Quality of healthcare

Viewed internationally, Switzerland has a high-quality healthcare system. However, many reform projects are driven purely by cost considerations. Against this background, it is hardly surprising that the discussion of reform is currently focused mainly on funding, and more specifically on the health insurance providers, rather than on the benefits provided by the healthcare system. It is vital for more quality-related discussions to take place in the Swiss healthcare system, instead of allowing this aspect to be drowned out by a focus on costs.

Health technology assessments (HTA) help to put cost-related discussions on an objective footing. They are intended to create a basis for greater quality and cost-effectiveness in the healthcare system. A current example is the review of the value of cannabis in medicine. Following a mandate from the Federal Council, the Federal Office of Public Health (FOPH) is planning to commission a health technology assessment of the scientific evidence available for cannabis in various indications, e.g. treatment of chronic pain or spasms associated with multiple sclerosis. The objective is to elucidate the cost-effectiveness, and with it the appropriate form of funding, of cannabis-based medicinal products. Experience and the current discussion surrounding excessive consumption of opioids have led to the suggestion that the public health aspect should also be included in the HTA.

The federal government’s current HTA activities are focused heavily on examining the efficacy of medicinal products. Yet these are the only benefits provided by the healthcare system that are already institutionalised, and are reviewed every three years for efficacy and cost-effectiveness. Interpharma is therefore calling for a wider and more balanced focus to enable HTAs to contribute generally to increased quality in the Swiss healthcare system.

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. 

Rationing leads to two-tier healthcare

The blessing of ever-greater life expectancy poses enormous challenges for research and for society as a whole. The issue also raises ethical and moral questions that will feature heavily in future public health policy. The question occupying health economists trying to make sense of rising costs is the following: how much can an additional year of life be allowed to cost? There are various models for calculating this value, but the conclusion they reach always means rationing medical care. The pharmaceutical industry rejects an approach of this kind because it will inevitably lead to two-tier healthcare.

The main issue here is therefore not financially motivated decisions but social and, to an even greater extent, moral and ethical decisions. Discussion of this issue has begun in Switzerland but is not yet taking place on a broad enough basis. The same applies to palliative medicine. The federal government has initiated a trial regimen and there is growing acceptance of palliative care, but there is still a great need for discussion in society of the distinction between palliative and curative therapy.