Policy responses for Switzerland - HSRM


Policy responses for Switzerland

4. Paying for services

Adequate funding for health is important to manage the excess demands on the health system. This section considers how countries are PAYING FOR COVID-19 SERVICES. Health financing describes how much is spent on health and the distribution of health spending across different service areas. The section also describes who is covered for COVID-19 testing and treatment, whether there are any notable gaps (in population coverage and service coverage), and how much people pay (if at all) for those services out-of-pocket.

4.1 Health financing

On 20 March 2020, the Financial Delegation approved an urgent supplementary credit of CHF 350 million for the procurement of medical supplies. These procurements were designed to last for 60 days. On April 8, the Federal Council decided to purchase medical protective materials, tests, and medications for up to CHF 2.23 billion over the next four months. Additional CHF 10 million have been earmarked as targeted contribution to the international Coalition for Epidemic Preparedness Innovation (CEPI), which aims to develop one to three vaccines that could be submitted to regulatory authorities by early 2021. The request was passed on to the Parliament's Finance Delegation and, as requested, a first tranche of 775 million francs was approved as an urgent advance during the week of April 13 (request was publicly published on April 17).

The government has earmarked CHF 288 million for Covid-19 tests, which is enough for 1.7 million tests.
As of August 4, approximately 250,000 tests had been carried out since the introduction of federal cost coverage for medically indicated testing (starting June 25), with overall costs of about CHF 42 million.

Apart from these measures, no formal decision has been taken to inject additional funds into the health system. However, the federal government has issued several regulations and communications to clarify rules applying during the COVID-19 pandemic concerning (1) compensation for COVID-19 related expenditures of hospitals and health professionals, (2) compensation of teleconsultations; and (3) compensation for loss of income.

Efforts to manage the COVID-19 pandemic have led to various additional expenses for the Federal Office of Public Health this year, such as for public awareness campaigns, running phone hotlines and developing the SwissCovid app. Therefore, on its meeting on August 12, the Federal Council decided to request a supplementary credit (from Parliament) of CHF 31.6 million for 2020 to cover the cost of managing the COVID-19 pandemic.

(1) Compensation for COVID-19 related expenditures

Inpatient treatment in hospital: During the coronavirus pandemic, existing inpatient capacities can be expanded or used for other purposes. The FOPH has drawn up guidelines to ensure that the pricing and cost absorption of inpatient treatment is regulated uniformly throughout Switzerland. The DRG-based hospital payment has been slightly modified (e.g. creation of new ICD-10 code) to enable reimbursement of COVID-19 patients.

Drugs and lab tests: The FOPH asked the health insurers to take the current situation into account when reimbursing pharmaceuticals and reviewing conditions (26.03.2020). The rules concerning cost coverage of coronavirus tests have changed several times (see section 4.2).

Rehabilitation: Hospitals may have to make room for infected individuals. They can transfer other patients to rehabilitation without the need for a prior cost credit from the health insurer.

Costs for the procurement of important medical goods: These costs are pre-financed by the Confederation to the extent that it procures the goods. The cantons, charitable organisations and third parties have to reimburse the Confederation as quickly as possible for the purchase costs of medical goods supplied to them. The Confederation bears the costs of supplying the cantons with the essential medical supplies that have been procured. The cantons bear the costs for the redistribution of these essential medical supplies within the canton.

(2) Compensation for teleconsultations

The FOPH has compiled the currently valid rules for billing telephone consultations and issued recommendations for temporary solutions during COVID-19 (status April 6):

In general, according to the Swiss fee-for-service schedule (TARMED 01.09), the following rules apply to telephone consultations:

• Duration is limited to 20 minutes per session.
• Consultations of up to 30 mins are possible only for persons under 6 and over 75 years of age or for persons with an increased need for treatment.
• Psychiatrists and psychotherapists may even charge 40 min sessions for persons with an increased need for treatment or if they are under 6 or over 75.
• Psychotherapists working within a physician’s office (delegated psychotherapy) may usually bill only a total of 240 minutes per 6 months.
• The number of sessions is not limited.
• The limitations and billing rules are identical to those for consultations in doctors' practices except for psychiatrists and psychotherapists, where the first session is usually limited to 90 minutes and subsequent sessions to 75 minutes.
• Psychiatrists can also bill the fee for psychiatric crisis intervention if performed by telephone.

