The large cost differences illustrate the core theme of the healthcare ballot proposal.
The financing reform is intended to reinforce the trend towards more outpatient rather than inpatient procedures.
In the voting battle over financing reform in the health care system, there is often talk of redistribution between premium payers and taxpayers. The main driver of the reform was not the question of distribution, but rather the desire to alleviate an expensive disincentive in the system.
The costs of outpatient procedures in accordance with the Health Insurance Act are currently borne entirely by the compulsory health insurance company (OKP) and thus its premium payers. For inpatient procedures (i.e. if the patient stays overnight on site), the health insurance company only pays 45 percent of the costs; 55 percent is borne by the cantons and thus the taxpayers.
Outpatient procedures are therefore only worthwhile for health insurance companies if their costs are less than 45 percent of the total costs of inpatient procedures. The reform now standardizes the distribution of costs. The cantons (taxpayers) now pay 26.9 percent and the health insurance companies 73.1 percent – for outpatient treatment, inpatient procedures and care.
The overall picture counts
Ultimately, the total costs are decisive. Measured against these, outpatient treatments perform far better than inpatient procedures. The potential for a higher proportion of outpatient treatment in Switzerland is still great. With reference to data from the OECD country association, the federal government emphasizes that in 2021 the “market share” of outpatient procedures in Switzerland was only 20 percent of the treatments recorded, while various other European countries achieved 30, 40 or even over 50 percent would have.
It’s not about small things. The Swiss Health Observatory (Obsan) provides information. Whose Website shows cost data for some types of procedures for which the principle of “outpatient before inpatient” has officially applied since 2019. This means that the OKP only pays for outpatient treatments – unless there are special circumstances, such as additional difficulties for the patient. This year the Interior Department expanded the list of affected operations; it now includes eighteen intervention groups.
Obsan data for cost comparison is only available for seven procedures. The differences shown are enormous. An example: In 2022, an arthroscopy of the knee joint cost an average of around 2,100 francs for an outpatient procedure and 8,100 francs for an inpatient procedure. According to Obsan, the costs mentioned should be understood as an estimate of a rough order of magnitude, especially for the outpatient area. On average, for the seven procedures recorded, the inpatient/outpatient cost ratio is around 4:1 (see graphic). The estimated costs correspond to the income that the hospitals received for the procedures.
With such differences, outpatient procedures would already be worthwhile from the perspective of health insurance companies. However, the cost differences between the types of interventions included on the federal list may distort the picture somewhat. In the cases recorded, inpatient procedures could have been more expensive because there were aggravating circumstances and the principle of “outpatient before inpatient” was therefore broken.
One Study The consulting firm PwC in 2016 listed thirteen procedures for which inpatient treatment was on average 2.3 times more expensive than outpatient procedures. With such a cost difference, health insurance companies still have no significant incentive to support outpatient treatment.
More expensive infrastructure
Depending on the procedure, inpatient treatment could be 1.5 times, twice or even three times as expensive as outpatient treatment, says Kristian Schneider, director of the Biel Hospital Center. The reasons for the much higher costs are by no means just in the hotel industry, as he makes clear: “Inpatient treatment requires a larger infrastructure, beds, 24-hour care, more and specialized staff. The operating rooms are also much more expensive.”
According to Schneider, the hospital currently earns “significantly more” for inpatient procedures, but there is also underfunding there. According to the H+ hospital association, in 2023, outpatient hospital services were underfunded by an average of around 28 percent and inpatient services were “only” underfunded by 8 to 9 percent.
The financing reform does not initially change the fact that hospitals earn more with inpatient treatment. Kristian Schneider also admits this. But the reform creates the conditions for a strengthening of the trend towards outpatient treatment. The financing reform is the “first step” towards this. The second step will follow with the introduction of outpatient flat rates together with the change from the outpatient doctor’s tariff Tarmed to Tardoc, probably at the beginning of 2026.
Incentives via tariffs
The third step for Schneider would then be the discussion about outpatient tariffs. With the current financing reform, “health insurance companies have more incentive to accept higher outpatient flat rates and thus promote cheaper outpatient treatment,” emphasizes the hospital director.
The health insurance companies may be reluctant to announce something like this in advance. But Pius Zängerle, director of the health insurance association Curafutura, says it this way: “The negotiating situation of all participants – hospitals, insurers and cantons – will be realigned. This will strengthen outpatient care. This can also be reflected in a willingness to receive better compensation.”
Another health insurance representative said it years ago as follows: “As long as services in the outpatient and inpatient sectors are financed differently, new and innovative compensation models and tariff incentives will also have a difficult time.” Paul Sailer, a healthcare expert at the consulting firm PwC, also takes the same line: The financing reform is “the basis for tariff development. This ensures that the tariffs reflect the cost reality in the future.”
Hospital director Schneider predicts a “boost” in outpatient procedures for the reform scenario, including the subsequent steps. According to Schneider, in the Biel Hospital Center “around 8 to 12 percent” of inpatient hospitalizations could be avoided in the short term in five or six departments. And: “In the longer term, a reduction of 20 percent would be possible.”
Prospect of higher discounts
The voting proposal is also intended to make alternative insurance models more attractive. According to estimates, only around 20 to 30 percent of all insured people are currently insured in models with care management via the family doctor and doctors share responsibility for the budget.
One of the pioneers of such models is the Zurich doctor Felix Huber, President of Medix Switzerland, an association of ten regional doctor networks. According to Huber, the reform enables “a stronger distinction between good and bad insurance models, since the good models will be able to pass on the full savings to the insured in the future. This enables a discount of up to 25 percent instead of 20 percent.”
According to Huber, the family doctors in the Medix models have no risk of financial loss, but if the cost and quality targets are achieved, additional remuneration for the doctors of up to 10 percent is possible. Medix models currently offer discounts of 14 to 20 percent, depending on the insurance, as Huber says. He cites the avoidance of unnecessary examinations, the strong focus on generics for medications – and the reduction in inpatient procedures by around 10 percent as sources of savings.
