|Who should control outpatient supply after 2009?|
|Implemented in this survey?|
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.
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:
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.
|Medienpräsenz||sehr gering||sehr hoch|
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.
|Implemented in this survey?|
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.
|Federal Council||sehr unterstützend||stark dagegen|
|National Council||sehr unterstützend||stark dagegen|
|Council of States||sehr unterstützend||stark dagegen|
|Hospitals||sehr unterstützend||stark dagegen|
|Medical Association (FMH)||sehr unterstützend||stark dagegen|
The legislative change was welcomed by all the actors (except H+; see  and ), 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 ). 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.
|Federal Council||sehr groß||kein|
|National Council||sehr groß||kein|
|Council of States||sehr groß||kein|
|Medical Association (FMH)||sehr groß||kein|
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.
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 ). 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 , , , and ) 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  and ) 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.
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):
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.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
|Who should control outpatient supply after 2009?|
Process Stages: Strategiepapier, Gesetzgebung
Iva Bolgiani (proof reading by Luca Crivelli, Ignazio Cassis and Mary Ries)