Cantons want better control in health care

Finally a breakthrough: After about three years of consultations, twelve meetings, even more clarifications and postponements, the Health Committee of the Council of States has decided who should finance health care costs in the future. A shift has been visible for years: not only in general practice, but also in hospitals, more outpatient treatment is taking place and patients are admitted less often at night. This has a direct impact on the premiums: while the outpatient costs are financed by the health insurers, the canton contributes 55 percent to the hospital costs.

This means that the premium volume is growing while the costs of the cantons are stagnating. Center National Councilor Ruth Humbel used her home canton of Aargau as an example: when the Health Insurance Act came into effect in 1996, health insurers paid 748 million francs a year later and the canton 545 million francs for health services. In 2019, a total of CHF 2.53 billion was financed in Aargau through health insurance premiums. The canton contributed 809 million Swiss francs to costs and 106 million to cuts in premiums.

Since 2009, the House of Representatives has been debating an initiative by Humbel that calls for a new funding key and allows for greater efficiency: the type of treatment should not depend on the funder, but on the quality, of the best care for the patient. The uniform financing of ambulatory and inpatient care (EFAS) should ensure this, via one joint fund. Depending on the study, between 1 and 3 billion Swiss francs could be saved annually thanks to increased efficiency.

What sounds plausible is difficult to implement: the cantons resisted the change for a long time because they would become more and more responsible for financing. They demanded that care be included in addition to outpatient and inpatient services. This makes sense from an efficiency point of view, as all services must be financed from the same pool. For premium payers, however, this could mean that rising healthcare costs are increasingly reflected in premiums.

The big problem, however, is the implementation: it does not calculate the actual costs incurred. Because each canton has its own financing regime for healthcare, the municipalities and the canton sometimes share the costs, sometimes they are divided very unilaterally.

Despite these difficulties, the Health Commission took action and developed a model for the costs of care. Since the cantons spent on average about CHF 7 billion on outpatient hospital services and about CHF 3 billion on health services between 2016 and 2019, the cantons now have to pay a fixed annual fee of CHF 10 billion to the insurers to fund the services. They cover about a quarter of CHF 39 billion in total costs for basic insurance. However, this amount is a static consideration: both expenditure items develop dynamically: they grow. However, the Health Commission still wants to take the time to develop a sophisticated model that takes all healthcare costs into account.

In addition to the extra costs, there is a second problem for the cantons with Efas: the cantons have to pay bills that they cannot control. That is why they demand access to all billing data to know exactly what they are co-financing.

So the issue of auditing could suddenly jeopardize the entire bill. Because the insurers are against this concern. The two umbrella organizations Curafutura and Santésuisse speak with rare love of an “unnecessary duplication”. And they point out that, thanks to auditing, health insurers have recently managed to save more than 3.5 billion francs. This corresponds to about 10 percent savings on the premium. The associations signal that serious work is being done. A double check, on the other hand, is inefficient – and thus contrary to the spirit of the bill.

The Health Commission sees it the same way, also warning that there are problems with data protection – and only wants to give full visibility to intramural services, with about 1.3 million accounts. On the other hand, aggregated data should suffice to monitor the outpatient accounts. Health insurers check more than 130 million invoices every year. The cost of checking invoices for basic insurance alone amounts to approximately CHF 400 million per year. According to information from Santésuisse, half of the approximately 12,000 employees work in the benefits sector.

If the cantons want to check the accounts with the same diligence, they would have to add 6,000 jobs. But the cantons refuse. It concerns the traceability of the invoices and samples. To check the steering. (aargauerzeitung.ch)