Helsana's position statements, in brief and clearly comprehensible: The Helsana Group issues policy documents explaining its position on important questions and problems relating to the healthcare market.
- Health Technology Assessment
- Per-capita premium system
- Suspension of benefits
- Benefits catalogue
- Managed Care and integrated treatment
- Medication supply in Switzerland
- Orphan drugs
- Personalised medicine
- Risk adjustment
- Compulsory insurance
Health Technology Assessment
We believe that a nationally unified, institutionalised process for the assessment of medical procedures and technologies is advisable for the Swiss healthcare sector. The Federal Government should develop a national solution; individual cantonal solutions should be rejected. A structured approval process should be applied on the basis of a cost-benefit evaluation. Thus, the basic health insurance benefits catalogue would remain limited to what is necessary and appropriate. To ensure the necessary consensus, the Health Technology Assessment (HTA) must remain independent of special interests whilst simultaneously involving all healthcare stakeholders. Ideally, this would be achieved by coordinating with existing institutions and providers.
Per-capita premium system
The partial financing of basic medical care by means of per-capita premiums (where the cantons contribute to the cost of inpatient hospital treatment via taxes) has the advantage that the financial burden can be structured on the basis of both social and socially responsible principles. Thanks to the individual premium reduction (individuelle Prämienverbilligung, IPV), people in modest economic circumstances receive financial support. At the same time the per-capita premium system strengthens personal responsibility, transparency and true-cost pricing. The premiums basically follow benefit costs. Thanks to the pay-as-you-go system no deficits are accumulated at the expense of future generations. Helsana is therefore in favour of keeping the per-capita premium system and calls for proper structuring of the IPV and tax deductions.
Suspension of benefits
The Swiss parliament alleviated the consequences of suspension of benefits (suspension of insurance coverage in the event of default) with effect from the beginning of 2012: since then, the cantons have assumed 85 percent of the accrued outstanding premiums and costs on submission of a loss certificate. At the same time suspension of benefits in the event of outstanding premiums was abolished. The cantons are free, however, to "black list" people who do not pay their premiums and restrict their medical care to emergency measures. Helsana regrets this change to the system, as it prevents standard nationwide implementation of compulsory health insurance. In addition, abolition of the suspension of benefits weakens personal responsibility. No instrument other than the individual premium reduction (individuelle Prämienverbilligung, IPV) is required to mitigate the consequences of late payment. Insurers must assume the risk of payment default independently.
Access to basic medical care is guaranteed on the one hand by the compulsory health insurance and on the other by the uniformly defined benefits catalogue. By law, the compulsory health insurance only assumes benefits that are effective, expedient and cost-effective. Helsana is of the opinion that all benefits under compulsory health insurance must be medically indicated and justified according to the criteria of "evidence-based medicine" (i.e. on the basis of scientifically and empirically proven effectiveness) in all cases. In order to ensure the approval of new benefits and the systematic review of the benefits catalogue, Switzerland also needs a clearly defined evaluation or assessment procedure.
Managed Care and integrated treatment
Although the Managed Care model was rejected in June 2012 by the electorate and the cantons, alternative insurance models continue to enjoy increasing popularity. More than 60% of all insured persons are currently enrolled in an alternative insurance model, i.e. they voluntarily forego the free choice of doctor, preferring to trust in a gatekeeping model and take advantage of premium discounts. Helsana's experience and various scientific studies show that, thanks to integrated care and with appropriate cost-conscious behaviour within the networks, significant risk-adjusted savings can be made on benefit costs. Helsana remains convinced that the wide variety of forms and activities in the field of integrated care can make a lasting contribution to cost containment in healthcare, particularly with regard to improved risk adjustment.
Medication supply in Switzerland
Medicines should be subjected to annual price verification and parallel import should be possible for patented drugs too. The approval process should be speeded up to ensure rapid access to innovative treatments. Practice shows that, despite clear rules on pricing, there is room to manoeuvre at ordinance level on the specific regulatory pricing of a drug. The introduced prevalence model makes the rules more complex. In the spirit of transparency, proposed prices and the rulings of the Federal Office of Public Health (FOPH) should be public.
As long as the FOPH specifies drug margins, the wrong incentive – doctors earning money on supplying patients with medications – must be curbed by reducing the margins. But a change in the system would be ideal: funding bodies should be able to negotiate terms with the specific delivery channel.
The special financing solution decreed by the Federal Council is not an answer to the central issue of equitable cost-benefit analysis of medications outside the applicable limitations in individual cases. The insurer can only effectively counter allegations of arbitrary evaluation of the benefit if there are clearly specified criteria. For this reason, Helsana has developed a science-based model of benefit assessment and is calling for its industry-wide application.
The objective of this model is to enable innovative off-label drugs with an acceptable cost-benefit ratio to be compensated at a fair price. This will give seriously ill people access to urgently needed medicines.
The developments subsumed under personalised medicine have enormous potential both for funding bodies and for generating improved care for patients. For this reason, Helsana takes a fundamentally positive view of this trend. That said, the framework conditions should be structured such that opportunities may be exploited and risks contained. However, payment for new treatment options must remain adequate and medication costs should not rise to an incalculable level. As regards compensation, the same basic rule that governs all adjustments to the benefit spectrum under health insurance should apply: rapid access to innovative treatments must be ensured, without having to accept negligent limitations to established criteria (effectiveness, expediency and cost-effectiveness).
The risk compensation (RC) currently definitively anchored in legislation takes into consideration age, gender and inpatient stay in the previous year from 4 days and more, however it does not adequately represent, in particular, chronically ill patients and cost-intensive patients with outpatient medical expenses. Helsana therefore welcomes a further refinement of the RC and supports the planned introduction of a medication costs threshold at the beginning of 2017. At the beginning of 2019 the RC is to be supplemented with the average costs of certain chronically ill patients who can be identified on the basis of their medication (so-called Pharmaceutical Cost Groups). In the medium and long term, risk compensation is to be further refined, in particular in inpatient care, it must, however, not become compensation of costs.Up
Helsana recognises that compulsory insurance is an important achievement of the Swiss healthcare sector. Compulsory insurance ensures unrestricted access to basic medical care for the entire population. Financing for healthcare provision is ensured by means of the socially cushioned per-capita premium system with individual premium reduction (individuelle Prämienverbilligung, IPV). However, well-functioning risk adjustment is absolutely essential for an insurance system with compulsory admission and a single premium. This must be further improved as quickly as possible.