement is seen as a sufficient control mechanism.
Based on the feedback of the members of the College, the reporting and follow up of
applications, delegated to the SFF medical doctor could still be improved and be more
systematically.