Establishing transparency in the health sector

The costs of the system grow only moderately. Federal Government has to assume its monitoring function.

Savings in the insurance sector must be transferred to policy holders.

Interview with Carlo Conti, new president of the Swiss Conference of Cantonal Ministers of Public Health GDK

zf. The new GDK president and director of the Basel health office recognizes a lack of understanding of the health policy objectives. Generally more transparency and clarity about the financial flows are required.

Councilor Mr Conti, from 1 January on you will assume office as the President of the Bureau of the Swiss Conference of Cantonal Ministers of Public Health. What are your concerns and goals?

From the cantons’ perspective the competencies in health care are to be clarified and the axis between the Confederation and the cantons is to be strengthened. Increasing competition and market elements require a clear role of regulators. According to the Constitution, these are primarily the cantons, but there are also federal responsibilities. Specifying this separation of roles, this composite task, is one of the main goals. A second important issue is the clarification of financial flows in health care. Personally, I would like to move the economic aspects of health care to the fore.

What do you mean by clarification of financial flows?

The increasing shift of financial burden from taxpayers to premium payers is an offense, more so as we in our country are at the highest level – according to the OECD – of direct financial costs for individual health care services that are not covered by health insurance. Therefore, there is need for action as far as premiums are concerned. Medical and technical progress cause an increasing shift from inpatient to outpatient care and the public sector must make financial contributions in this area.

What are the basic deficits you discovered?

There is a lack of political agreement on health policy objectives. This ought to be clarified between the federal government and cantons. In an increasingly market-oriented health care, an adjudicatory authority is needed that can intervene and regulate. This can only be a democratically legitimated body, and is certainly not the insurances’ task.

“It is important that transparency is established”

Are the cantons or rather the federal government to the fore?

The cantons have the constitutional competence. Centralized health care systems do not lead to better performance. On the contrary, they tend to scaling down. Our population, however, does not want this to happen. However, the cantons must cooperate better. 26 different systems are no longer suitable for everyday use. We require a development towards health care regions.

On 1 January the new hospital funding comes into effect. The cantons finance about 55 percent of inpatient costs. But there is still the threat of rapidly increasing costs.

First, it should be noted that the costs for hospitalization stagnate whereas the total cost of the health system grow only moderately. The health insurance premiums rise, however, as the ambulant patient services – which are funded only by premium payments – are higher than average.

What other effects lead to increases in premiums?

It is new that the investment costs of hospitals will be financed by the health insurances up to 45 percent. This leads to an increase in premiums. The Parliament wanted it that way. However, they were silent about the additional burden on premium payers.

Are there any other shifts at the expense of premium payers?

With the free choice of hospital, the new hospital financing extends the scope of basic insurance. This causes a shifting of costs from supplementary to basic insurance, which means additional pressure on the premiums for basic insurance. All in all, however, no additional costs arise in health care through the new hospital funding.

Investment costs have been paid by the public sector so far. So it credits at the expense of premium payers?

The financial burden will indeed be shifted. It is true that investment accounts of the cantons are credited and the accounts of the basic insurance are debited.

This would mean to lower taxes.

That would be a logical consequence, which we might demand of a regulatory policy. The Ministers of Public Health, however, would like to use these redundant funds for the premium payers’ relief. This is even more important since the new hospital financing with its diagnosis-related groups (Swiss DRG) means that more services are provided for outpatient treatment.

Is such a trend towards ever higher premiums any longer acceptable?

It must be a priority to analyze the financial system and the shift to the premium payers in particular. This development will excessively charge mainly young middle class families and their monthly budget. More tax funds are required to finance the entire health system. The change must also be affordable for the cantons by revising the distribution key and setting it at 45:55 percent.

The cantons could have set their share of funding the treatments at the hospital at a higher level. A majority even remained below the targeted rate of 55 percent laid down in the Health Insurance Act.

That is correct. But there is no way for the cantons to come to a mandatory and binding agreement with the insurances, in order to use additional taxes to reduce premiums. When indicating the premiums at the federal level, the insurances do not differ in detail between costs for inpatient and outpatient treatment. The entries are not transparent. Therefore, the cantons could not and would not make use of additional tax revenue. This requires a transparent mechanism.

Will you negotiate with the insurances on the funding distribution during your presidency?

The insurances must have an interest in seeking solutions to stop the upward pressure on premiums, especially as the total cost of the system only increase modestly.

You also mentioned shifts from supplementary to basic insurance. The additional insurance premiums have been reduced for 2012 but not significantly. Where does the money go? Who benefits?

The insurances. They did not lower the premiums for supplementary insurance accordingly. After all I heard from representatives of insurances that they were being cautious and wanted to first wait how things would come out and then check the appropriate transfer of premium benefits to those who were additionally insured. Some insurers have also reduced the premiums to some extent.

Should the supplementary insurances not pass on their savings already in the course of the next year?

This does not play a major role for me. It is important that transparency is created. I expect the insurance companies and above all, the federal government, which needs to strengthen its supervisory role, to establish more transparency, so that savings in the insurance sector are actually passed on.

Is this an appeal to the FINMA?

It is an appeal to the Swiss Financial Market Supervisory Authority FINMA, but also to the Federal Office of Public Health (BAG). One must consider the overall pie: The developments in the compulsory basic insurance and the additional insurance sector should be assessed in parallel.

Doctors and nurses fear that the new hospital funding could be associated with a loss in quality.

The population would not accept a loss of quality in health care, nor restrictions on the access to new medical treatments and innovative products. This has been clearly demonstrated in all surveys and studies. Those hospitals that have a poorer quality will be in trouble in the new competitive system.

Competition requires transparency, the quality can only be assessed this way. What is being done for its promotion?

In addition to their actual role as regulators, the cantons must assume an important task mainly in the field of quality. Quality indicators are to be defined, checked, and one must intervene in case these indicators are not kept.

“Hospitals with poor quality will have troubles in a competitive system”

Did you already set targets for next year?

There is the National Association for Quality Development (ANQ). In various cantons there were discussions about quality and indicators for quality were defined. This process will develop. My idea is that we will define some indicators and standards throughout Switzerland.

What did you arrange in Basel?

We have defined some indicators together with the hospitals, with the service providers and the homecare management. On the basis of the new health law, we have designed a so-called “Gesundheitsversorgungs-Bericht”, a report about health care supply. The first edition is published. Therein we will annually publish the financial flows, the patient flows, but also quality aspects.

The duration of hospital stays is being reduced. Are the cantons prepared to guarantee the care after the hospital stay?

The situation in the cantons is different. In some cantons one does not assume that an additional transitional care will be needed, in others probably yes. In Basel the already built facilities should be enough. But we will observe the market and, if necessary, intervene.     •

^{Source: ©Neue Zürcher Zeitung , 31.12.2011
(Translation Current Concerns)}