We are committed to a competitively organised healthcare sector, so that the medical care of the future continues to be of high quality and affordable.
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 Switzerland having a well-working health system, as generally recognised.
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 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 Cantons and health insurers are 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.
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 must benefit from the premium reduction, it is important to reconsider the criteria. The distribution of money must not be made with the watering can.
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.
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 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.
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 for the insurers to provide offers according to the customersț needs, it is crucial thatthey have, in the future too, the necessary freedom of action.
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.
The demand for quality in the provision of medical services is addressed at several points in the Federal Health Insurance Act. While numerous quality activities are currently under way throughout Switzerland, they are uncoordinated, without a common understanding of quality. They are fragmentary, non-binding and opaque, and do not take a results-oriented approach. Quality has not played a role in the payment of medical service provision to date.
The new legal framework for the coordination and systematic development of quality activities in basic insurance is therefore important in obliging tariff partners to press ahead with binding activities.
Even with compulsory health insurance, minimum quality standards and transparency with regard to indication and outcome indicators are an absolute necessity. A uniform national understanding of quality is vital to ensuring that services and products become comparable for both patients and insurers, and sanctions can be applied in the event of poor quality.
The national quality commission should focus on the essential and base its approach on existing, tried-and-tested structures. The federal authorities should only exercise a coordinating function.
The price paid for such products accounts for around a quarter of all healthcare costs covered by basic insurance in Switzerland. Currently, what is needed is a more systematic evaluation of therapeutic products and greater transparency of the official pricing process, which is utterly opaque. Neither health insurers nor other stakeholders are able to appeal against official decisions. The result: prices that are too high, and lack of transparency.
The official price-setting process should take into account the impact on healthcare expenditure, and the relevant stakeholders should be granted right of appeal.
Innovation in the development of new therapies is important, but so is access: innovation must be affordable.
When setting prices, the authorities need to consider not only cross-border and cross-therapy comparisons, but also the effects on healthcare expenditure. The international price comparison should be based on the prices actually paid. Shop-window prices must be systematically excluded. Innovation premiums should be limited to therapeutic areas with an extremely strong medical need, such as antibiotics. The authorities should also permit parallel imports of medicinal products protected by patent and their inclusion in the specialities list of medication covered by statutory health insurance. As already happens with all other therapeutic products, Swissmedic would be responsible for approving them and ensuring their safety.
This would allow new and innovative medicines to continue to be financed by basic insurance going forward and would therefore make them accessible to all relevant patients – provided, of course, that they are effective, appropriate and cost-effective.
Official pricing should be limited to those therapies for which there are no alternative treatments, which means that they are not subject to the forces of competition. Where patent-expired products are concerned, a competitively organised fixed-rate system must be introduced, i.e. setting the lowest price for medicinal products with identical effects. In order to avoid supply shortages, guarantees of supply as well as price could form part of fixed fees.
Many therapies deployed in Switzerland are not included in the specialities list (SL). The term «off-label use» is applied to products used outside their approved technical information or limitations. Article 71 a - d of the Health Insurance Ordinance allows, exceptionally and in individual cases, for the reimbursement of therapeutic products or indications that are not in the SL. However, with each passing day, it is becoming increasingly hard to ensure customer access to new therapies via the standard approval process within a reasonable timeframe. The exception is increasingly becoming the rule.
As a consequence, access to and reimbursement of therapeutic products is having to be regulated on a case-by-case basis.
Helsana is committed to an industry-wide solution that prevents the unequal treatment of patients by ensuring access to innovative and expensive therapies in accordance with uniform criteria. Generally speaking, though, greater importance should also be attached to the criterion of cost-effectiveness: health insurers have an active role to play here, but the fundamental issue regarding the duty to reimburse must not lie with individual health insurers.
In order to avoid constant circumvention of SL approval, payment of therapeutic products must be limited in time in accordance with Article 71 a – d. A registration requirement will fill gaps in evidence, thereby ensuring that proper approval can be completed on expiry of this period at the latest. It is important to ensure that access is guaranteed at all times. Legal adjustment of the implementation of a right of request for health insurers and other key stakeholders is central to this issue.
New innovative therapies should be assessed on a uniform basis throughout Switzerland in terms of effectiveness, appropriateness and cost-effectiveness. These assessments must be based on scientific knowledge and made publicly available. This would provide the basis for a uniform assessment in each individual case.
