health insurance law
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EMBA June 9, 2012. Health Insurance Law. Approach. A focus on Switzerland The overview of the present system A few choice of topics to study in depth (choice by students) Class discussion about future rationing of health care & ethical issues. Plan of the class. Some numbers to discuss - PowerPoint PPT PresentationTRANSCRIPT
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June 2012
Health Insurance Law
EMBA June 9, 2012
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Approach• A focus on Switzerland
• The overview of the present system
• A few choice of topics to study in depth (choice by students)
• Class discussion about future rationing of health care & ethical issues
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Plan of the class
1. Some numbers to discuss
2. The Swiss insurances
3. Health insurance: for patients & for professionals
4. The future: should costs be contained? How? What ethical safeguards?
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Health insurance concerns encountered?• Should I get insurance? • Complementary insurance?• Why is so expensive?• Will I be reimbursed?• Can I choose my health care providers?• Who will pay me if I am sick?• How do I get my product reimbursed?• Do I need an authorization?
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PART 1: SOME NUMBERS
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What do they mean? What are the implications?
• For governments – federal and cantonal
• For taxpayers• For patients• For doctors• For companies
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PART 2: THE SWISS INSURANCES
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A variety of insurances Public insurances:• Old age + survivors • Invalidity / disability• Health care• Accident (work & non-work)• Maternity• Military• Unemployment• Old age (professional) (occupational benefit plan) (LPP)*
Private insurances
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Three pillars system for old age benefits
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Some definitions• Illness « any impairment to the physical, mental or
psychological health that is not the consequence of an accident and which requires a medical examination or treatment or results in incapacity for work »– The Champix case.
• Accident « the sudden, unintentional, harmful influence of an exceptional external force on the human body, resulting in the impairment of physical, mental or psychological health or death. »
• Important implications whether accident or illness.
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PART 3: HEALTH INSURANCE
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The basics of the system (I)
• Since 1996– Several revisions
• Mandatory– For whom? Exceptions? – Basic + supplementary private insurance
• Paid by– Premiums + State assistance + State direct payments– What kind of premiums?
• Approved by State (minimal oversight)• By 3 age groups• By canton• By insurance fund
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The basics of the system (II)
• Choices left to the patient– Insurance fund (80-90)
• can be changed every year, sometimes twice a year– Deductible per year
• 300 (500) – 2’500 for adults; 0 (100) to 600 for children– Healthcare network with primary care physician as point of care
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The basics of the system (III)
• Choices left to the insurance fund– Setting premiums– Very little: cannot refuse anyone for basic insurance– Health questionnaire prohibited for basic insurance
• What about risk selection?– Risk compensation: yes, but to be improved– But « tiers payant » vs « tiers garant » for drugs– The case of Assura…?
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What is covered?• Fixed set – identical for all
– Mandatory for insurance funds
• Territorial principle– What about treatment abroad?
• Outside the canton? EU? Outside EU?• What if less expensive?
– No « Cassis de Dijon »
• System of open or closed list– Open: health care services
• Exceptions OPAS: annexe 1– List of specialties (drugs)– List of devices (semi-closed)
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Tarmed and Swiss DRG• For ambulatory care
– TARMED– The difficulties
• Insurance funds’s control over doctors’ diagnostic
• For hospital care– Swiss DRG– The fears:
• Will patients be kicked out of the hospital too soon?• Will private clinics be unfairly advantaged?
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Maternity• All « normal » maternity care
– e.g., 2 ultrasounds scans; antenatal checkups; antenal class for CHF 100; amniocentesis if over 35 years or risk factor over 1:380; 3 breastfeeding consultations.
• Without any copay !• Covers the first 3 months of the baby for « normal » care.
• Loss of wages covered by separate insurance
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What is typically not covered?• Loss of wages (in practice not by health care insurance)• Dental care• Most medically assisted reproduction services• Private care in hospitals• Experimental treatment + clinical trials• Off-label drug use (with exceptions)• What is covered by another insurance
– health care insurance plays residual role
• + statute of limitations: 5 years.
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What costs do patients bear?• Premiums
– Minus government subsidy for about 30% population
• Deductible– Max. to be chose: CHF 2’500
• Copay (retention fees)– 10% - sometimes 20% for certain drugs– Max. CHF 700 a year for adults / 300 for children
• Hospital copay– Up to CHF 15.- a day.
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Private insurance• Left to the discretion of the patients
– Significant part of the population has at least 1
• Insurance funds free to propose or not and what to propose– Only way to make money for insurance company
• Much less regulated: federal law on private insurance contracts.
• A great variety of policies proposed– Typical: Private or semi-private care in hospitals– Also: alternative medicine. – Also: approved drugs but not on LS
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Control over excessive care
By regulatory means:
By judicial means:• Obligation to reimburse for patients
– Rare. – If « not effective, expedient or economical »
• Obligation to reimburse for health care providers– Legal basis: article 56– Common– Very controversial– Complex– Has changed recently for drugs
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How do drugs become reimbursed?• Detailed submission to FOPH• Administrative decision. Appeal possible only by manufacturer• How is the factory price set?
– 2 comparisons:• Foreign price• Reference product
• How is the final price set?– Add margins and VAT
• What further conditions to reimbursement?• No more marketing/publicity
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What if a generic drug?• Mandatory discounts based on market’s size.
– min. 10% difference if below CHF 4 million a year (over the 4 years preceding patent expiry)
– min. 20 % if between 5 and 8 millions– Min. 50% if between 8 and 16 millions– Min. 50% if between 16 and 25 millions– Min. 60% if above 25 millions.
• Different copays depending on the price difference– 10% in normal cases– 20% if important price differences between drugs with same active
substance
• Possible substitution by the pharmacist– Paid by the insurance fund
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What if a drug is not reimbursed?• Free pricing
• Antitrust law
• Price supervisor
• Parallel imports
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PART 4: COST CONTAINMENT
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The Myozyme decision of the Supreme Court
• Drug outside the LS• Drug for rare disease• Price: half a million a year• Two efficacy requirements• One economicity requirement• The conclusion• The debate – the implications• The ordinance was then changed, confirming the judgment.
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The QALY tool• Cost per quality-adjusted life year
– Takes into account both survival benefits and quality of life– Standardized for all kinds of treatments
• Thresholds– Around CHF 100’000 in Switzerland– Below £ 30’000 in the UK
• More if end-of-life?
• Advantages of the QALY system• Drawbacks of the system
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Cost containment in the pharma sector• Negotiations with industry• Retrospective controls over previously accepted drugs• Extending reference pricing: more countries• More frequent price comparisons: every 3 years• Reimbursement of revenues if first price is excessive• Increased discounts for generics• Reduced distribution margins• More FOPH limitatio
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What more could be done?• How to bring patients and providers to be more cost-sensitive
without discouraging needed care?• Popular vote of June 17: is it a good solution?• Unique healthcare fund? Is it a good idea?• Setting premiums on the basis of revenues + fortune?
• Your ideas?
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Ethical principes• How to implement fairness and equality?• Should ressources be increased? Shared differently?• Should care be rationed?
– Who should make the sacrifice?
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PART 5: CONCLUSION
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Thank you !
Questions ?