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Which regulation for ambulatory medical care?

Country: 
Schweiz
Partner Institute: 
Università della Svizzera Italiana, Lugano
Survey no: 
(14) 2009
Author(s): 
Iva Bolgiani (proof reading by Luca Crivelli, Ignazio Cassis and Mary Ries)
Health Policy Issues: 
Rolle Privatwirtschaft, Organisation/Integration des Systems, Politischer Kontext, Zugang, Vergütung
Reform formerly reported in: 
Who should control outpatient supply after 2009?
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein ja nein nein

Abstract

The moratorium on the opening of new medical surgeries will expire at the end of 2009. After renewing it twice, Parliament has decided to procrastinate by yet a further two years, while introducing some substantial changes. The new decree will expire at the end of 2011 in the expectation that consensus will be reached for a new alternative model which will regulate the ambulatory sector on a permanent basis.

Neue Entwicklungen

The debate concerning the future regulation of ambulatory medical care has been going on in Switzerland for almost 10 years. The various actors present on the political arena were not able to reach consensus on the solutions to be adopted.

The Federal Council's bill concerning the freedom to contract is presently on the agenda of the corresponding commission of the National Council, which has to evaluate it together with two other amendments of the Health Insurance Act: the promotion of Managed Care Networks and the co-payment issue. In the meantime, the need to regulate the ambulatory sector more effectively is still pending, but there are different political views: on the one hand the promoters of greater planning intervention by the Cantons, on the other those who wish to give more leeway to the contracting partners (i.e. insurers and physicians), thus creating competition which can improve the efficiency of the of the system [see 1].

In December 2008, after four years of work, the Council of States decided to postpone the discussion on the freedom to contract again and to leave the task of dealing with it to the other chamber. Since the deadline for the expiry of the provisional disposition was very close (31.12.2009), Parliament opted for a partial revision of the law - remember that in accordance with the law in force at present the authorization to open a new surgery is bound to the existence of a proved need. Therefore, on 16th January 2009 the National Council's Commission on Social Security and Health approved an initiative of Parliament intended to further extend the clause of need for the issue of new authorizations as from 1st January 2010; but the moratorium should be limited to "specialist" physicians only  [see 2]. On 25th March 2009 the Commission passed the bill on to the Federal Council for an opinion [see 3]. The Federal Council [see 4] recognized the fact that there was insufficient time to draw up a final solution to substitute the moratorium and agreed with the commission's proposal, giving this umpteenth temporary solution the green light.

The third extension of the moratorium was formally accepted by Parliament on 12th June 2009, will come into force on 1st January 2010 and will expire on 31st December 2011. The amendment of article 55a of the Health Insurance Act provides for some new items, as has already been mentioned:

  • in order to transmit a strong signal in favor of primary medical assistance, GPs are excluded from the moratorium.
  • to avoid possible attempts to elude the restriction on authorizations, the field of application of article 55a has been extended to the sector of outpatient care in hospitals.

Thus Parliament has opted once again for a temporary solution to the problem, further postponing the search for a final regulation. However, doctors' claims have been taken into consideration for the first time, as well as the need to re-assess the primary care sector and to improve the role of the GPs. It was deemed necessary to make the distinction between the medical profiles in order to face up to the risk of a shortage of GPs and to strengthen their role as coordinators in the chain of treatment. The new disposition should thus encourage medical students to choose primary care medicine as their field of further training. The aim of the extension of the field of application to the sector of outpatient care in hospitals is to limit the increase in costs in a sector in full expansion. A similar proposal concerning the planning of the hospital outpatient sector was also put forward by the Federal Council as an urgent measure to contain health costs. In the autumn session this was rejected by the National Council (cfr. hpm-report Urgent measures to curb costs and control premiums), which felt it was not correct to confer more planning power on the Cantons, especially in a health care sector which is not directly financed by cantonal tax revenues . Moreover, the planning of the hospital outpatient sector poses some problems in its application, such as the difficulty in making a clear distinction available between inpatient and outpatient activities within hospitals.

