We are committed to a competitive and organised health system.
We are convinced that this is the only way to ensure that medical care will remain good and affordable too in future.
We therefore fight to ensure that the health system is developed further in accordance with our position statements.
- Evaluation of the overall system
- Compulsory health insurance & per-capita premium system
- Risk compensation
- Benefits catalogue
- Supplementary insurances
- Systematic performance evaluation
- Quality in the health system
- Supply of pharmaceuticals
- Personalised medicine
- Unitary funding of services
- Hospital care
- Funding of nursing care
- Health care research
- Alternative insurance models
- Freedom of contract/Tariff autonomy
- Personal responsibility and cost sharing
- Digitalization in the health system
- Health literacy
- Prevention and health promotion
Evaluation of the overall system
The medical care for the population is good - but it also has its price.
The Swiss health system follows the guiding idea that competition, and not the state control, ensures medical care for the population.
This practice contributes to the fact that it is generally recognized that Switzerland disposes of a well-working health system.
Therefore, Hesana is against any attempts to introduce state medicine solutions by means of lump-sum budgeting procedures or even the elimination of the insurance system (so-called single insurance fund).
The compulsory insurance offers to any person living and/or working in Switzerland a protection against the financial consequences of illnesses. Everybody has an unrestricted access to medical care. Every person pays an amount in the form of the health insurance premium, wherein premium of a health insurer must be identical for all people in the same premium region. Financially disadvantaged households are granted a premium reduction.
However, this well-developed healthcare provision has its price. The Swiss health system is expensive, it has too many inefficiencies and a lack of transparency.
So, it must be developed further in order that future generations may also enjoy this comprehensive protection.
Therefore it should be possible that contracts between service providers and health insurers a freely negotiated.
In order to ensure the future viability of the Swiss health system, service providers and health insurers must be allowed to negotiate contracts freely. This is the only way to achieve more efficiency and transparency. The current obligation to contract impedes this development.
Therefore the hospital funding should be entirely carried out by health insurers.
There is also a need for action regarding hospital funding. Today the Cantons and health insurers are currently jointly paying the inpatient’s hospital stay. But, as it is well known, too many cooks spoil the broth, which means that considerable, unnecessary, additional costs and hence inefficiencies arise. It is better when only one partner takes on the hospital funding.
As the Cantons are not only responsible for safeguarding continuity in the healthcare system but are also owners of many hospitals, it makes more sense if the funding is entirely ensured by health insurers, as it is already currently the case with the outpatient care sector. This is the only way to keep an eye on the whole treatment chain in accordance with the interests of patients.
Since treatment decisions should be made from a medical point of view, rather than based on financial considerations alone.
Therefore the benefits’ catalogue should be reviewed.
All services that are needed for a treatment must be available to the patients. However, it must be ensured that these services are also really effective, expedient and cost-effective. The benefits’ catalogue has to be reviewed in this respect. It is the only possible way to determine the basic needs for treatment and to ensure its funding in the long term. All other benefits need to be funded in some other way, for example by means of supplementary insurances.Up
Compulsory health insurance & per-capita premium system
Compulsory health insurance and per-capita premiums are indispensable achievements – solidarity is ensured.
The compulsory health insurance is an important achievement of the Swiss health system. It guarantees the unrestricted access to primary medical care for the whole population. Funding is provided to a large extent by means of per-capita premiums. This ensures that the medical benefits are used in a self-reliant manner, without imposing financial burdens on the future generations. Increasing premiums are caused by increasing costs.
On the one hand solidarity is ensured by the fact that persons in modest economic conditions receive financial support from federation and cantons (premium reductions), on the other hand the cantons contribute with tax revenue to the funding of the inpatient medical care.
Therefore the compulsory health insurance should be maintained and the criteria for premium reduction reconsidered.
Both the compulsory health insurance and the per-capita premiums must be maintained.
The redistribution between poor and rich is a task of the state, therefore the system of individual premium reduction must be maintained. However, since more and more households have to make use of the premium reduction, it is important to reconsider the criteria for it. The distribution of money must not be made with the watering can.
