The level of health insurance premiums is strictly regulated, with insurers setting their premiums based on the costs they expect to incur in the following year. This calculation also takes account of the reserves that each insurer holds (see also: Opinion: «Surpluses in basic insurance»). The premiums arrived at in this way must then be signed off annually by the federal government. To this end, insurers submit them to the Federal Office of Public Health (FOPH) at the end of July each year, together with their budgeted costs and an overview of their insurance portfolio. In due course the FOPH gives its approval based on the Health Insurance Supervision Act (KVAG).
The health insurance system operates on the principle of solidarity. This means that people who are in good health also pay for those who are in poor health. However, the solidarity principle operates not only between healthy and sick people but also between the various health insurers: this is referred to as «risk balancing».
Risk balancing is the process by which the risks of health insurers whose customers are mostly in good health are balanced against the risks of those whose customers are at greater risk of becoming ill. At present the risk indicators used are: age, gender, and time spent in a hospital or nursing home in the previous year. Pharmaceutical cost groups (PCGs) were added as an indicator in 2020. These relate to patients who suffer from cost-intensive chronic conditions such as asthma, diabetes and multiple sclerosis.
SWICA welcomes comprehensive risk balancing because it encourages competition in the area of quality. Health insurers should compete on the basis of good service quality, attractive products, professional advice, and the provision of assistance to insured persons suffering from the effects of illness or accident.
Unscrupulous agents often use aggressive cold-calling methods and false information to persuade potential customers to meet them. Some of these agents make promises about premiums and claim to be working with SWICA.
SWICA rejects all dubious practices of this sort. SWICA does not share customer information with third parties and does not therefore work with brokers or agents who call from abroad or make groundless promises about reduced premiums. Insurance cover depends on the individual requirements of each insured person. These circumstances can only be clarified during a professional advisory meeting.
In order to take action against these nuisance calls, SWICA – together with 39 other health insurers – signed an industry-wide agreement in January 2020. The signatories to this agreement reject cold calling as a means of acquiring new customers. They also place limits on commissions for sales staff. The maximum commission in basic insurance is set at 70 francs, while the commission for supplementary insurance will be limited to one annual premium. Furthermore, the agreed quality and transparency standards will give customers more legal certainty. The agreement will come into force on 1 January 2021.
If someone calls you, allegedly on behalf of SWICA, please ask the caller the following questions:
- How did you get my/our number?
- What company do you work for?
- Where did you get my information?
Please note the information you receive and pass it on to us. Please also ask for the caller's phone number and forward it to SWICA using the contact form. You can also report dubious agents to santésuisse (the association of Swiss health insurers) or to the State Secretariat for Economic Affairs SECO. Thank you for your help.
By law, health insurers are not permitted to generate profits in mandatory healthcare insurance (OKP). They are required to use the premiums to cover the cost of benefits. If, nonetheless, they occasionally produce a surplus, they have two options under the Health Insurance Supervision Act (KVAG). Either they can pay a portion of the premiums back to their customers, or they can transfer the surplus to their reserves. At SWICA, all surpluses are transferred to reserves, not least because the law requires insurers to form reserves.
However, since health insurance is part of Switzerland's social security system, these reserves again benefit all insured persons by ensuring that the costs of illness and care are covered. The service providers, for their part, can be assured that the services they provide have proper financial backing.
While health insurers are not permitted to make a profit on basic insurance, this is not the case for supplementary insurance. Supplementary insurance plans are governed by the Insurance Contract Act (VVG). This is profit-oriented private insurance business and is subject to supervision by the Swiss Financial Market Supervisory Authority (FINMA)
Since 2012, cantons have had the option under the Art. 64 of the Federal Health Insurance Act (KVG) to maintain a list of individuals who default on their premium payments. These cantons can therefore blacklist insured persons who have failed to paid their basic insurance premiums despite debt collection proceedings. Insured persons on this list will have their benefits suspended and will only be covered for medical emergencies, unless they pay for their treatment in cash. With this measure, the cantons that keep a blacklist are hoping to encourage individuals to improve their payment behaviour in the health sector and thus to achieve savings.
Every canton can decide individually whether to keep a blacklist. Currently (as of November 2020), six cantons have elected to do so, which means that health insurers there are obliged by law to notify the cantonal authorities about insured persons who are subject to debt collection proceedings due to unpaid premiums or co-payments. Some cantons which had originally maintained blacklists have now concluded that administering them costs money but does not improve payment behaviour and have therefore done away with them.
Our analysis shows no change in payment behaviour in cantons which have introduced blacklists. SWICA therefore rejects the use of blacklists.
