Uniform outpatient / inpatient financing (EFAS)

Although outpatient treatment is mostly cheaper than inpatient procedures, many cases are nevertheless treated on an inpatient basis. One of the reasons can be found in the way the system is financed. Outpatient treatment is funded entirely through the premiums paid by insured persons, inpatient care only up to 45%. As a result, some procedures are performed on an inpatient basis although the same level of medical care could be provided on an outpatient basis for less money. This holds back both the sensible shift towards outpatient care and the development of integrated care. These false incentives could be eliminated by adopting a uniform system of financing for outpatient and inpatient services (EFAS) which proposes that, in future, health insurers will reimburse 100 per cent of the costs in all service areas while the cantons fund a share of the total costs in their canton equivalent to the contribution they are currently making towards inpatient care. These funds would find their way back into the system, thus preventing a rise in premiums for insured persons. EFAS is supported by all the market participants and relevant professional associations. Only a few cantons have voiced opposition to the reform thus far: given that, under the new model, insurers would be responsible for processing payments for all services, CSS believes this means that the checking of invoices should also carried out by the health insurers alone. This would render cantonal authorities’ additional checking of invoices for inpatient care obsolete. The reduction in the administrative burden would relieve premium and tax payers. Checking invoices is a vital part of verifying benefit entitlement and one of the core tasks of the health insurance industry: the checking of invoices by health insurers leads to savings of more than CHF 3.5 billion a year.
Another bone of contention is the integration of long-term care into EFAS: the cantons insist that health insurers should also participate in the costs of care, as well as the cost of services provided by the medical profession and hospitals. This is a case of ‘moving the goalposts’, as it would mean integrating an area for which underlying data is not yet available. CSS is generally open to the integration of care, provided the necessary cost transparency is possible.

CSS itself expressly welcomes a rapid changeover to uniform financing, as EFAS not only eliminates the false incentives in the system, it also allows additional discounts to be offered for integrated care models, thus, benefiting the insured persons. Moreover, EFAS would mean that the checking of bills for services provided would no longer be duplicated, but be carried out solely by the insurer as a 'one-stop shop'.