The risk compensation is a mandatory prerequisite for a fair competition among health insurers.
In a compulsory health insurance system with compulsory admission and uniform per-capita premium a well-working risk compensation among the health insurers is a mandatory prerequisite for a fair competition. Since each health insurance company has a different structure of insured persons and it is not allowed to determine the premiums on the basis of the medical risk, the insurers with "sicker" insured persons must receive from the insurers with "healthier" insured persons a compensation for the additional costs incurred. Without this compensation mechanism the health insurance market would collapse, because the insurers with "sicker" insured persons could not survive in competition.
The risk compensation must work well, in order to ensure the competition among health insurers. Therefore, it is continuously further developed and improved. In the past, in order to depict the differences in the structures of insured persons, what was taken into consideration was merely the age and the gender of the insured persons and whether they had stayed in a hospital or in a care home. As from 2017, the consideration of the medication costs will be introduced.
Therefore the risk compensation should be continuously improved.
The permanent improvement of the risk compensation is to be welcomed. In particular, chronic illnesses put a heavy financial burden on our health system. For this reason, such factors, for instance, should also be included, because the better the risk compensation takes into consideration the medical condition of the insured persons, the more equitable the system and the fairer the competition among insurers is.Up
The benefits catalogue is not currently reviewed regularly and systematically, even though the legislator postulates it.
According to the law, the compulsory health insurance may only reimburse services that are effective, expedient and cost-effective.
While, for instance, in the medication area the List of Specialties clearly defines which pharmaceuticals must be reimbursed, medical services performed or delegated are reimbursed according to the principle of trust: what the physician does or disposes is subject to reimbursement.
Therefore the benefits catalogue should be continuously reviewed and be based on measurable criteria.
For higher efficiency and transparency it is necessary that the entire benefits catalog – this means all existing and already approved medical benefits – should be regularly reviewed.
The basic insurance should no longer reimburse pharmaceuticals or other services whose benefits are not sufficiently documented.Up
Supplementary insurances cover important customer needs beyond the compulsory area and are therefore an important element of the health system.
The compulsory health insurance must ensure the access to the basic medical care. In order to ensure that the basic health insurance remains financially feasible in the long term, the benefits catalogue has to be permanently reviewed, so that only what is necessary and useful is funded based on solidarity.
With supplementary insurances the customers have the possibility to insure themselves according to their individual needs. For example, in the area of complementary medicine, prevention and precaution or as related to organisational services such as second opinion or extended access to services.
The supplementary insurance is an important element of the health system, as it stimulates the patient‘s personal responsibility and is needs-oriented.
Therefore the insurers should have, in future too, freedom of action as regards the supplementary insurance.
In order that the insurers can provide offers according to the customer needs, it is crucial that they have, in future too, the freedom of action necessary for it.Up
Systematic performance evaluation
There is no systematic basis in the evaluation of medications and therapeutic procedures.
In Switzerland there is no systematic evaluation of medications and therapeutic procedures in the healthcare provision. There is too much reimbursed that does not bring about any additional benefits.
Regular evaluations are necessary in order to treat the funds for the basic insurance in an economical manner.
Therefore the scientific verification system HTA should be applied more intensively.
Health Technology Assessment (HTA) examines products and medical services for their benefits, security and costs, based on the latest scientific knowledge. With the aid of HTA the authorities check if a product provides an additional benefit and calculate the associated additional costs. On the basis of this information it must be then decided – in Switzerland by the Federal Office of Public Health (FOPH) – whether a reimbursement through the basic insurance makes sense or not. Thus, a more intensive application of HTA would have a cost-reducing and beneficial effect on the health care system.Up
Quality in the health system
In the payment of the medical service provision quality does not play the role that has been actually established by law.
The demand for quality in the provision of medical services is repeatedly enshrined in the Health Insurance Law. Indeed, there are currently numerous quality activities throughout Switzerland, but they are uncoordinated, do not have a common understanding of quality, are fragmentary, non-binding, intransparent and not result-oriented.