As a health insurer, SWICA has a statutory duty in the area of basic insurance to check submitted invoices and determine whether they are cost-effective, appropriate and efficacious. In fulfilling its duty, SWICA checks around ten million invoices every year. Although most benefit statements are correct, we regularly discover mistakes. However, not every mistake is deliberate. It is therefore important for insured persons to make their own careful check of each invoice. Clear, well-structured benefit statements help insured persons to identify errors themselves and report them to SWICA. We can then carry out targeted checks.
Deliberately receiving or charging for unjustified services is not only unfair, it is also against the law. Cases like these constitute insurance fraud and are to the detriment of all insured persons. SWICA takes action to combat abuses of this kind. If we find discrepancies or specific indications of abuse, the department responsible for combating insurance fraud launches an investigation. Around one hundred cases of insurance fraud are detected in this way every year. In doing so, SWICA complies with the requirements of social security law at all times.
Integrated care is a fundamental component of SWICA's strategy, as it contributes to customer satisfaction through improved patient safety, quality of outcome, and efficiency. Patients are actively involved in decision-making and enjoy high-quality treatment. Integrated care involves the coordinated cooperation of various medical and non-medical specialists on a voluntary basis. Together with a range of service providers, SWICA operates structured care programmes for the treatment of diverse ailments.
SWICA welcomes the fact that the Federal Council wants to promote integrated care. However, the federal government's package of cost containment measures (Package II), the consultation process for which ran from August to November 2020, results in a rigid framework which jeopardises the continued existence of current models and will hamper the development of new innovative models. Narrowly defined state control undermines the insured person’s freedom of choice and therefore the chance of making a full recovery.
SWICA rejects the idea that compulsory initial consultation centres should be prescribed by the state. Alternative insurance models, as chosen by more than 85% of people insured with SWICA, are attractive and assume the gatekeeping function. This helps to keep costs down and reduce total healthcare costs. Incentives for voluntary models produce more sustainable results than coercion. As well as incentivising people to take personal responsibility, they also help to deliver higher-quality care and reduce costs.
On 1 May 2020, SWICA announced that it would accede to the Tardoc (outpatient physician rate) and LOA V (pharmacy rate) rate schedules with effect from 1 January 2021. Previously, the Federal Council had considered the rate proposal submitted by FMH and curafutura to replace Tarmed as ineligible for approval, as curafutura and its affiliated health insurers (CSS, Helsana, Sanitas and KPT) only represent around 41% of insured persons in Switzerland. With SWICA, which represents around 10% of insured persons, there is now a majority of 51%.
By acceding to the two modern rate schedules, which are based on cooperation, SWICA aims to strengthen the rate partnerships in the Swiss healthcare system; these are of vital importance in the implementation of SWICA's integrated healthcare business strategy. In the case of the LOA V pharmacy rate, accession has now been affirmed and a submission has been made to the Federal Council. In the case of Tardoc, the one outstanding issue (ensuring cost-neutral introduction) has now been clarified among the concerned parties. The rate has now also been put before the Federal Council.
In parallel with Tardoc, santésuisse and FMCH (a merger of expert societies representing practitioners of surgical and invasive procedures) want to pay for outpatient treatment as far as possible by means of flat rates. They have submitted a range of flat rates to the Federal Council for approval. SWICA also supports this measure. Outpatient flat rates are a key prerequisite in the promotion of integrated healthcare. SWICA therefore proposes that Tardoc be approved as the new rate structure; at the same time, the individual service rates contained in Tardoc should be replaced by flat rates wherever this is possible and appropriate.
The "Uniform Financing of Inpatient and Outpatient Treatment" (EFAS) is intended to encourage a shift from inpatient to outpatient treatment, because outpatient treatment is often equally effective but cheaper. The goal is to curb cost growth in the healthcare system. The current system, in which the cost of inpatient services is borne jointly by the cantons and health insurers, but only by the insurers in the outpatient sector, creates a financial disincentive. As a result, some operations are performed as inpatient procedures, even though they could be performed more cheaply and with the same medical efficacy as outpatient procedures.
However, EFAS also gives a boost to integrated care which aims to better coordinate the management of patients along their entire treatment path. This improves the efficiency and quality of treatment and reduces the cost of services. With the shift from inpatient to outpatient care, alternative insurance models (e.g. the family doctor and telemedicine models) will also become more important; savings are also possible in this way for both insured persons and service providers.
SWICA supports the amendment to the Health Insurance Act for the uniform financing of outpatient and inpatient services.