Rationing - Interpharma

Putting the focus on patients

Rationing

A more efficient reimbursement process is needed to ensure that patients in Switzerland can benefit sooner from medical innovation.

Overview The authorisation and reimbursement process Pricing Off-label use Orphan drugs Rationing

Rationing means that the provision of medically justifiable benefits is artificially restricted. It would mean, for example, that a patient might be refused a hip operation because she has reached a certain age and surgery is no longer thought to be worthwhile as a result.

In 2016, after years of legal dispute, the Swiss Federal Supreme Court confirmed a judgement handed down by the St. Gallen Cantonal Insurance Court that marked a legal milestone for patients with rare diseases. In the judgement, the health insurer KPT was required to pay for vital treatment needed by a patient with the rare neuromuscular condition Pompe disease. The necessary medicinal product is on the List of pharmaceutical specialities, but the insurance provider had criticised the criteria for inclusion of the product in the List (specifically effectiveness and cost-effectiveness). It therefore declined to pay for the cost of treating the patient. The Federal Supreme Court decided in its judgement that the patient fulfilled the conditions for reimbursement of the costs in accordance with the List and that the health insurance provider was not entitled to object to the inclusion of the medicine in the List or to its price. This is a very important judgement for all patients with rare diseases because it can help to prevent gaps in treatment due to time-consuming legal proceedings and to achieve more treatment equality in Switzerland. 

Avoiding two-tier healthcare

Access to innovation must be ensured in the future too. Methods that seek to oversimplify and fixed cost thresholds for individual benefits, on the other hand, are rightly the target of criticism. These are rationing instruments that ignore fundamental values in society and find no acceptance in the voting Swiss population. In reality, rationing always means providing two tiers of healthcare. Economically vulnerable individuals are by definition excluded from benefits that their health insurance does not cover. The established principle of social health insurance, according to which all patients are entitled to receive the medical care they need, irrespective of their economic situation and ability to contribute, is incompatible with two-tier healthcare and rationing. Switzerland has a high-quality healthcare system that is based on solidarity with the sick and vulnerable in society.

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