In the payment of the medical service provision quality does not play any role so far.
Therefore it is necessary to introduce a binding, nationally coordinated quality management system.
Even under a compulsory health insurance a minimum of quality specifications (incl. evidence of them) is an absolute matter of course. A nationally uniform understanding of quality is indispensable, ensuring that services and products become comparable.
However, a binding, nationally coordinated quality management system should be confined to essentials and based on existing, tried and tested structures.
The federal authorities should only exercise a coordinating function.Up
Supply of pharmaceuticals
a) Prices of pharmaceuticals
The prices of pharmaceuticals are too high and the price setting intransparent.
Medication costs make up around a quarter of the costs in the basic insurance.
What is missing today is, on the one hand, a systematic evaluation of the pharmaceuticals and, on the other hand, the possibility to inspect the completely intransparent pricing process carried out by authorities. Health insurers and other stakeholders do not have the possibility to file a complaint against decisions of authorities. The result: too high medication prices and lack of transparency.
Therefore the authorities should consider the impacts on the health expenditures when they set the prices, and the relevant stakeholders should be given the right of complaint.
Innovations are important in the development of new medicines; and so is the access to them. Therefore, innovations should be affordable.
Thus, in the price setting carried out by authorities, apart from the cross-comparison with other countries, the therapeutic cross-comparison and an innovation surcharge restricted to exceptions, it is also important to take into account the impacts on the health expenditures. Furthermore, the parallel import of patented pharmaceuticals and their inclusion on the list of specialties for drugs covered by the health insurance needs to be authorised. Swissmedic is responsible for the authorisation and for ensuring the drug safety, like in the case of all other pharmaceuticals.
In this way, new and innovative medicines can be funded from the basic insurance in future too and thus they are accessible to all patients affected, provided they are effective, expedient and cost-effective.
The price setting carried out by authorities should be confined to those pharmaceuticals for which the competition is not possible because there are no therapy alternatives.
In areas where the patent has expired a fixed-amount system should be introduced, which means the reimbursement of all medicines with identical effect at the lowest price.
In addition, the relevant stakeholders should be given the right of complaint.
b) Access to special pharmaceuticals
There are promising pharmaceuticals which are outside the List of Specialties or outside the indication and have to be used.
Many medicines used in Switzerland are not included in the List of Specialties (SL).Others are included in SL, but are used by the service provider outside the authorised indication. This is called off-label use. The studies related to such medicines or areas of application usually do not (yet) meet the authorisation criteria. But the first study results are often very promising, which is why the patients affected should not be deprived of such innovations. Then the reimbursement is made on a case-by-case basis.
Therefore there should be a better regulation on dealing with off-label products as well as an arbitration board for cases of dispute.
If a customer develops a severe illness, there is no treatment alternative and data documenting a good efficacy of off-label products is available, the health insurance company takes up discussions with the respective manufacturing firm in order to agree on the price. A collaboration can be established with many firms, unfortunately not with all of them. This situation is unsatisfactory both for the health insurance company and the patient. That is why a better regulation on dealing with off-label products is necessary, for example by appointing an arbitration board for those cases in which agreement cannot be reached.Up
The supply of pharmaceuticals in customized form can favour the therapy success.
The aim of the personalised medicine is to offer the supply of pharmaceuticals to the patients in customized form and no longer based on the watering can principle. In many cases it was possible to provide evidence that preceding gene analyses facilitate an individually oriented therapy.
The personalised medicine assumes that each person is different and does not assimilate, tolerate and metabolize any medicine in the same way.
Therefore the procedures of the personalised medicine should be reviewed.
In order to ensure a wide access to such innovations too within the health system, the procedures of personalised medicine should be systematically and scientifically reviewed.
It is necessary to identify what additional benefit is generated by a procedure or a gene test, at what additional costs.
Extremely important here: data and privacy protection must always be guaranteed. The regulatory framework conditions must also take into consideration ethical aspects, especially the obligation to provide information and explanations or "the right not to know".Up
Unitary funding of services
So far insurers and cantons share the costs of the inpatient care.