 Suchhilfe

Characteristics of this policy

Innovationsgrad traditionell neutral innovativ
Kontroversität unumstritten unumstritten kontrovers
Strukturelle Wirkung marginal marginal fundamental
Medienpräsenz sehr gering gering sehr hoch
Übertragbarkeit sehr systemabhängig recht systemabhängig systemneutral
current current   previous previous

The solution adopted by the Swiss political system is a transitory solution which does not bring radical changes concerning the regulation of the ambulatory sector. Therefore, it is a consensual solution, which is not very obvious to the population and depends to a large extent on the legislation already in force.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein ja nein nein

Initiators of idea/main actors

  • Regierung
  • Parlament
  • Leistungserbringer

Stakeholder positions

Extending the moratorium for the third time was a solution reluctantly accepted by a majority of the Parliament, in order to find a temporary answer to a problem which requires a final solution; yet the latter eludes Parliament. The lack of consensus at political level on the introduction of freedom to contract drove the legislator to stall yet again, extending a strongly criticised regulation; however, it enables the ambulatory medical supply to be regulated at least in part. The strongest opposition came from the Association of Swiss Hospitals; the hospitals fear that their leeway will be limited within their own structures, waiting lists will appear and the quality of treatment delivered to patients will worsen. Santésuisse also gave it a lukewarm welcome; they would have preferred a final solution to be adopted which gave them greater bargaining power with respect to physicians. Most probably, the solution which will have to be debated in the next few months in the Swiss Parliament will therefore be based on one of the three models already proposed in the preceding report (12/2008). The expectations regarding the adoption of one of these final solutions are still unclear with all partners agreeing on the need to resolve the ambulatory problem. The continuous surge of costs and the proposal of urgent measures (but temporary in nature) on the part of the Federal Council ensure that the debate can no longer be postponed.

Actors and positions

Description of actors and their positions
Regierung
Federal Councilsehr unterstützendunterstützend stark dagegen
Parlament
National Councilsehr unterstützendunterstützend stark dagegen
Council of Statessehr unterstützendunterstützend stark dagegen
Leistungserbringer
Hospitalssehr unterstützenddagegen stark dagegen
Medical Association (FMH)sehr unterstützendunterstützend stark dagegen
current current   previous previous

Influences in policy making and legislation

The legislative change was welcomed by all the actors (except H+; see [5] and [6]), even if with mitigated enthusiasm.

The important new aspect is the fact that family doctors (specialists in general medicine, internal medicine, pediatricians and GPs) are exempted from the clause of need. It was important to give a positive signal to family doctors.For some time they have been claiming that the role of GPs as coordinators of the different health care partners in the country be enhanced  and that a shortage of GPs be  considered a real future possibility. The protest demonstrations against the adjustments in the reimbursement schemes put forward by the Federal Council reached their peak last spring when the government decided on a revision of the fees for laboratory analyses. Faced with the expected reduction in the revenues of their surgeries, the perceived dismantling of family medical care and the dreaded decrease in the quality of care supplied to patients, the GPs took to the streets on 1st April 2009 in many Swiss cantons to promote a "day of national action for general practitioners"  [see 7]. Therefore, the legislative change aims at increasing the number of family doctors, who it is thought will probably immigrate from the bordering EU countries; it is also intended to improve the role of the GP. Those most directly involved did not welcome this opening to EU physicians, as they fear increased competition. The role of the Cantonal Medical Associations and of the FMH (the body at the federal level), which has always supported these claims, was important for the purposes of the decision (see [8]). However, the implementation of a new role for the family doctor will now have to be confirmed in both the draft bill concerning the freedom to contract and the development of integrated networks of care. Moreover, it must be noted that in September 2009 GPs set up a national association, so the members of the Swiss Societies of General Medicine, Internal Medicine and Pediatrics merge in a single organization. This new general association, called "Hausärzte Schweiz" , has decided to launch a popular initiative during the autumn of 2009 called "Yes to family medical care" [see 9]. The aim is to enhance the value of their profession, avoid a shortage of GPs and guarantee quality medical care with family doctors becoming a fundamental component of primary care. The means to achieve this objective is the direct intervention of the Confederation and the Cantons, through adequate norms regulating the whole sector in detail.

Legislative outcome

Enactment

Actors and influence

Description of actors and their influence

Regierung
Federal Councilsehr großgroß kein
Parlament
National Councilsehr großgroß kein
Council of Statessehr großgroß kein
Leistungserbringer
Hospitalssehr großneutral kein
Medical Association (FMH)sehr großneutral kein
current current   previous previous
Medical Association (FMH)Federal Council, National Council, Council  of StatesHospitals

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The adoption of the third extension of the moratorium on medical surgeries was welcomed by all partners as a logical consequence of the lack of consensus on the project concerning the freedom to contract. The only winners of this amendment may be family doctors, whose role is properly recognized in the new version of article 55a. On the other hand, the hospitals are the actors who challenged the new text, as they consider that they are penalized by the inclusion of the hospital outpatient sector in the moratorium. In particular, they claim that hospital outpatient medical care should be considered in a different way from that practiced outside their structures. In their opinion, hospital outpatient medical care can be practiced within the hospital inasmuch as it is based on well-defined competence centers and is carried out in multidisciplinary teams [see 6]. Their slogan is"hospital outpatient medical care is economical and practiced in the right place", considering the too high investment costs which would have to be assumed by doctors outside their structures in order to supply the same services. The average cost of a visit to the doctor is CHF 150.-, whereas to the hospital's outpatient sector it is CHF 350.-.  However, it has to be emphasized that, according to the ordinance limiting the number of service providers admitted by the compulsory health insurance, the cantons will have the option of regulating this sector.

