The capitation and risk compensation discussion in Switzerland

In the event of illness, the Swiss healthcare system differentiates between basic insurance, which has its legal basis in the Federal Health Insurance Act (KVG), and private supplementary insurance, which is subject to the Insurance Contract Act (VVG). In contrast to other countries, supplementary insurance in Switzerland is complementary and not a substitute. People who take out additional insurance cannot avoid paying the basic insurance premium. Unlike in Germany, for example, once you reach a certain income limit you cannot say goodbye to statutory health insurance and thus to the solidarity community by switching to private health insurance. Civil servants also have to pay a basic insurance premium - with the exception of certain military personnel who are currently on active duty.

>> In the German discussion it is not uncommon for the opinion to be expressed that Switzerland introduced the capitation allowance (in Swiss German: the capitation bonus) with the introduction of the KVG. This is a distortion of the facts. The capitation allowance already existed before, but it was calculated based on the insured person's entry age. This is no longer the case today. The big change came with the KVG through the introduction of compulsory insurance, which in German terminology corresponds to citizens' insurance based on a capitation fee.
This is important in terms of health care policy because - regardless of how you feel about financing the health insurance premium - citizens' insurance creates an act of solidarity that has not yet been discussed in Germany. In the Swiss system, civil servants and those earning higher incomes also pay capitation payments into basic insurance, thus making a certain solidarity contribution.
New hospital financing
As part of the KVG partial revision, Parliament decided to switch from a cost-based to a price system that is to be based on uniform tariff structures across Switzerland:
• The contracting parties agree on flat rates for the reimbursement of inpatient treatment, including stay in a hospital (Art. 39 Para. 1) or a birthing center (Art. 29). As a rule, flat rates per case must be set; The flat rates are performance-related and are based on uniform structures across Switzerland. The contracting parties can agree that special diagnostic or therapeutic services are not included in the flat rate but are invoiced separately. The hospital tariffs are based on the compensation of those hospitals that provide the compulsorily insured service with the required quality efficiently and cheaply. (Art. 49 Para. 1 KVG)
• The collective bargaining partners, together with the cantons, set up an organization that is responsible for the development and further development as well as the adaptation and maintenance of the structures. To finance the activities, a cost-covering contribution can be made for each billed case. The hospitals must provide the organization with the necessary cost and performance data. If there is no such organization, the Federal Council will make it mandatory for the collective bargaining partners. The structures developed by the organization and their adjustments are submitted by the collective bargaining partners to the Federal Council for approval. If they cannot agree, the Federal Council determines the structures. (Art. 49 Para. 2 KVG)
For somatic acute hospitals, Diagnosis Related Groups (DRGs) should be used, which are to be developed based on the German DRGs.
A new distinction is made between hospitals approved for compulsory health care insurance (OKP) based on the hospital list or by contract. If a canton puts a hospital on the hospital list, the public sector must co-finance the services within the framework of the granted service mandate. In this case, the health insurer is subject to contractual obligations and has to pay its share. Hospitals that are not or incompletely placed on the hospital list have the opportunity to conclude contracts with individual insurers within the framework of the OKP. In this case, the insurer pays the agreed price and the public sector does not make any contributions. According to Art. 49a Para. 4 KVG, the insurers may only assume, at the expense of the OKP, their share of the remuneration applicable to the canton residents concerned. The share that is allocated to the cantons in the listed hospitals must therefore be borne by the insured or by additional insurance.
The canton's share of listed hospitals is at least 55 % of the flat rate. This share now also includes investment amortization.
Public services (research and university teaching as well as maintaining hospital capacity for regional policy reasons) must be financed by the public sector.
Cracknut risk compensation
But DRGs are not simply good or bad. Their effects also depend to a large extent on the environment in which they are intended to work. The federal regulator would be required to change the incentive mechanisms. He should be guided by the maxim that all actors in a social insurance system (insured persons, patients, service providers and insurers) do best when they manage to treat highly complex cases as effectively and efficiently as possible.
In order to realize this incentive, an improvement in risk equalization among health insurers would be necessary in a system of uniform premiums. The consideration of hospital and nursing home stays approved by Parliament in connection with the new hospital financing cannot be sufficient.
The new compensation mechanism - just like hospital financing - stands at odds with the current political efforts to promote integrated care. With the new hospital financing and the new risk compensation formula, the incentive in several respects is likely to mean that previously day-care cases are increasingly carried out as inpatients and not as outpatients. Especially for short-term residents, the outpatient tariff is likely to be more expensive for the health insurance companies than a short-term DRG for patients with only basic insurance. In the latter case, the health insurance companies pay a maximum of 45 % of the performance-oriented flat rates, whereas in the outpatient sector, apart from the patient's contribution to the costs, they pay everything." In addition, in the case of a hospital stay that lasts longer than three days, the health insurance company's stay also " Money” brings in the calculation of the risk compensation.
Today, health insurers with many chronically ill patients have little interest in promoting integrated care concepts. If health insurers did this, such offers could motivate chronically ill people - possibly supported by self-help groups, patient organizations and doctors - to switch to insurers with good integrated care offerings. However, this deteriorates the insurer's market position because it has to adjust premiums upwards due to the poorer risk structure.
Outpatient doctors who treat chronically ill patients well in advance and, together with other service providers, also provide good medication, among other things, are at a disadvantage. They are committed to integrated care, help to avoid unnecessary hospital stays, live by the principle of “outpatient before inpatient” and risk being penalized because of hospital financing and risk compensation incentives. This is because their relative market position deteriorates as a result of these incentives. The same applies to outpatient hospital treatment, which has historically been much more common in Switzerland than in Germany because there is no such strict sectoral separation.
As part of risk compensation, it is important to make improvements that take into account the morbidity, i.e. the state of health or illness of the insured. Germany and the Netherlands have introduced corresponding systems in Europe.
In Germany the so-called Morbi-RSA (for morbidity-related
oriented risk structure compensation) came into force on January 1, 2009. The first health insurance companies have begun to work more intensively with doctors to care for chronically ill people. The German Employee Health Insurance Fund (DAK), for example, has initiated a variety of new care concepts together with selected service providers within the framework of selective contracts. It also helps in this system that the health insurer in Germany has to pay a certain amount of wages in the event of illness.
Conclusion
As far as health services research is concerned, Germany can learn from Switzerland, particularly in the area of solidarity between those with statutory and private insurance. This relatively rigid duality is problematic in terms of supply policy. Switzerland can learn from Germany, particularly in the area of morbidity-oriented risk structure compensation, but also from the less significant distortions between the outpatient and inpatient costs to be covered by the health insurance companies. Above all, however, the integration of part of the continued wage payment costs by the statutory health insurer is likely to show a significantly stronger interest in prevention and investment in good healing procedures than in the Swiss case, where the healing progress financed by health insurance companies often lies with other third parties in addition to the patient, such as disability insurance or the This applies to employers who, in the Swiss system, generally do not pay a single cent to finance health insurance premiums. <<