While the outpatient care is completely paid from premiums, in the inpatient care we currently have a dual funding. It means that the patient’s canton of residence bears at least 55%, the health insurance company maximum 45% of the costs incurred. So, health insurers and cantons share the costs. Thus, the cantons as operators and owners are in a conflict of interests.
Therefore we should convert to a unitary funding of services by the health insurers.
The conversion to a unitary funding means that one stakeholder assumes full responsibility for costs. This should be the insurers, as they already reimburse all outpatient care costs. The canton would transfer its part to the health insurance company and then the insurance company pays for all services.
This would encourage the thinking in the treatment chains and prevent those inefficiencies in the transition from the outpatient to the inpatient care which are based on funding viewpoints. One stakeholder keeps track of all care costs and implements efficiency-raising measures without conflicts of interests.
To leave the funding responsibility to the canton would be detrimental to the health system, because it is already subject to numerous conflicts of interests.Up
The new hospital funding 2012 has created good conditions: the money follows the patient and does not simply finance institutions.
The new hospital funding 2012 has created the prerequisites for a well-working quality and price competition in the internal market Switzerland. Now the money must follow the patient not simply finance institutions. Consequently, private and public hospitals are equally funded by means of unitary lump sums per hospital stay. The canton of residence has a contribution of 55% to the costs. Furthermore, a (conditional) freedom of movement for the patients in the choice of out-of-canton hospitals has been introduced.
In the hospital planning and the awarding of service contracts the cantons must treat private and public providers in the same way and coordinate their hospital planning with one another.
Therefore it is necessary to stimulate the competition among hospitals, without state intervention.
The quality and price competition among hospitals must be stimulated in terms of efficiency and quality. An extensive planning of the offer and the limitation of the patients‘ freedom of movement by cantonal planning decisions hampers this mechanism. If the health care is ensured, there is no need of state intervention in the form of detailed planning.
Reasonable (minimum) numbers of cases for each responsible operator are an important quality indicator for many medical interventions. They should be taken into consideration in the hospital planning much more intensively than before.
Therefore there should be a coordination as regards the offer, in particular also in the highly specialised medicine, rather than an arms race among cantons.
In the hospital sector there is currently an arm race with additional funds from the cantons. This must be stopped, as the investments are finally refunded by means of the case lump sums of the basic insurance.
Moreover, financial subsidies that exceed the case lump sum lead to distortions of competition, excess capacities and inefficiencies.
For the purpose of quality assurance there should be a coordination among the cantons as regards the offer of the highly specialised medicine. This is the only way to prevent offers oriented to interests of regional policy alone rather than to considerations necessary for the health care.Up
Funding of nursing care
The principle of equal treatment established in the Swiss Federal Law on Health Insurance is violated in the funding of the nursing care.
Since 2011, only contributions to the nursing care services of Spitex and care homes have been paid from the basic insurance. The Federal Council determines which contributions for how many minutes of nursing care are reimbursed.
In care homes three different instruments continue to be used for clarifying the nursing care needs and recording services provided. Consequently, despite the nationally uniform contributions, reimbursements for patients with the same nursing care needs may vary. This is an obvious violation of the principle of equal treatment established in the health insurance law.
Therefore a unitary instrument should be applied in care homes for reimbursing nursing care services provided.
A nationally unitary instrument for reimbursing provided nursing care services allows the equal treatment of insured persons, therefore it must be introduced. This is the prerequisite for a future-oriented further development of the nursing care funding.
Therefore, in future too, no nursing care insurance should be introduced.
Despite the increasing need for nursing care, no nursing care insurance should be introduced. A new compulsory nursing care insurance in the sense of a fully comprehensive insurance would create false incentives and result in a massive increase in health costs.Up
Health care research
The efficacy of medical services and pharmaceuticals in everyday life is far too little known.
