SWICA’s opinions on health policy

The "Uniform Financing of Inpatient and Outpatient Treatment" (EFAS) is intended to encourage a shift from inpatient to outpatient treatment, because outpatient treatment is often equally effective but cheaper. The goal is to curb cost growth in the healthcare system. The current system, in which the cost of inpatient services is borne jointly by the cantons and health insurers, but only by the insurers in the outpatient sector, creates a financial disincentive. As a result, some operations are performed as inpatient procedures, even though they could be performed more cheaply and with the same medical efficacy as outpatient procedures.

However, EFAS also gives a boost to integrated care which aims to better coordinate the management of patients along their entire treatment path. This improves the efficiency and quality of treatment and reduces the cost of services. With the shift from inpatient to outpatient care, alternative insurance models (e.g. the family doctor and telemedicine models) will also become more important; savings are also possible in this way for both insured persons and service providers.

SWICA supports the amendment to the Health Insurance Act for the uniform financing of outpatient and inpatient services.

SWICA, in common with all the other supplementary insurance providers, is currently in the process of renewing its contracts with hospitals for semi-private and private insurance customers. The changes are necessary in order to meet the new requirements defined by the supervisory authority Finma, increasing cost pressures in the hospital environment and changed customer needs. The aim of the new contracts is to increase the transparency and traceability of the services billed. The intention is to complete the negotiations by the start of 2024. Insured persons and insurers should be able to understand which services provided by hospitals go beyond basic insurance and are billed as additional services. In addition, SWICA will formulate the new contracts in such a way that newly developed products can also be included. For example, SWICA is working with selected clinics to examine offerings which also provide further choices for outpatient procedures. At the same time, in negotiating the new contracts SWICA is pursuing the goal of reducing premiums sustainably and thus making them even more attractive for customers.

SWICA's hospital directory shows the hospitals for which full cover of costs is not guaranteed.

As in the past, SWICA is striving to achieve partnership-based, fair and solution-oriented cooperation with the service providers. Rate negotiations between supplementary insurers and hospitals are becoming challenging because the cantons, which cover part of the cost of inpatient services under basic insurance, are also paying increasing attention to cost efficiency. SWICA does not rule out the possibility that a situation could arise with some hospitals – hopefully only temporarily – in which no contracts are concluded. This would jeopardise full cost coverage for interventions. If it appears that this situation could become a reality, SWICA will proactively approach the affected customers with the aim of finding a good solution for each inpatient procedure in discussion with them.

Answers to potential questions can be found in the document below.

On 10 November 2021, the Swiss Federal Council referred the counterproposal to Die Mitte's cost containment initiative to the Federal Assembly. The counterproposal suggests introducing cost targets to specify the percentage by which health costs can go up each year. The Federal Council would set the overall target for costs as well as the cost targets for the individual cost blocks and cantons. The cantons would be responsible for meeting their cost targets. In the event of deviations, they would be able to introduce corrective measures that would primarily be aimed at reducing rates and/or restricting the scope of medical services offered.

Neither the popular initiative nor the counterproposal are compelling. The focus of both draft bills is on costs, i.e. on placing limits on rates and volumes. Both the volume of medical services provided and the rates paid for those services are artificially suppressed, while at the same time the Federal Council guarantees the provision of and payment for all statutory services. This runs the risk of creating a financial imbalance in the healthcare sector, with less money flowing into the health system than is required to finance the services provided. Cross-financing by increasing the public spending ratio or raising taxes is the inevitable consequence.

SWICA is in favour of measures to manage costs provided they bring about an effective reduction in healthcare costs by reducing the financial burden on premium payers and ideally reduce the public spending ratio at the same time. This could be achieved by promoting innovative and integrated healthcare provision models, or by coordinating services both within and between regions in the long term. Effective and efficient solutions to relieve the burden on the population can only be found if all the parties involved – and the cantons, service providers and health insurers in particular – work together for the benefit of patients.

 

Swiss health insurers are required by law to build up reserves in basic insurance so that they will remain solvent even if a "once in a century" event occurs. The level of the reserves is based on the solvency ratio. At present, insurers must always hold reserves which are equal to least 100 percent of the minimum level prescribed in the ordinance. The Health Insurance Oversight Ordinance provides for a voluntary reduction in health insurers' reserves, whereby an insurer must keep a minimum in reserves even after a voluntary reduction. In concrete terms this means that a health insurer must remain solvent for at least one year, even if a "once in a century" event occurs in that year. The funds from the reduction in reserves will benefit insured persons.

