In March 2018, the Federal Council approved a cost-containment program based on an expert report. The program aims at relieving compulsory health insurance (AOMS). The Federal Council instructed the Federal Department of Home Affairs (FDHA) to assess the new measures and apply them in the framework of two separate packages, the first by autumn of 2018 and the second by the end of 2019. The FDHA has elaborated the first package of measures. With these new measures, the Federal Council provides the tariff partners with additional tools to exploit the potential for efficiency and contribute to the containment of the costs of the AOMS. It also reminds them of their responsibilities regarding the interests of insured citizens and taxpayers.
The system of reference prices and tariffs
An experiment will be introduced with the aim of carrying out innovative pilot cost reduction projects outside the framework of the Federal Health Insurance Act (KVG/LAMal). This could be, for example, pilot projects aimed at the uniform funding of inpatient and outpatient services, or trials in integrated care. A system of reference prices for drugs with an expired patent will also be introduced. For drugs having the same active ingredient, a maximum rate will be set (reference price). This will allow the AOMS to remunerate only the reference price.
To avoid the time lost in the tariff negotiations, as in the case of the TARMED medical rate card, a national tariff organization will be established. Flat rates will be promoted to improve efficiency in the outpatient sector. In order for the cost increase to be contained within a logical level from a medical point of view, the service providers and insurers will be required to provide, in tariff agreements valid for the whole of Switzerland, measures to correct an unjustified increase in the volume of benefits and of costs.
The Federal Council report is in favour of a national tariff organization
The Federal Council adopted the report on postulate 11.4018 "Criteria for the conclusion of tariff agreements in the healthcare sector," which concludes that the majority of tariff partners are required to approve a tariff agreement. However, the tariff agreements presented by a minority can be the subject of further assessments.
If a tariff structure meets the legal requirements, it can be accepted as a unitary structure valid throughout Switzerland. With this procedure, the individual tariff partners are further encouraged to perfect the tariff structure. Moreover, the report states that the creation of a national tariff organization, as proposed now in the context of cost containment, is appropriate to improve the situation between the tariff partners.
Checking of invoices and right of appeal
Service providers will be obliged to send a copy of each invoice to the insured, which will allow better control by the insured. In addition, all tariff partners will be compelled to provide their data to the Federal Council so that the latter can approve the tariff structures presented to it, adapt the existing ones or adjust them for all the service providers of a single sector.
From now on, the insurance fund associations will also have the right to appeal against the decisions of the cantonal authorities concerning hospital lists, nursing homes and nursing homes. In this way, it is intended to avoid costly excess supply, as well as relieve policyholders and taxpayers.
There is a tendency to limit the evolution of the costs of benefits borne by the AOMS and to limit the increase in premiums paid by policyholders. This will, in the long run, save several hundred million francs a year for the benefit of the AOMS. However, such a result will depend on the consistent application of the measures proposed by the actors involved.
The consultation on the first package of measures will last until the 14th of December, 2018. By the end of 2019, the Federal Council will launch the discussion of the second package, whose priorities will focus on the areas of medicines, adequate health care and transparency. Data must be more efficiently connected, completed and made more accessible at the national level.
See the full report in Italian (switch to French or German in the top-right corner) here.
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