The most medical services chargeable to the compulsory health insurance are not checked for their cost-benefit ratio. Most notably, pharmaceuticals are assessed based on clinical trials alone.
Health care research involves investigating the results of the medical care under everyday conditions, that is outside the artificially defined environment of the studies.
The importance of the health care research can be seen in the selection of patients for clinical trials alone. For example, they may not suffer from more than one disease. Because of this criterion, it is exactly old people who are excluded, though in everyday care these pharmaceuticals are prescribed to them. Thus, the efficacy of pharmaceuticals for this group of patients is usually not considered in authorisation procedures and price setting.
Thereforethe health care research has to be extended, for better efficacy, profitability and treatment quality.
The health care research must be extended in Switzerland, in order to gain knowledge on the efficacy of medical measures in the concrete administration. With such knowledge the health system can be further developed in the sense of a better health care.
An important prerequisite for this is the access to data. Helsana uses such data in its health care research to call into question certain treatment schemes. Of course, data and privacy protection is consistently observed.
Our goal is to make a contribution in this respect and thus improve the efficacy, profitability and treatment quality.Up
The principles of corporate governance in health insurance must be observed.
The principles of corporate governance are focused on the company’s sustainable interest. They must satisfy the criteria for maintaining the decision-making ability and the efficiency. At the top management level they must ensure the necessary transparency and a balanced relationship between management and control.
Health insurers must satisfy these principles in two completely differently regulated insurance segments: basic insurance and supplementary insurance.
Therefore the supervision should be effected within a reasonable framework, for the protection of the insured persons, without detailed regulations and limitations of the entrepreneurial freedom.
The supervision should be confined to the creation of reliable framework conditions and the enforcement of the compliance therewith. Protection of insured persons and system stability should be central elements. Supervisory authorities should be able to intervene in case of malpractice or imminent insolvency. Although, detailed regulations and limitations of the entrepreneurial freedom without any legal basis have to be fought.Up
Alternative insurance models
Alternative insurance models are beneficial for everybody.
Alternative insurance models are quite popular with customers. Meanwhile more than 60% of all insured persons have chosen such models. They renounce the free choice of doctor in favour of a premium discount. In addition, studies show: patients are qualitatively better looked after, while incurring lower costs. Such models are beneficial both for patients and for the health system as a whole. The success can be attributed in particular to the newly created incentives, such as the financial co-responsibility of the attending physicians.
Therefore in the configuration of alternative insurance models there should be freedom of contract, without formal detailed specifications being provided by the state.
Only the freedom of contract can ensure the further development and the spreading of alternative models. To make possible that a higher demand for such models emerges, they must be promoted first of all by additional incentives (for example, exemption from the cost sharing for compliance programmes, adequate discount, multi-annual contracts etc.).The type and extent of the models should be negotiated and defined freely between service providers and health insurers. Formal detailed specifications provided by the state would ruin these efforts.Up
Freedom of contract/Tariff autonomy
The obligation to contract between health insurers and acknowledged service providers in the basic insurance impedes the further development of the health system.
To this day, in the basic insurance the health insurers have the obligation to conclude a contract with each service provider. If a service provider is acknowledged in Switzerland and possesses authorised medical-office premises, its services must be reimbursed by all health insurers, without further requirements. Requirements concerning the quality and profitability of the service provision do not de facto play any role.
Thus, in the health system the central competition instrument, the choice, is not available. All health insurers must conclude contracts with all service providers, all service providers with all health insurers. Whether in a canton or a region there is an excess supply of service providers or their service provision works well, whether a health insurance company offers fair conditions, all this is currently irrelevant for the admission in a collective agreement. Many service providers receive the same price for the services they have provided, regardless of their efforts.
Therefore freedom of contract should be introduced.
The advantages of the freedom of contract for the health care of insured persons are obvious: an excess medical care can be efficiently prevented and at the same time it is possible to create an incentive, for a higher quality, a better distribution of the service provision by regions and specialties and an improved transparency in the system.