As far as SWICA is concerned, our reserves are solid, but not excessive. SWICA's strategy has always been to minimise premium increases, or to avoid them altogether. For this reason, it calculates its premiums without a safety margin. By this practice SWICA is accepting that this can lead to very modest, or even negative, results in some regions. In the case of negative results, it can rely on its reserves. The goal is for the solvency ratio to settle at around 150 percent eventually.

We regard reducing the reserves to 100 percent to be irresponsible because this massively increases the risk of premium hikes and intra-year premium increases. A reduction in reserves for political reasons has already happened twice since the KVG came into force. On both occasions this was followed by sharp increases in premiums. The increase in premiums as of 1 January 2023 also reflects the pressure on reserves. Any reduction in reserves must therefore be planned with the utmost care and carried out in strict compliance with the legal requirements.

The level of health insurance premiums is strictly regulated, with insurers setting their premiums based on the costs they expect to incur in the following year. This calculation also takes account of the reserves that each insurer holds (see also: Opinion: «Surpluses in basic insurance»). The premiums arrived at in this way must then be signed off annually by the federal government. To this end, insurers submit them to the Federal Office of Public Health (FOPH) at the end of July each year, together with their budgeted costs and an overview of their insurance portfolio. In due course the FOPH gives its approval based on the Health Insurance Supervision Act (KVAG).

The health insurance system operates on the principle of solidarity. This means that people who are in good health also pay for those who are in poor health. However, the solidarity principle operates not only between healthy and sick people but also between the various health insurers: this is referred to as «risk balancing».

Risk balancing is the process by which the risks of health insurers whose customers are mostly in good health are balanced against the risks of those whose customers are at greater risk of becoming ill. At present the risk indicators used are: age, gender, and time spent in a hospital or nursing home in the previous year. Pharmaceutical cost groups (PCGs) were added as an indicator in 2020. These relate to patients who suffer from cost-intensive chronic conditions such as asthma, diabetes and multiple sclerosis.

SWICA welcomes comprehensive risk balancing because it encourages competition in the area of quality. Health insurers should compete on the basis of good service quality, attractive products, professional advice, and the provision of assistance to insured persons suffering from the effects of illness or accident.

Unscrupulous agents often use aggressive cold-calling methods and false information to persuade potential customers to meet them. Some of these agents make promises about premiums and claim to be working with SWICA.

SWICA rejects all dubious practices of this sort. SWICA does not share customer information with third parties and does not therefore work with brokers or agents who call from abroad or make groundless promises about reduced premiums. Insurance cover depends on the individual requirements of each insured person. These circumstances can only be clarified during a professional advisory meeting.

In order to take action against these nuisance calls, SWICA – together with 39 other health insurers – signed an industry-wide agreement in January 2020. The signatories to this agreement reject cold calling as a means of acquiring new customers. They also place limits on commissions for sales staff. The maximum commission in basic insurance is set at 70 francs, while the commission for supplementary insurance will be limited to one annual premium. Furthermore, the agreed quality and transparency standards will give customers more legal certainty. The agreement will come into force on 1 January 2021.

If someone calls you, allegedly on behalf of SWICA, please ask the caller the following questions:

• How did you get my/our number?
• What company do you work for?
• Where did you get my information?

Please note the information you receive and pass it on to us. Please also ask for the caller's phone number and forward it to SWICA using the contact form. You can also report dubious agents to santésuisse (the association of Swiss health insurers) or to the State Secretariat for Economic Affairs SECO. Thank you for your help.

By law, health insurers are not permitted to generate profits in mandatory healthcare insurance (OKP). They are required to use the premiums to cover the cost of benefits. If, nonetheless, they occasionally produce a surplus, they have two options under the Health Insurance Supervision Act (KVAG). Either they can pay a portion of the premiums back to their customers, or they can transfer the surplus to their reserves. At SWICA, all surpluses are transferred to reserves, not least because the law requires insurers to form reserves.

However, since health insurance is part of Switzerland's social security system, these reserves again benefit all insured persons by ensuring that the costs of illness and care are covered. The service providers, for their part, can be assured that the services they provide have proper financial backing.

