Will the rope pulling soon come to an end?

Back in 2009, the parliamentary initiative “Financing healthcare services from a single source” was submitted – and supported by virtually all players in the healthcare sector. However, little has changed since then, and inpatient and outpatient services are still financed differently today. What is behind the EFAS* idea and could the plan work out after all?

*Uniform financing of outpatient and inpatient services.

With hearings of the EFAS Alliance in the Council of States Health Committee, the plan for a uniform financing of outpatient and inpatient services in the Swiss healthcare system picked up speed again in April after a long lull. By introducing such a solution in a timely manner, numerous stakeholders such as FMH, curafutura, pharmaSuisse and the hospital association H+ hope to achieve greater efficiency in the healthcare system – with corresponding savings. Because of the great potential for cost reduction, proponents are calling for rapid implementation of the EFAS model in the acute sector, followed by integration of long-term care in a second step. In 2019, the National Council passed the bill, and now the decision of the Health Committee of the Council of States remains to be seen.

The basic idea

The increasing shift from inpatient to outpatient treatment – which is to be welcomed from a macroeconomic perspective – means that more and more costs can be saved in the healthcare system. Nevertheless, these savings are currently paradoxically leading to increases in health insurance premiums instead of reductions. The reason: In the case of inpatient treatment, the health insurer currently covers only 45% of the costs, and 100% in the case of outpatient treatment. So while more than half of the inpatient financing goes through the cantons, premium payers pay for all outpatient treatment themselves. In addition to placing a higher burden on health insurers in the outpatient sector, this also leads to false incentives for the sometimes unnecessary – and altogether more expensive – inpatient implementation of interventions.

The EFAS initiative envisages that cantons and premium payers should now pay into the health insurance funds, which would then finance all outpatient and inpatient treatments equally. Both payers, cantons and health insurers, would thus have a joint interest in reducing overall costs. According to the EFAS Alliance, a billion Swiss francs could be saved annually by further shifting from the inpatient to the outpatient sector. In addition, the new financing model would provide incentives for integrated care models such as the family doctor model, which proponents expect to save an additional three billion Swiss francs per year.

Hardened fronts

As plausible as the EFAS model may sound, the fronts seem to be hardened after eleven years. While everyone agrees that something needs to change in funding. Exactly how the cost shares are to be distributed, however, repeatedly causes red heads to turn. For example, while the cantons are willing to contribute to outpatient costs as well, they are demanding that insurers co-finance long-term care in return. For these, in turn, the costs in the area of long-term care are too opaque. They therefore suggest that long-term care should only be included in the financing model as it progresses. How long this tug-of-war will last remains unclear, as does the outcome and the question of whether the bill will ultimately be put before the people. The only thing that is certain at present is that the potential for cost containment exists. Every day.

Literature:

1. FMH media release: End the imbalance in outpatient and inpatient services. 12. April 2021.
2. www.pro-efas.ch/de (last accessed 08.05.2021)

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