The FOPH further clarifies that during COVID-19:
• Patients at particular risk of Covid-19 infection can be considered as having an increased need for treatment, regardless of age.
• Fees for telephone consultations may be billed for any telephone call, i.e. traditional phone call and video conference.
• In exceptional cases (when medically necessary), more than one session per day may be billed for the same patient but only if there is a break between the calls, i.e. it is not allowed to bill a 60 min call as two 30 min calls.
• Psychiatrists and psychotherapists may bill also 75 min sessions for their usual patients, i.e. those who are usually undergoing therapy at their office.
• For psychotherapists working within a physician’s office, the limit for telephone consultations is temporarily increased to 360 minutes (72 x 5 minutes) per 6 months.

Midwives: For midwives, TARMED does not provide for telephone consultation. The FOPH therefore recommends the following:
• A brief consultation by telephone can only be invoiced if services are provided within the scope of the ordinance on services in compulsory health insurance and therefore attendance services are replaced by this.
• Midwives' services that can be provided at a distance are limited to comprehensive advice during pregnancy, in particular on pregnancy-related complaints, care in the postpartum period and breastfeeding advice.
• Midwives can invoice these services as short telephone consultations. The service providers have to indicate on the invoice that remote treatment has been provided.
• All other services included in the tariff cannot be provided by telephone.

Home visits of midwives are usually limited to 15km. However, if the special situation makes this necessary, midwives can currently charge travel costs also for home visits to patients living more than 15km away. In addition, midwifes may receive CHF 5.00 per consultation for patients with a positive Covid-10 test result or with respiratory symptoms or for vulnerable patients.

(3) Compensation for loss of income

If physicians or hospitals experience a decrease of income as a result of lower levels of activity (e.g. because hospitals do not perform elective procedures or patients try to avoid physician visits), physicians’ practices and hospitals can make use of the same financial aids and support mechanisms that have been put in place for other businesses. Apart from short-time work compensation, this includes bridging loans and deferral of payment of social security contributions.

For short-time work compensation, the following rules apply, which are more generous than the pre-Corona rules:
• Short-time work compensation can also be paid to employees with fixed-term contracts and to persons working for a temporary work organisation.
• Loss of working hours can also be taken into account for persons who are in an apprenticeship.
• Short-time work compensation can also be paid to employees who are similar to employers. Employer-like employees include, for example, shareholders of a limited liability company who work as salaried employees in the company for remuneration.
• Persons who work in the business of the spouse or registered partner can also benefit from short-time work compensation.
• Employees do not have to reduce their overtime hours before they can benefit from short-time work compensation.
• The processing of applications and payment of short-time work has been simplified with the adoption of new provisions. For example, it is now possible to advance wage payments that are due via short-time work compensation.

The employer has to apply for short-time work by submitting an advance notification to the cantonal office that is responsible. Employees must agree to be sent on short-time work. The employer must clarify this beforehand and confirm it in writing in the pre-notification.

Since April 16, self-employed doctors, dentists and health professionals whose income for the year 2019 was between CHF 10,000 and CHF 90,000, are also entitled to the general “compensation for loss of earnings for self-employed persons” and the rules are the same as those for self-employed persons in other sectors (see Section 6).

Furthermore, some cantons are taking subsidiary measures to supplement the federal government's package of measures (not only for physicians), e.g. the Canton Baselland grants a fixed amount of CHF 7,500 and an additional contribution of CHF 250 per employee (up to a maximum amount of CHF 10,000) as immediate aid. Basel-Stadt has arranged bridging loans with cantonal guarantees, which can be applied for through local banks. In addition, training companies are supported by reimbursing the difference between the apprentice's salary paid and the short-time work.

Rent reductions are not foreseen. It can only be demanded if the use of the rental object is restricted, in case of defects or changes in the reference interest rate. However, with the ordinance of March 27 (COVID-19 Ordinance on Rent and Lease), the Federal Government decided that the payment period for arrears of rent or ancillary costs will be extended from 30 to 90 days. This applies to rents and incidental costs due between March 13 and May 31 2020.

Dunning procedures The Federal Council has decided on a nationwide legal standstill for prosecution proceedings. As a result, insurers do not have to comply with the specified deadlines for reminders. The cantons nevertheless assume 85 percent of the amount of the loss certificates arising from unpaid premiums and cost sharing.

