«EFAS alone is not a magic bullet»

Tobias Müller, what exactly is EFAS all about?

EFAS stands for the uniform financing of outpatient and inpatient services in the area of acute care. The bill proposes that the cantons and health insurance funds should cover the same percentage of costs, whether they are financing outpatient or inpatient services. The prime objective is to bring about a shift from inpatient to outpatient treatment, with a view to stabilising healthcare costs. However, it is important to note that EFAS is only concerned with the distribution of costs between cantons and health insurance funds, not with the level of costs.

How is care financed at the moment?

Today, outpatient and inpatient services are financed differently under compulsory health insurance (OKP). Inpatient services are generally much more expensive, but 55 percent are covered by the cantons and only 45 percent by the health insurance providers. Outpatient treatments, on the other hand, must be financed 100 percent by the health insurance companies and thus by those who pay the premiums. Or put another way: today, more than half of the bill for the last hospital visit is covered by the canton of residence; but the bill for the last consultation with the family doctor is paid in full by the health insurance company.

With the amendment, the share covered by the health insurance providers and cantons will be the same for outpatient, inpatient and nursing care costs. The health insurance companies would cover a maximum of 73.1% of all costs, the cantons a minimum of 26.9%. Which means that the cantons would also bear a share of the costs of outpatient treatment in the future.

Why is uniform financing important?

In the current system, health insurance companies have a financial incentive for as many patients as possible to be treated as inpatients, because then they don’t have to foot the entire bill themselves (just 45%). This can lead to excessive treatment in the inpatient sector, even though the same treatments could be provided on an outpatient basis at lower cost. The proponents say that a uniform funding structure would do away with these false incentives.

As I see it, they are overstating the influence that health insurers have on the place of treatment. The decision as to whether treatment is provided on an outpatient or inpatient basis lies primarily with the doctors. Health insurance funds only exert a limited influence, as they can only intervene after treatment has taken place by checking invoices and services, for instance by checking invoices for correctness or recognising conspicuous clusters of services provided by individual service providers. In Switzerland, however, the insurers’ hands are tied, as billing data does not contain any diagnoses.

Opponents of the revision fear higher health insurance premiums. What’s your take on that?

It is indeed possible that EFAS might put pressure on premiums, as health insurers now bear a higher proportion of inpatient costs. At the same time, the larger cantonal contribution to outpatient treatment costs is likely to soften any increase in premiums. It is hard to predict which effect will predominate.

EFAS may encourage outpatient care, but it is likely that hospitals will react to declining revenues. Without far-reaching reforms, such as moving away from volume-based remuneration systems (e.g. TARMED/TARDOC), cost growth in the healthcare system will be difficult to curb. So EFAS alone is not a magic bullet that will suddenly whip our healthcare system into shape. But it could be a step in the right direction.

Interview: Sandro Nydegger