After the premium shock: ‘The health insurers miscalculated’

Mr Engelberger, the chairman of the health insurer Santésuisse, wants to strip the cantons of power in the field of hospital planning. How does that resonate with you?
Lucas Engelberger: Simply pointing the finger at other players in healthcare seems too easy to me. The health insurers have grossly miscalculated their premium income. And they have had poor results with their investments. This has partly led to the fact that we are now in this difficult premium autumn.

The bonus autumn also includes the Schwarzpeter game, which then starts again every time. Aren’t the cantons responsible for the cost growth?
We need to become better at planning and working together even more closely. But it is also a fact: where the cantons can apply the leverage, especially in the inpatient hospital sector, costs grow more moderately year after year than elsewhere. The statement by the president of Santésuisse that we offer hospitals that are too expensive is therefore incorrect. We must work together to find solutions in the existing system. I reject semi-revolutionary ideas.

The people would have the final say. How would you counter the initiative?
I don’t want to prejudge this discussion. One thing is certain: it would be a radical system change. What is taken for granted today should be questioned. The cantons pay for more than half of inpatient hospital treatment. Why should they continue to do this if the planning to do so is taken away from them? That would be a matter for the federal government.

Would you even trust the federal government to do proper hospital planning?
Today, the federal government is quite removed from day-to-day health care. He would have to build structures and acquire the know-how – it would be a huge system restructuring. And then imagine how this would be received by the population in the cantons if a federal office were to close one of their hospitals. That simply does not fit our direct democratic system.

Nobody likes to give up power. Has the GDK set up a crisis team?
No. I actually notice a lot of unrest in the public discussion. Everyone is now putting their slow-moving items back in the display window. Health directors are in favor of gradual improvement and against radical system change.

Why is this taboo breaking by insurers happening now?
Insurers feel under pressure. Suddenly people are thinking about a unified fund again. This is a worrying prospect for health insurers.

Is the common fund demanded by the SP also a red rag for the GDK?
We have not yet agreed on a position.

What is your personal opinion?
I am very skeptical that anything can be achieved with such a system conversion. Most of these proposals focus on financing. Costs are the big challenge. People are living longer and receiving healthcare services that are becoming increasingly better and often more expensive. Now it’s about finding a way to fund this sustainably.

In St. Gallen, the hospitals put 440 people on the street. Are there still too many hospitals there?
Throughout Switzerland, the financial situation of hospitals has deteriorated significantly. Like all businesses, they are also affected by inflation, especially when it comes to energy costs. But the pressure is also high in the HR department. It is even difficult to find enough skilled workers. This forces employees to make concessions: shorter working hours and wage increases, which in turn lead to higher costs. However, on the revenue side, rates are rigid. It will take some time before the rise in inflation in recent years can be reflected. However, this will have to be taken into account.

In the Netherlands, where twice as many people live as in Switzerland, there are about a hundred hospitals. We have three times as many. Insurers say surplus hospitals are a major health care expense. Do you agree to this?
When it comes to inpatient treatment, you do not see this in a multi-year comparison. Once again: the insurers are making it too easy for themselves. The number of hospitals is not important. Much more important is how efficiently the hospitals are organized. Switzerland is not the Netherlands. We have a different topography and are a multilingual, federally organized country.

But the equation is clear: where there is a large supply, more healthcare is consumed. Health insurance premiums are most expensive where there are many doctors.
The cantons of Basel-Stadt and Basel-Landschaft have joint hospital planning. We discovered that we actually make far above-average use of certain medical treatments. We then tried to limit performance mandates. But we were only partially successful. Individual measures ended up in court. These are legally demanding procedures that cannot be completed at the push of a button. The federal government would also have this experience if it were to take over hospital planning.

More about the debate about healthcare costs

Criticism of budget health insurance

“Undermining the solidarity system”

Visana relies on the American model

“We don’t force anyone to wear a heart rate monitor”

“Integrated care”

The American model aims to heal the Swiss healthcare system

Because politicians don’t save money

No more new services!

Against the premium shock

FDP wants cheap health insurance for everyone

Does Switzerland really need twelve hospitals that perform bypass operations?
You could actually make this more efficient. As a society we place high demands on availability and accessibility. We want to get to a hospital quickly and not have long waiting times. In countries with tightly controlled medicine, patients can wait months or years for joint replacement surgery. This makes healthcare cheap – but whether it makes economic sense is another question.

What is your answer to that?
Anyone who has to wait a long time for a new hip joint has limitations in his or her ability to work and perform. It is therefore also thanks to our healthcare system that we have such high productivity in Switzerland. Remember: healthcare is a location factor! Saving money actually makes it more expensive from a macroeconomic perspective.

However, the unbridled cost growth means that the call for one fund is becoming increasingly popular. Then there may be a risk of circumstances like those in England.
That’s right, the pressure to act is increasing. We must now do everything we can to keep volume growth, which is an important cost factor, within limits.

But Parliament cannot do exactly that. Last week, the National Council scuttled projects that Health Minister Berset said would have offered the most savings potential.
These companies have been in discussions for a long time and are not suddenly going in a different direction. The provisional decisions in the committees and parliamentary groups had been taken a long time ago. We must look ahead: collective labor agreement negotiating partners, insurers and service providers must make sensible agreements now. In any case, the GDK has fundamentally supported the Federal Council’s cost control proposal.

We complain about the explosion of premiums – and run to the emergency room over a trivial issue. How do you explain this contradiction?
This is deeply human. Each season has its specific concerns. In October these are the health insurance premiums. In January or February, when hospitals are full of flu patients, it’s all about capacity: do I have a hospital bed when I need it? The bottom line is that security of supply and quality are still more important to people than the cost aspect.

And yet the premium burden for medium-sized companies is now becoming crucial.
We must take this problem seriously. As cantons, we are responsible for ensuring social balance through individual premium reductions. We must not abandon those who live in modest circumstances.