Sources and links:

• New regulations on health insurance in response to COVID-19: https://www.bag.admin.ch/bag/de/home/krankheiten/ausbrueche-epidemien-pandemien/aktuelle-ausbrueche-epidemien/novel-cov/regelung-krankenversicherung.html 
• Letter of March 26 of the FOPH to health insurers: https://www.bag.admin.ch/dam/bag/de/dokumente/kuv-aufsicht/rakv3/infoschr-2020-03-26.pdf.download.pdf/Informationsschreiben%20Kantone_d.pdf
• Fact sheet COVID-19; Reimbursement of SARS-CoV-2 test: https://www.bag.admin.ch/dam/bag/de/dokumente/kuv-leistungen/leistungen-und-tarife/Analysenliste/faktenblatt-coronavirus-verguetunganalyse.pdf.download.pdf/Faktenblatt%20vom%2013.03.2020_Coronavirus_Verg%C3%BCtung%20der%20Analyse%20SARS-CoV-2.pdf
• Health System in Transition (HiT) Review: Switzerland, Section 3.4: https://www.hspm.org/countries/switzerland25062016/livinghit.aspx?Section=3.4%20Out%20of%20pocket%20payments&Type=Section
• Ordinance on Measures to Combat the Coronavirus (COVID-19): https://www.admin.ch/opc/en/classified-compilation/20200744/index.html#a4l Information on COVID-19 provided by major Swiss health insurers: https://curafutura.ch/corona-pandemie/
• Massnahmen zur Abfederung der Auswirkungen des Coronavirus auf Wirtschaft und Gesellschaft – Zweite Nachmeldung zum Nachtrag 1/2020: http://www.parlament.ch/centers/documents/de/br-bundesrat-2020-04-16-d.pdf
• Bundesrat will 550 Millionen Masken kaufen: https://nzzas.nzz.ch/schweiz/bundesrat-will-550-millionen-masken-kaufen-ld.1552474
• Finanzdelegation gibt 775 Millionen Franken frei für dringende Beschaffungen von Sanitätsmaterial und Arzneimitteln sowie für die Beteiligung an der Entwicklung von COVID-19-Impfstoffen : https://www.parlament.ch/press-releases/Pages/mm-findel-2020-04-15.aspx?lang=1031
• Coronavirus: Federal Council to ease further measures from 11 May:https://www.bag.admin.ch/bag/en/home/das-bag/aktuell/medienmitteilungen.msg-id-78948.html
• Coronavirus: Massnahmenpaket zur Abfederung der wirtschaftlichen Folgen: https://www.seco.admin.ch/seco/de/home/Arbeit/neues_coronavirus.html
• FMH - Häufig gestellte Fragen rund um COVID-19 (Status: 27. April 2020): https://www.fmh.ch/files/pdf23/haeufig-gestellte-fragen-rund-umcovid-19.pdf
• Kostenübernahme für ambulante Leistungen auf räumliche Distanz während der COVID-19-Pandemie: https://www.bag.admin.ch/dam/bag/de/dokumente/cc/kom/covid-19-faktenblatt-kostenuebernahme-ambulant.pdf.download.pdf/covid-19-faktenblatt-kostenuebernahme-ambulant.pdf
• Reimbursement of costs of diagnostic analysis for SARS-CoV-2 from 22 April 2020: https://www.bag.admin.ch/dam/bag/en/dokumente/kuv-leistungen/leistungen-und-tarife/Analysenliste/faktenblatt-coronavirus-verguetunganalyse.pdf.download.pdf/Factsheet_COVID-19_Reimbursement_of_costs_of_diagnostic_analysis_for_SARS-CoV-2_from-22-April-2020.pdf
• Coronavirus: Federal government to assume test costs, SwissCovid app to start on 25 June: https://www.bag.admin.ch/bag/en/home/das-bag/aktuell/medienmitteilungen.msg-id-79584.html
• On Corona test costs: https://www.medinside.ch/de/post/so-viel-kosten-uns-die-corona-tests
• Coronavirus: Large-scale events to be permitted from October under strict conditions and with a permit (12.08.2020): https://www.bag.admin.ch/bag/en/home/das-bag/aktuell/medienmitteilungen.msg-id-80054.html