The KOF Swiss Economic Institute at the Federal Institute of Technology of Zurich (ETH Zurich) is forecasting growth in healthcare spending of 7.1% in 2021. The main reason for this growth is the fight against the COVID-19 pandemic. According to KOF, growth rates are likely to slow down in 2022 (+1.3%) and 2023 (+1.2%) if the pandemic situation lets up. According to estimates, COVID-19-related additional costs covered by basic insurance were approximately CHF 700 million in 2021.
The Federal Council has called on health insurers to reduce the sometimes high reserves in favour of policyholders and has specified the conditions for the voluntary reduction of reserves and the reimbursement of excess premium income in its Health Supervision Ordinance. As a result of this decision, average health insurance premiums have fallen by 1.2% for the first time since 2008. The reduction of reserves is expected to delay the surge in premiums. Insurers, on the other hand, are hoping that the Swiss parliament will implement cost containment measures in order to counteract the expected increase.
Number of employees in the Swiss healthcare sector
Full-time equivalents (2020, source: Federal Statistical Office)
Initial package of measures to contain costs
The Federal Council has divided the healthcare cost containment programme into two packages of measures. These are based on recommendations from an international expert group, which approved the report to the Federal Council on «Cost containment measures to relieve the burden on compulsory basic health insurance» in August 2017.
The Federal Council is pursuing the following main objectives with the initial package of measures:
- Facilitate pilot projects (experimentation article) and reimburse treatments abroad
- Improve tariff negotiation structure (national tariff organisation)
- Introduce flat-rate outpatient charges
- Reduce the price of generics / introduce reference pricing model
- Improve invoice verification
Parliament approved the first part of the first package of measures in summer 2021. The focus is on the newly created experimentation article. The aim of this is to test innovative and cost-containing pilot projects to ease the burden on premium payers that deviate from the previous statutory regulations. The pilot projects are limited in terms of content, time and location and must be approved by the Federal Department of Home Affairs (FDHA). Experiments with alternative insurance models or in the field of integrated care may be carried out. Digitalisation is also to be promoted through pilot projects.
The associations of service providers and insurers must now set up an organisation structure that is responsible for developing and expanding as well as adjusting and maintaining the tariff structures for outpatient medical treatment.
In the second part of the package of measures in 2021, the National Council, as the first legislative chamber, spoke out against the introduction of reference prices. The Council of States also opposed reference prices during the winter session. Parliament is thus refraining from introducing reference prices. Concerns are too great that the security of the supply of medicines could further weaken.
Direct imports of medicinal products
Under the title «Parallel Imports», the National Council has approved a regulation allowing direct imports of medicinal products from the European Economic Area. Direct imports would mean that Swissmedic would neither be able to grant approval nor assume market surveillance for the products in question. This would mean that the relevant authorities would no longer know which medicinal products are on the market in Switzerland, meaning batch recalls would also no longer be possible. All medicinal products authorised in the EU/EFTA would be legally marketable in Switzerland – for example, medicinal products with a package leaflet and patient information written in Greek. Galenica resolutely rejects direct imports of medicinal products because they make it harder for specialist advice to be provided, while also leading to inevitable supply bottlenecks and damaging the quality of drug and patient safety. The Council of States rejected this proposal for direct imports of medicinal products during the winter session, which differs from the position of the National Council. In doing so, it creates an incongruity with the National Council, which will be cleared up in 2022.
The package also contains «Measures to manage costs», which Pharmasuisse, the Swiss Pharmacists Association, and the FMH Swiss Medical Association firmly reject. These measures mean that the quantitative development of the items and the development of the allocated costs must be monitored, with penalties in place for the unjustified development of billed costs. The National Council and the Council of States narrowly rejected the «Measures to manage costs» proposal, each with the deciding vote of the Council President.
Pharmacies in Switzerland
(2021, source: Pharmasuisse)
Second package of cost containment measures: critical assessment of the consultation package
The Federal Council submitted the second package of measures under the healthcare cost containment programme for consultation in autumn 2020. The FDHA published the consultation report in April 2021. 328 opinions were received during the consultation process.
The dispatch and draft legislation should be approved and submitted to parliament in 2022. The package mainly covers the following areas:
A clear majority of those taking part in the consultation refused to introduce cost targets. The FDHA wrote in its report on the results of the consultation process that, in particular, the service providers and patient and consumer associations reject the measure, but also many insurers and business organisations.
Nevertheless, the Federal Council submitted the proposal of cost targets to parliament in November 2021 as an indirect counterproposal to the popular initiative «For lower premiums – to curb healthcare costs». «The introduction of cost targets aims to strengthen the transparency of the medically explainable increase in costs, raise cost awareness among the responsible actors and limit the cost growth of compulsory health insurance to a medically justifiable level», writes the Federal Council in response to a parliamentary procedural request.
Initial point of consultation
When they have health problems, insured persons are required always to contact their family doctor as an initial point of consultation.
Initial points of consultation were rejected by a clear majority during the consultation process, in particular by service providers, business associations, insurers and umbrella associations of municipalities, towns and mountain regions as well as patient associations and organisations. According to the FDHA in its consultation report, consumer associations, most cantons and some political parties are cautiously in favour of the measure. The requirement for doctors to take over this triage function may be rejected rather than the proposition to introduce initial points of consultation. This contradicts the idea of interprofessional collaboration.