Monitoring and evaluation

It should be noted that no direct wide-ranging evaluation of the long lasting impact of the introduction of the moratorium has been carried out so far. In 2004 an impact study financed by the Federal Office of Public Health was published (see [10]). In our opinion the period of the analysis was too early to collect strong evidence on the real impact of the regulation. Other studies were carried out in the meantime (see [11], [12], [13], and [14]) with the aim of defining the present state of medical supply in the outpatient sector, to outline possible future developments or to work out alternative regulatory mechanisms. In these cases we cannot speak of impact studies.

The amendment of article 55a was carried out on the basis of a series of studies (see [15] and [16]) which demonstrated that there was a shortage of medical staff, especially GPs. However, the role of the pressure exerted by the GPs themselves at political level on the legislative outcome must not be underestimated.

The fact that there was no impact study on the 2002 regulation is certainly a great shortcoming since it has not been possible to monitor the impact of this measure on the costs, quality and accessibility of health care in a scientific way. Due to the urgency, Parliament has always extended the legislative article without a real evaluation of the measure itself. Nor is monitoring envisaged for this latest extension, which in principle should be the last of the series, while a final solution to the problem of regulating the ambulatory sector is awaited.

Expected outcome

It is difficult to reach a consensus within Parliament regarding the final regulation of the number of doctors authorized to practice in the ambulatory field. The National Council will probably discuss the bill concerning Managed Care, the freedom to contract and co-payment in 2010. In the meantime, different models have been presented and various groups are reflecting on the problem. As always the solution gravitates around three possible variants (see survey round 12/2008):

  1. the generalized abolition of mandatory contracting: regulation of the ambulatory health care sector by means of selective contracting, entrusted to the health insurers;
  2. generalized planning of the supply of ambulatory services (FMH-CDS model): optional regulation in the case of excessive supply entrusted to the cantons, who, after considering the opinion of the professional associations, would have the faculty to subordinate the concession of new authorizations to a test of need; in their assessment they would discern the region where the new surgery would open and the physician's speciality, as well as the effective level of activity (i.e. taking into account when planning physician supply the greater incidence of part-time working conditions, which, in particular, enable female physicians to reconcile professional activity with maternity and other family situations) .
  3. the creation of a dual insurance system, which for every insured person would imply the choice between (a) remaining in the present system (mandatory contracting) or (b) opting for a managed care contract (with less freedom but more affordability).

A decision will have to be made in the course of the next two years. Taking the present political context into consideration it can be imagined that the new solution will take the family doctors' claims into account and, at the same time, will tend to encourage the creation of integrated health care networks (of the managed care type). In fact, these two aspects are the point of consensus in the different political groups. The great debate to be faced will probably focus on the degree of competition versus regulation which the ambulatory sector will have to be based on and on the kind of financing (will the State also be called on to intervene in the ambulatory sector?) The problem of the shortage of doctors, especially of family doctors, which Switzerland will have to deal with in the next few years must be emphasized. In fact, it is obvious that since the moratorium came into force, many young doctors who could not open their own surgeries have continued to work in the hospital sector, thus privileging the hospital career. The choice of this alternative and the reduced attractiveness of the profession as family doctor for the younger generations (working alone in a surgery, excessive working hours, professional activity in outlying areas, less income in comparison with technical specialities) has had important consequences: fewer and fewer young doctors choose the profession of GP. The most important result is that Switzerland will soon run up against a shortage of GPs, an even more serious shortage if it is considered that one of the reforms to be discussed next will be related to the constitution of health care networks of the managed care type, where GPs will have to be the center of the system.

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch
current current   previous previous

 

