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

KCE Reports 133 Special Solidarity Fund 69
o embolie pulmonaire à répétition ;
o dégénérescence musculaire ;
o asthme;
o etc.
• Polypathologies, when a patient suffers from more than one disease,
resulting in a state of invalidity and requiring a period of treatment that is
exceeding 6 months. For instance, a patient suffering from blindness, while
at the same carrying the consequences of a hip fracture (article L. 322-3-
4° du Code de la Sécurité Sociale).
For some specific rare diseases, a number of ‘simple’, pharmaceutical products that are
used by rare disease patients are not (fully) reimbursed by the public health insurer,
even if they are reimbursable if they are prescribed for other diseases. A good example
is vitamins that are prescribed to mucoviscidosis patients.
Article 56 of Social Security Finance Law (Loi de Financement de Sécurité Sociale, 21
décembre 2006 35 ) enables the exceptional and temporary reimbursement (renewable
period of 3 years) of certain non-reimbursed prescribed drugs, products or treatments
for chronic or rare diseases. The following conditions have to be fulfilled:
• There is no other, appropriate alternative available within the
conventional reimbursement system;
• The use of the product or treatment is primordial for the health status of
the patient or necessary to avoid aggravation
• The product or treatment has been subject to a recommendation or
advice within (6 months) of the Haute Autorité de Santé (HAS) who asks
systematically for the advice of AFSSAPS
Applications for a recommendation by the HAS can be introduced by the minister of
Health, the minister of social security or the “conseil de l’Union nationale des caisses
d’assurance-maladie.
Decree n° 2008-211 36 concretizes the conditions under which the HAS needs to treat
such requests and the time frame that should be respected with respect to a final
decision 22 .
7.1.3 Recent Health French System Reforms
Cost control is a key issue in the French health system, as the health insurance scheme
has faced large deficits for the last 20 years. More recently the deficit has fallen, from
€10-12 billion per year in 2003 to a €6 billion in 2007. This may be attributed to the
following changes, which have taken place in the last two years:
• A reduction in the number of acute hospital beds
• Limits on the number of drugs reimbursed; around 600 drugs have been
removed from public reimbursement in the last few years
• An increase in generic prescribing and the use of over the counter drugs
• The introduction of a voluntary gate keeping system in primary care
• Protocols for the management of chronic conditions
• From 2008, new co-payments for prescription drugs, doctor visits and
ambulance transport will not be reimbursable by complementary private
health insurance
Recent health policy developments include:
• Act of 13 August 2004 on the health insurance reform, based on three
main pillars:
22 http://www.has-sante.fr/portail/upload/docs/application/pdf/2009-06/guide_methodo_art56_web.pdf