Networks for coordinated care
In principle, almost all respondents in the consultation were in favour of promoting coordinated care. However, many organisations reject the proposed measures. The majority of service providers, umbrella organisations for business, insurers and political parties are rather negative on the matter.
Pricing models and reimbursements
Pricing models should ensure rapid, cost-effective access to innovative medicinal products. The Federal Council proposes that marketing authorisation holders should reimburse part of the costs to the insurers. They would benefit from prices no longer having to be published.
Pricing models were supported by a large majority of those taking part in the consultation process, with some insurers and some service providers being critical of the notion.
Hospitals in Switzerland
(2020, source: Federal Statistical Office)
Revision of distribution share: second consultation planned
Following the consultation on the 2018 distribution share in 2021, the FDHA has developed a new model based on two pillars:
- Uniform distribution share for medicinal products with the same active ingredient composition
- Planned adaptation of the model of the distribution share
The new two-pillar model will be submitted for consultation in the first half of 2022. The model will enter into force in 2023 at the earliest.
With the revision of the distribution share, the Federal Office of Public Health (FOPH) expects annual savings of CHF 100 to 120 million. Several stakeholders take a critical view of the proposals, as they are seen as the introduction through the back door of the lowest-cost principle and reference prices, which parliament rejects.
In 2021, parliament adopted a motion (20.3936) instructing the Federal Council to revise the distribution shares in Art. 38 of the Health Insurance Benefits Ordinance (HIBO) in agreement with the affected service providers so that they effectively cover distribution costs.
Doctors in Switzerland
(2021, source: Swiss Medical Association)
Implementation of the SBR V tariff model delayed
Curafutura, the association of innovative health insurers, and the Swiss Pharmacists Association Pharmasuisse submitted the new SBR V (service-based remuneration V) pharmacy tariff together with a proposal for a revised distribution share to the Federal Council in May 2020. Under the proposal, the distribution share and service-based remuneration would be approved as a package. For example, the salary costs of the pharmacy team to provide pharmaceutical services would be removed from the distribution share and instead now be billed via SBR V. The head of the department of the FDHA has asked the tariff partners to revise the agreement in order to maintain cost neutrality.
The date the agreement will enter into force is undecided and will depend on the introduction of the revised distribution share. It would not be appropriate for the system to eliminate personnel costs from the distribution share without mapping the expenses in the SBR at the same time.
Introducing electronic patient records hesitantly – EPRA revision to follow
New medical service providers that want to invoice services via basic health insurance must now join a certified reference community. In March 2021, parliament passed a motion requiring not only new service providers but all healthcare professionals to join a reference community.
In August 2021, the Federal Council published its «Electronic patient record. What remains to be done before it can be used extensively?» report. It proposes various measures to promote the dissemination and use of electronic patient records (EPRs). The Federal Council is expected to pass a policy decision on the further development of the Electronic Patient Record Act (EPRA) at the end of February 2022.
In order for EPRs to be a success, applications that can be used quickly, such as electronic vaccination records, e-medication plans, e-prescriptions, admittance and discharge reports, and patient wills are required. An obligation of service providers to adopt electronic prescriptions and electronic medication plans could help the use of EPRs to achieve a breakthrough. Such motions have already been submitted, but have been rejected by the Federal Council.
Mail-order sales of OTC drugs should be simplified
The Federal Council is planning to simplify the mail-order process for over-the-counter (OTC) drugs.
Galenica shares the position of the Federal Council that the requirement in the Therapeutic Products Act (TPA) that a patient must have a doctor’s prescription prior to ordering a non-prescription medicinal product for mail order is no longer up-to-date. Specialist advice and patient safety are also important for over-the-counter medicines, as they may be associated with side effects and interactions with other medicines. Patient safety can also be ensured digitally if the purchaser is clearly identified.
In its communication, the Federal Council states that it is planning to submit a corresponding revision of the TPA for consultation at the beginning of 2023.
Naturally, the packages of cost containment measures are primarily aimed at reducing costs. There is a risk that the focus on efficient service provision will be lost and that the savings will lead to reduced services and rationing at the expense of patients.
The price trend for medicinal products is a cause for concern. On the one hand, costs in the high price range are rising, while on the other hand, opportunities to save on low-priced drugs have been virtually depleted following several rounds of price reduction. These must not lead to even more low-priced medicines disappearing from the market and hardly any new, low-priced medicines being approved anymore.
For the Galenica Group, the focus is on efficient service provision and the prevention of inappropriate, excessive and inadequate supply. It supports targeted measures to reduce costs, for example by promoting parallel imports or eliminating false incentives in relation to the distribution share. Galenica does, however, oppose any measures that de facto lead to the rationing of benefits and thus to poorer patient care.
The coronavirus pandemic has shown that the digital transformation of healthcare is lagging behind. Digitalisation is a top priority at Galenica. Health data ecosystems that can communicate with one another are needed to make data-based knowledge a reality. Stakeholders are required to come up with joint solutions, and the legislative powers must quickly adopt the necessary decrees.
Generally speaking, digital solutions that improve care and/or make it cheaper are to be promoted. Digital solutions also have to cope with people’s changing consumer and shopping habits. For example, simplification of the mail-order business of OTC drugs are to be supported while also preserving patient safety.