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

KCE Reports 133 Special Solidarity Fund 57
6.1.4.3 Appeal procedure
According to some of the interviewees the labour courts do not have sufficient
expertise in assessing the criteria and the conditions for decision-making.
6.1.5 The criteria for decision-making
The decision-making criteria are not elaborated in depth. Different views exist between
the members concerning the decision-making process. Some consider each case as an
individual one (case-by-case handling), while others are striving for more uniformity in
the decision-making process.
There is consensus between the interviewees that the legal criteria and requirements
for eligibility are open for interpretation. Particularly, “expensive treatment”, “rare
disease”, “experimental phase” and “vital functions” are terms that might cause
confusion and discussion. Some respondents consider the broadness and vagueness of
the criteria as an obstacle for coherent decision-making. However, most of them
welcome the possibility of interpretation, given the role of the SSF as an additional
safety net. The rareness of a disease is regarded in perspective to the orphaned
criterion of a prevalence of 1/2000.
The ‘College of medical directors’ translates the criteria as defined by the law during
the decision-making process in a pragmatic way. For the criteria “expensive” internal
criteria per episode and per year are handled.
Whether the personal financial situation of the patient should be an element to be taken
into account, when deciding on reimbursement (or portion of reimbursement) by the
SSF, is an issue for some respondents. Today this is not a criterion applicable to the SSF
reimbursement system
6.2 THE SOCIAL SERVICES
6.2.1 Brief presentation of the interviewed social services
In all the hospitals included in the sample, the social service is a central hospital
department. Individual social workers are in all cases directly linked to one or more
hospital wards and medical services. As a consequence they have a good knowledge of
specific pathologies and interact with a limited number of permanent medical doctors.
In university hospitals, characterized by a frequent turnover of medical doctors in
training, social workers interact with more contact persons during a shorter time
period.
The number of staff working in the social services varies between 3.5 FTE and 60 FTE.
The range of tasks to perform is very extensive and diverse. It includes social and moral
support, monitoring of complaints, handling payment difficulties of hospital invoices,
completion of administrative formalities for example with the sickness funds, the
organization of practical assistance related to the dismissal of the patient such as home
care. For these tasks the initiators asking for support are patients, family, nurses or the
medical doctors.
Providing support for and monitoring of SSF (special solidarity fund) files represents
only a tiny fraction of the social workers’ workload. The initiator asking for support
from the social service in SSF cases is almost always the patients’ treating medical
doctor.
During our interviews no substantial differences in the answers were identified
according to the different categories we distinguished (university versus non university
hospital/French versus Flemish hospital/big versus small SSF applicant).