Opting for outpatient care is the change proposed by EFAS, an object on which we will vote on November 24. It is one of the key reforms of the decade, not so much in terms of its financial content as in terms of its effects. It will promote outpatient interventions that have become faster and less invasive thanks to medical progress. Treatments that required a hospital stay will increasingly be replaced by their more modern version, which allows you to return home the same evening. Caregivers will have to reorganize themselves, patients will have to get used to it. Supporting EFAS means taking a leap into the future, like in Canada, where 80% of elective interventions take place on an outpatient basis, compared to 20% currently in Switzerland. This means adopting a lighter solution and generally half as expensive, according to the OFSP’s findings in 2019. This is at least 440 million francs in expenses saved with a direct effect on premiums.
Negotiate more
Medical rates must reflect costs. If an eye operation is done in ten minutes instead of thirty thanks to a new technique, the remuneration for the procedure must be reduced. However, the pricing tool for outpatient services, the Tarmed, has hardly been able to be updated since its beginnings in 2004. Its replacement, the Tardoc, proposed in 2019, and to which the CSS contributed, will come into force. force on January 1, 2026. The right of veto of the various participants in the discussions has long prevailed, as the FMH regrets. It is by refusing failure and providing new bases for discussion in the negotiation that we can hope to reach compromises acceptable to all.
Believe in digital
The potential of digital technology is enormous provided you get used to making the necessary investments. The electronic patient record stores all medical history in one place. We can easily imagine the time saved, and the savings made, by avoiding double examinations, unnecessary consultations, searching for old documents, or on the contrary, being alerted very early on preventive care. However, although launched in 2017, the electronic patient record has still not become established. The financial aid granted this year by the Confederation, coupled with that of the cantons, should facilitate its dissemination, both to healthcare providers and to policyholders. And the current revision of the law provides for the consolidation of existing structures into a single platform and a generalization of its use.
Another national digital project could open up interesting prospects. This involves the creation of a Swiss medical data collection center, a data trust center, which would allow Swiss research teams to make progress on issues that are difficult to finance, such as rare diseases. Such a center could be managed and secured by a federal authority.
But the digital leap also depends on the willingness of each insured person to entrust their personal medical data to shared digital structures. All data protection measures must be implemented and their application regularly monitored by all parties involved, whether health insurers, hospitals or doctors. The key word here is trust.
Coordinate in a transdisciplinary network
Ensuring that each patient has the right care at the right time, according to their particular situation, at all stages of their health journey, requires good coordination of the practitioners who care for them. Even if they don’t know each other. Even if they are not located in the same place. Achieving such coordination is obviously not simple. But it is possible, if the practitioners of a region are ready to consider it, if they organize themselves into an integrated care network as broad as possible, ideally including office medicine, hospitals, rehabilitation, etc. ‘at the EMS. As an insurer, we can provide support.
Test new solutions
Faced with certain areas of dissatisfaction in the field, daring new care solutions can prove beneficial, both to control the progression of the disease, improve lifestyle, strengthen therapy and to counter the risk of relapse .
Thus, it is not always easy to optimize the journey of chronic and polymorbid patients so that their health stabilizes and prevents it from getting worse. Hence the idea of providing them with a specially trained person who orchestrates their medical journey in a personalized manner. This is the bet that the CSS is making with the Ensemble Hospitalier de la Côte, in the Morges region. This new coordinator position will be effective from January 1st.
On the connected health side, innovative applications provide solutions to situations that we used to accept. Ylah offers support between two psychological consultations, Carity offers personalized coaching to people who have suffered a heart attack. CSS pilot projects make it possible to test some of these applications.
Support prevention
Currently, prevention is the poor relation of the health insurance law (LAMal) where it represents only 3% of expenses. However, this is another area where everyone can act. However, it is not always easy to take charge of your health alone. Some health insurers go beyond their traditional role and support the insured in their health. The CSS thus provides an app, Active365, which provides advice on nutrition, stress and sleep management and physical activity monitoring. With the Ensemble Hospitalier de la Côte, CSS policyholders also have access to a prevention offer from 2025, in the form of a health assessment and personalized prevention advice.
Finally, the health insurer can also take on a prevention awareness role through targeted information to potentially affected policyholders. However, a slight amendment to the data protection law would be necessary.
Check invoices
Checking invoices is an obligation of LAMal. Before proceeding with reimbursement, the health insurer must check two things: on the one hand, if the invoice is correctly established according to the law and the price list, and, on the other hand, if the service meets the three criteria of the LAMal. Any service must have proven medical effectiveness, be adapted to the diagnosis, and meet economic requirements, i.e. have a reasonable price. We were thus able to avoid 797 million francs in unjustified expenses, and uncover 36 million in fraudulent expenses in 2023. To be effective, the insurer must regularly adapt its automatic control tools and equip itself with sufficient teams, just like the The insured person can make sure to take a look at their invoices.
This range of possible advances shows the extent to which our health system needs to be modernized. But above all, it shows that much progress depends directly on each of us, insurer, patient, doctor, administration, federal parliament. It is by becoming proactive, by trusting in the dialogue and cooperation that can be established with other stakeholders, that we will better control costs and make this health system more efficient.