While health insurers are not permitted to make a profit on basic insurance, this is not the case for supplementary insurance. Supplementary insurance plans are governed by the Insurance Contract Act (VVG). This is profit-oriented private insurance business and is subject to supervision by the Swiss Financial Market Supervisory Authority (FINMA).

Since 2012, cantons have had the option under the Art. 64 of the Federal Health Insurance Act (KVG) to maintain a list of individuals who default on their premium payments. These cantons can therefore blacklist insured persons who have failed to paid their basic insurance premiums despite debt collection proceedings. Insured persons on this list will have their benefits suspended and will only be covered for medical emergencies, unless they pay for their treatment in cash. With this measure, the cantons that keep a blacklist are hoping to encourage individuals to improve their payment behaviour in the health sector and thus to achieve savings.

Every canton can decide individually whether to keep a blacklist. Currently (as of december 2022), five cantons have still elected to do so, which means that health insurers there are obliged by law to notify the cantonal authorities about insured persons who are subject to debt collection proceedings due to unpaid premiums or co-payments.The Federal Council would like to abolish the lists of defaulting insured persons. Such lists could impair basic medical care for insured persons in modest economic circumstances and that their benefit has never been proven.

SWICA analysis shows no change in payment behaviour in cantons which have introduced blacklists. SWICA therefore rejects the use of blacklists.

As a health insurer, SWICA has a statutory duty in the area of basic insurance to check submitted invoices and determine whether they are cost-effective, appropriate and efficacious. In fulfilling its duty, SWICA checks around ten million invoices every year. Although most benefit statements are correct, we regularly discover mistakes. However, not every mistake is deliberate. It is therefore important for insured persons to make their own careful check of each invoice. Clear, well-structured benefit statements help insured persons to identify errors themselves and report them to SWICA. We can then carry out targeted checks.

Deliberately receiving or charging for unjustified services is not only unfair, it is also against the law. Cases like these constitute insurance fraud and are to the detriment of all insured persons. SWICA takes action to combat abuses of this kind. If we find discrepancies or specific indications of abuse, the department responsible for combating insurance fraud launches an investigation. Around one hundred cases of insurance fraud are detected in this way every year. In doing so, SWICA complies with the requirements of social security law at all times.

Integrated care is a fundamental component of SWICA's strategy. Integrated care aims to identify and improve interface problems, inefficiencies and contradictions at all levels within health care. It includes treatment processes, the service providers involved, and above all the competences and objectives of the patients. This helps to improve quality and reduce costs.

SWICA welcomes the Federal Council's plan to strengthen integrated care. However, the suggestions put forward by the Federal Council will not achieve this aim. In fact, they will cripple initiative and innovation. The networks for coordinated care suggested by the Federal Council will have to comply with a very narrow set of specifications. For example, they will require a cantonal service mandate and must restrict themselves to outpatient benefits, which makes flexible and patient-oriented action difficult. Whereas voluntary models are promising and lead to effective cost reductions, as SWICA has shown in its diabetes study.

On 1 May 2020, SWICA announced that it would accede to the Tardoc (outpatient physician rate) and LOA V (pharmacy rate) rate schedules with effect from 1 January 2021. By acceding to the two modern rate schedules, which are based on cooperation, SWICA aims to strengthen the rate partnerships in the Swiss healthcare system; these are of vital importance in the implementation of SWICA's integrated healthcare business strategy. In the case of the LOA V pharmacy rate, a submission has been made to the Federal Council.

Together with the other rate partners (curafutura, FMH and MTK), SWICA also supported the submission of Tardoc to the Federal Council. SWICA is convinced that Tardoc enables an appropriate and balanced representation of medical services as well as the further development of interprofessionalism. SWICA regrets the Federal Council's decision not to approve Tardoc in its current form, as the delay puts patients, premium payers and service providers at a disadvantage.
In parallel with Tardoc, santésuisse and FMCH (a merger of expert societies representing practitioners of surgical and invasive procedures) want to pay for outpatient treatment as far as possible by means of flat rates. They have submitted a range of flat rates to the Federal Council for approval.
SWICA supports both approaches because outpatient flat rates are an important prerequisite for promoting integrated care. SWICA would therefore very much welcome cooperation between all those involved.