The range of services covered by compulsory health insurance (CHI) is an important and controversial part of the public health system.
Treatment covered by CHI must be effective, appropriate and economical (EAE). Unlike treatment not provided by doctors, the coverage of traditional medical treatment is not subject to compulsory monitoring but is accepted insofar as no evidence to the contrary is provided. This principle of trust towards the providers of medical services means that indisputable innovations can be made accessible for patients relatively quickly.
The principle of trust is justified only if treatment that is controversial from the “EAE” point of view is systematically evaluated and excluded from CHI cover if necessary. In practice, despite recent improvements, this system of elimination is inadequate. With no overview of the range of services provided and a lack of incentive on the side of the providers and insurance companies, only a fraction of the services covered by CHI are evaluated and those are chosen at random.
Under the Swiss service providers system, the proof that an uncertain service is deemed to meet the “EAE” criteria must be presented by the applicant. Prerequisites for applicants have been improved over the past few years. The application forms used at present do not take adequate account of integrated services, which are becoming more common, as well as non-indicatory services.
The criteria for the initial selection of objects to be examined by the Federal Services Board (FSB) are not clear enough and too poorly documented.
In practice, the external reviewers, who under the system of service provision should represent an important counterbalance to the applicants, carry too little weight and the quality of their reports does not come up to international standards owing to the fact that their job description is inappropriate.
As a “non-professional” board that does not have the advantage of its own resources, the FSB is in a weak position and, as far as regards the selection and evaluation of objects to be examined, depends to a large extent on the Federal Office of Public Health (FOPH). For its part, the FOPH plays a questionable, multiple role in the procedure, and the section that is responsible, namely Medical Services, clearly has too few resources for the task allotted to it. The result is that, in a system dominated by the applicants, there is no independent body to analyse the complex content of an application in a neutral way and to pass on its report to the FSB.
Despite considerable pressure from interest groups, the FSB normally manages to be objective. “Political” recommendations for the Department of Home Affairs (DHA) are rare. The Board does not work with sub-committees and still does not have its own internal regulations.
The “EAE” criteria by which decisions are taken as to whether CHI cover should be granted or not are not sufficiently precise, quantifiable or well documented. There is no clear yardstick for measuring, in particular, the cost-effectiveness of a service, which in practice is given far less weight than its impact.
In practice no clear distinction is made between the assessment (the scientific evaluation) and the appraisal (the evaluation of whether it would be appropriate for the service to be covered by CHI in the given context). For the appraisal there is no national health policy based on health and budgetary standards to guide the FSB in its decision.
The possibility of including a service under CHI cover for a limited period of time and under condition that a more detailed evaluation is made at a later date makes sense. The conditions for such an evaluation are not always clear enough, however, and in practice it has proved difficult to subsequently remove established services from CHI cover.
When making a decision regarding the list of medical services to be covered by CHI, the DHA has to rely to a large extent on preceding opinions and normally follows the recommendations of the FSB. At the DHA and FOPH level there is no systematic monitoring as would be necessary for appropriate steering and controlling of the process.
According to the terms of Article 32, para. 2, of the Health Insurance Act (HIA), existing services are in practice not verified periodically, or if so only in a rudimentary way.
The evaluations are completed relatively quickly. The structural and functional organisation of the process of designating services is straightforward. The system has proved to be adaptable and has been constantly improved since the HIA came into force.
As far as concerns international collaboration, there is as yet untapped potential in particular with regard to identifying questionable services at an early stage and re-assessing existing services.
The process of evaluation is not transparent. Certain important information used as a basis for decision-making is not available to the public, which is also true of some of the intermediate results.
In conclusion, the findings of the present study are mixed. The conceptual basis of the system and the institutional aspect are on the whole appropriate; the system addresses innovative services in a flexible and specific way, the relevant authorities are normally objective in their work, and evaluations are completed in a relatively short time. On the other hand, as far as concerns the implementation of the system in particular there are some obvious weak points. The system does not filter out questionable new or existing services consistently and rapidly. The criteria and yardsticks for evaluating services are not sufficiently clear, there is no independent body to analyse the complex subject matter for the FSB, there is not a clear distinction between assessment and appraisal, and the whole decision-making process is not sufficiently transparent to the outside world.