References

Sources of Information

  1. Bundesgesetz über die Krankenversicherung. Teilrevision. Vertragsfreiheit. http://www.parlament.ch/d/dokumentation/dossiers/vertragsfreiheit/seiten/vertragsfreiheit-zusammenfassungen.aspx
  2. Krankenversicherung. Übergangslösung zum Zulassungsstopp für Leistungserbringer 
    http://www.parlament.ch/d/suche/seiten/geschaefte.aspx?gesch_id=20090400
  3. Kommission für soziale Sicherheit und Gesundheit des Nationalrates (2009), Parlamentarische Initiative. Übergangslösung Zulassungsstopp. Bericht der Kommission für soziale Sicherheit und Gesundheit des Nationalrates vom 25. März 2009 
    http://www.admin.ch/ch/d/ff/2009/3413.pdf
  4. Bundesrat (2009), Parlamentarische Initiative. Übergangslösung Zulassungsstopp. Stellungnahme des Bundesrates (vom 13. Mai 2009) zum Bericht vom 25. März 2009 der Kommission für soziale Sicherheit und Gesundheit des Nationalrates. 
    http://www.admin.ch/ch/d/ff/2009/3423.pdf
  5. Die Spitäler der Schweiz (2009), Neue Verordnung schafft absurde Widersprüche, Medienmitteilung (8.09.2009). http://www.hplus.ch/fileadmin/user_upload/Aktuell_Medien/Medienmitteilungen/2009/VEZL_Personalrationierung/MM_090908_VEZL_Personalrationierung_V2.pdf
  6. Die Spitäler der Schweiz (2009), Qu'est-ce que la médecine ambulatoire à l'hôpital? Documentation distribuée aux membres de la Commission de la santé du Conseil national.
  7. Verbindung der Schweizerischen Ärztinnen und Ärzten (2009), Vermeintliche Sparübungen im Alleingang bringen nichts. Die FMH zum nationalen Aktionstag der Hausarztmedizin. Medienmitteilung vom 1.4.2009. http://www.fmh.ch/files/pdf1/2009_04_01_medienmitteilung_aktionstag_hausarztmedizin_d.pdf
  8. Verbindung der Schweizerischen Ärztinnen und Ärzten (2009), Ja zu einer Übergangslösung zum Zulassungsstopp. Die Meinung der FMH.http://www.fmh.ch/files/pdf1/Zulassungsstopp_Meinung_der_FMH_Mai_DEF_D1.pdf
  9. Schweizerische Gesellschaft für Allgemeinmedizin (2009), Eidgenössische Volksinitiative «Ja zur Hausarztmedizin» 
    http://www.jzh.ch/de/
  10. Rüefli. C. and G. Monaco (2004), Wirkungsanalyse Bedürfnisabhängige Zulassungsbeschränkung für neue Leistungserbringer (Art. 55a KVG). Berichtnummer 3/04.
    http://www.aramis.admin.ch/Default.aspx?page=Texte&projectid=15579&Sprache=de-CH#Table1
  11. Künzi, K. (2005). Grundversorgungsmedizin in der Schweiz. Stand der Diskussionen zur Frage der "Grundversorger/innen / Hausärzt/innen" und ihrer zahlenmässigen Entwicklung. Studie des Büro BASS im Auftrag des BAGs (14.11.2005).
    http://www.buerobass.ch/pdf/2006/Grundversorgungsmedizin.pdf
  12. Bertschi, M. (2005). Untersuchung der ärztlichen Versorgung. Schlussbericht (27.10.2005)http://www.santesuisse.ch/datasheets/files/200511071001210.pdf
  13. Spycher, S. (2004). Prognose und Planung der ambulanten Gesundheitsversorgung. Neuchâtel: Schweizerisches Gesundheitsobservatorium.http://www.obsan.admin.ch/bfs/obsan/de/index/05/03.Document.105395.pdf
  14. GDK Schweizerische Konferenz der kantonalen Gesundheitsdirektorinnen und -direktoren (2007), Zulassungsbeschränkung: Konzept für eine Nachfolgeregelung (31-07.2007)
    http://www.gdk-cds.ch/fileadmin/pdf/Themen/KVG-Revision_und_Vollzug/KVG-Revision/Nachfolgeregelung.pdf
  15. Jaccard Ruedin H., F. Weaver (2009), Ageing workforce in an ageing society. Wieviele Health Professionals braucht das Schweizer Gesundheitssystem bis 2030? Neuchâtel, Schweizerisches Gesundheitsobeservatorium.
    http://www.obsan.admin.ch/bfs/obsan/de/index/01/02.Document.123782.pdf
  16. Bétrisey, K. and H. Jaccard Ruedin (2007), Entwicklung des ärztlichen Aktivitätsgrads in der ambulanten Medizin zwischen 1998 und 2004, Neuchâtel, Schweizerisches Gesundheitsobeservatorium.
    http://www.obsan.admin.ch/bfs/obsan/de/index/01/02.Document.102482.pdf

Reform formerly reported in

Who should control outpatient supply after 2009?
Process Stages: Strategiepapier, Gesetzgebung

Author/s and/or contributors to this survey

Iva Bolgiani (proof reading by Luca Crivelli, Ignazio Cassis and Mary Ries)

 

Empfohlene Zitierweise für diesen Online-Artikel:

Iva Bolgiani. "Which regulation for ambulatory medical care?". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/ch/a14/2