Insurers should have to negotiate prices and terms jointly with the providers going forward. By joining forces in this scenario, insurers would achieve better negotiation results and be better placed to counter the frequently encountered monopoly situations on the provider side.
Finally, a well-functioning escalation process is needed so that complainants have someone to turn to if they believe that their insurer has come to the wrong decision. Creating a new ombudsman service would be one way of providing this.
Personalised medicine facilitates tailored treatment options. It assumes that every person is different and that not every therapy works the same way for everyone.
Individual treatment plans for cancer patients can be developed using biomarkers, comprehensive tumour profiles and genetic analyses. Therapy plans are tailored specifically to the tumour type and the molecular and genetic characteristics of the individual patient. These targeted therapies should only be used on patients who can be expected to respond well and for whom therapeutic effectiveness is assured. At the same time, undesirable and potentially harmful side effects are reduced.
The effectiveness of these therapies is becoming increasingly difficult to assess due to the sometimes very small cohort of patients. That said, it should be possible to ensure access to such therapies despite the unclear and, as yet, inconclusive evidence.
Access to these innovative therapies therefore needs redefining.
Rapid, regulated access to innovative and often also very expensive therapies calls for the examination of suitable financing models, quite apart from the situation regarding the positioning of the supply of therapeutic products. Moreover, accompanying and health services research is becoming increasingly important in these early-access therapies. Alongside clinical research, the quality of care and budget impact also need monitoring to get on top of the inadequate evidence and thus the access.
Harmonising official processes is also necessary, as new therapies and diagnostics together form a treatment complex. This is not the case at present. The approval and reimbursement processes must be coordinated with the corresponding testing and screening measures at the time the therapy is approved.
Even though personalised medicine using genomic information offers immense potential for the treatment of diseases, special attention must be paid to safeguarding the data: data and privacy protection must be assured every step of the way. The regulatory framework must also take ethical aspects into account, including the duty to inform or disclose and the "right not to know". Awareness raising and open communication are necessary so that those affected recognise that the advancement of research is dependent on accumulating as many datasets as possible. This calls for measures that strengthen the health competence of those affected.
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.
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.
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.
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.
Therefore the 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 efficacy, profitability and treatment quality.
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.
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.
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.
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.
The use of modern IT holds great potential for the healthcare sector. It is equally important to ensure that it is used in full compliance with personal privacy and data protection. This new technology can prevent needless duplicate examinations and provide access to valuable information, for example on allergies or medication safety (potential intolerances).
An increasingly important role is played here by digital health applications. However, their financing through basic insurance must, as is the case with all other statutory benefits, meet the legal requirements, in particular with regard to the criteria of efficacy, expediency and cost-effectiveness.
In 2015, parliament passed legislation on the electronic patient record (EPR). Since then, service providers are required, with patients’ consent, to make their patient data available electronically to other service providers for the purpose of treatment. It has now become clear that this law is not fulfilling its purpose.
The electronic patient record legislation therefore requires fundamental amendment in order to escalate the use and promotion of the patient record.
It is important to facilitate the autonomy and personal responsibility of patients in the handling of this data. Doctors providing treatment can only rely on relevant data if it is reliable and available in full – this level of reliability is essential for the electronic patient record to be successful in everyday treatment. The investments required in these technologies must be financed by the market participants who also derive the corresponding benefit.
Health insurers should not be called upon to finance the necessary infrastructure (for instance in the form of investment contributions or initial funding), because the law stipulates that insurance may and should only pay for medical services.
New health ecosystems such as Compassana are designed to combine the latest medical care with the advantages of digitalisation and to promote optimum communication between patients and healthcare service providers.
In general terms, health literacy can be understood as the ability of an individual to make decisions in their day-to-day lives that have a positive impact on their health. It is an essential requirement in the perception of personal responsibility, and should enable everyone to understand health-related information and take responsibility for their own health.
It is for this reason that health literacy among the population should be improved.
Measures aimed at improving general health literacy among patients must not form part of the benefits provided by basic insurance, which is intended only for the payment of medical benefits. In addition, the corresponding projects are funded by the foundation Health Promotion Switzerland, which is financed via a premium surcharge.
Health insurers can also help to promote health literacy, however, by informing policyholders about the choice of insurance, the benefits of the Federal Health Insurance Act (KVG) and the Federal Insurance Contract Act (VVG), the effectiveness of concrete therapies and the healthcare system as a whole. Helsana already does this via a Health Consultation service for its customers.
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 foundation 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.
We're here to help.