On the other hand, it is also expected that for those health insurers that do not dedicate themselves to the medical care of their patients it might be difficult to get contracts with service providers. This would have as a consequence that they would lose many insured persons.Up
Personal responsibility and cost sharing
The cost sharing on the part of the insured person stimulates the personal responsibility.
In the basic insurance the insured persons may choose between several levels of co-payment (deductible).The higher the deductible, the higher the premium discount. The form of cost sharing is an essential instrument to motivate insured persons to exercise their personal responsibility. The cost sharing has a damping effect on the health costs, as the medical services are used in a more cost-conscious manner.
Therefore the financial incentive to assume personal responsibility by cost sharing should be maintained and intensified.
Financial incentives are needed to respond to a cost-pushing consumerism in the social basic insurance. Thus, this important insurance coverage remains financially acceptable for everybody. Those who are dependent on medical help and make use of services are willing to bear a portion of costs. In the end this stimulates not only the personal responsibility, but – even more important – also the solidarity.Up
Digitalization in the health system
Modern information technologies can lead to better medical care.
The employment of modern information technologies has a good potential for the health system. It goes without saying that they may only be used with due regard for data and privacy protection.
With the aid of these new technologies it is possible to avoid double examinations and make valuable information accessible, for example on allergies or safety of pharmaceuticals (possible intolerances).
In 2015 the parliament adopted the new law on the electronic patient dossier (EPDG).Since then, with the patients‘ consent, service providers may make their patient data electronically available to other service providers for medical care.
Therefore electronic patient dossiers should be more intensively used and promoted.
It is important to stimulate the patients‘ self-determination and personal responsibility when dealing with such data. Attending physicians can rely on relevant data only if they are complete and reliable – and it is only by this reliability that the electronic patient dossier will gain acceptance in the day-to-day medical care.
The necessary investments in these technologies have to be funded by those market participants who also enjoy the corresponding benefits.
The health insurance must not be used for funding the necessary infrastructure (for example in the form of investment contributions or initial funding), since the law allows and requires that medical services be reimbursed exclusively.Up
Health literacy is a central prerequisite for exercising the personal responsibility in the health field.
Health literacy can be understood in the most general sense as the ability of an individual person to make every day life decisions that have a positive effect on health. It is an essential prerequisite for exercising the personal responsibility and must enable anyone to understand health information and assume responsibility for the personal health.
Therefore The health literacy in the population should be enhanced.
Measures for stimulating the general health literacy of the patients may not be a component of the benefits catalogue of the basic insurance, since it reimburses only medical services. In addition, relevant projects are supported through the foundation Health Promotion Switzerland. This foundation is financed by an premium supplement.
However, health insurers can absolutely stimulate the health literacy, for example by informing their insured persons in matters of insurance options, benefits under the Swiss Federal Law on Health Insurance and the Swiss Federal Law on Insurance Contracts, efficacy of concrete therapies as well as regarding the health system on the whole.Up
Prevention and health promotion
Prevention and health promotion are primarily the duty of every individual person.
In 2017 each premium payer shall pay CHF 3.60 and starting from 2018 CHF 4.80 p.a. to the foundation Health Promotion Switzerland. This is responsible for the development and implementation of health promotion and prevention programmes. No provision is made for further financing from the basic insurance. In 2012 the Federal Council failed to introduce a comprehensive law on prevention. Nevertheless, prevention should be intensified in the area of non-transmissible chronic diseases. It is assumed that a more intensive prevention could have a positive impact on the health condition of chronically ill patients and on the constant increase in costs in the health system.
Therefore the range of duties of the foundation Health Promotion Switzerland should not be further extended.
As a basic principle, health care and prevention are personal responsibility of the population and therefore they are not a duty of the health insurance, as by law this must only provide protection against financial consequences of illnesses.
Prevention services chargeable to the basic insurance and implicitly to the community are only justified in cases where the self-responsible action cannot apply and where there is also a high risk of illness with a correspondingly high illness-related affliction (e.g. protection by vaccination, prevention services within maternity).
However, in the supplementary insurance the health insurance can provide extended offers.