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

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70 Special Solidarity Fund KCE Reports 133 Keypoints France o The rationalization of healthcare: obligation to choose a regular GP, personalized medical files and introduction of a new Carte Vitale (a smart card containing the health beneficiary’s details) from 2007 to 2010. o A complementary contribution by each beneficiary: contribution of one non-reimbursable euro on each visit to a GP or specialist and flatrate hospital contribution of €15. o Combating fraud: more stringent checks on sick leave and Carte Vitale bearing an ID photo. • Act of 9 August 2004 on the public health policy, which introduces five major five-year programmes and regional public health policy management. The five programmes for 2004-2008 are: o The cancer plan, o The plan to combat violence, abuse, risk behaviour and addictive behaviour, o The plan to curb the impact of environmental factors on health, o The plan to improve the quality of life of patients with chronic illnesses, o The plan to improve treatment and care for patients with rare diseases. • In France, the distinction is made between universal, public health insurance, providing a standard benefits package for all residents (assurance maladie obligatoire) through large occupation-based funds, and complementary private health insurance. • The principle of cost-sharing where patient are carrying a part of the cost burden, or ticket modérateur, is extensively applied to public-financed health services in France. However, there are safety nets for categories of citizens that are exempt from co-insurance regulations and that are 100% reimbursed: this applies for people with invalidity or with work injury, people with specific chronic illnesses and low income patients. • Health insurers have a public and statutory character with a membership based on occupation. There is no competition and no system of risk adjustment provided, even though there is inadvertent risk selection based on occupation. • Healthcare providers (extra muros and intra muros) charge their delivered services in function of two elements: the classification (nomenclature) of groups of services based on their nature, and the negotiated price for these different service groups. The Nomenclature lists also all medicines that are reimbursed by public health insurance to the patient. • The French government elaborated an ambitious National Plan for Rare Diseases 2005-2008. The Plan has the general aim to improve the equal access to healthcare services for rare disease patients (from the diagnosis phase to the reimbursement of costs). • In France, the level of reimbursement of patients suffering from a rare disease is strongly linked to the recognition of their disease as a chronic disease. People that suffer from a chronic disease are exempted from costsharing and thus fully reimbursed by the public health insurance fund. This is only true for healthcare costs linked to the treatment of their chronic disease and not for any other disease they might have.
KCE Reports 133 Special Solidarity Fund 71 • The French healthcare system recognizes three categories of chronic diseases: 1) Chronic diseases that are listed as ‘ALD 30’, or diseases that require an extend period of treatment and an expensive treatment. The list of these 30 chronic diseases are defined and adapted by the Minister of Health; 2) Chronic diseases that are not listed as ‘ALD 30’, but that are recognised as a chronic disease as they require a period of treatment that is exceeding 6 months as well as an expensive treatment; 3) Polypathologies, or in case 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. • Temporary authorisation (ATU) for the use of new drugs outside of the framework of clinical trials, without Marketing authorisation (MA) in France, whether they benefit or not from a MA abroad, at individual patient level (at the request of the prescribing physician) or homogeneous group (cohort) level (at the request of the pharmaceutical firm) can be granted by AFSSAPS in a very short time laps. Solely drugs that are used for the treatment of serious or rare diseases, for which there is no other treatment available and cost-benefit analysis of the treatment was conducted, with a positive result are eligible for ATU. • Article 56 of Social Security Finance Law enables the exceptional and temporary reimbursements of certain drugs, products or treatments for rare or chronic diseases, if there is no other, appropriate alternative available within the conventional reimbursement system and if the product or treatment has been subject to a recommendation or advice of the Haute Autorité de Santé (HAS) 7.2 THE NETHERLANDS An introduction of the Dutch healthcare system and the organisation of the healthcare provision can be found in annex. 9.15. 7.2.1 Reimbursement of medicines 7.2.1.1 Extra muros vs. intra muros In order to get an idea about the reimbursement of medical care, one should make the distinction between healthcare provision intra muros (within the hospital) or extra muros (outside the hospital). Within the context of medicines, intra muros is not necessarily being considered as period of hospitalisation. Many medicines, in particular orphan drugs or expensive drugs, are prescribed and provided by hospital specialists without the patient being hospitalised.
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