Medication prices. Reimbursement under the LAMal (German: KVG) by compulsory health insurance providers for inexpensive medicines or medical aids purchased abroad; an effort to reduce prices and costs
What is at issue?
The motion calls for amendments to the Federal Health Insurance Act (LAMal) to enable reimbursement by compulsory health insurance for medicines and medical aids that patients personally acquire abroad. The following conditions must be met: The medicine or medical aid must be approved in Switzerland and prescribed by a doctor practicing in this country. In addition, the product purchased abroad must cost less than its equivalent in Switzerland.
The rationale behind the motion stems from the ongoing rise in healthcare costs and compulsory health insurance premiums. As average prices are lower abroad, the purchase of medicines and medical aids outside Switzerland should help contain compulsory health insurance cost increases.
Our Position
Swiss Medtech recognises the high burden on the public due to rising compulsory health insurance premiums, and supports sensible measures aimed at reducing costs. However, WZW criteria and the rule of law must also be taken into account, and, above all, treatment quality and patient safety must not be compromised. Any measures must also be sustainable, practicable, and technically feasible.
Swiss Medtech rejects the motion in its current form as it does not meet the above-mentioned requirements – particularly when it comes to medical aids and devices. We welcome the fact that both the Federal Council and the motion’s author are proposing a restricted number of items from the list of medical devices and appliances (MiGeL), as discussed in the National Council debate of 14 March 2024. This is the correct approach, but from the medtech industry’s standpoint falls short of the ideal. On closer inspection, most of the supposedly «unproblematic» products are not issue-free. The criteria must be made stricter to avoid disadvantaging patients. In addition, insured persons must be protected to prevent excess costs that could arise due to unclear «price» comparisons.
In order to guarantee treatment quality and patient safety, foreign dispensing outlets should be obligated to meet the same legal requirements as Swiss dispensaries (e.g. Art. 55 KVV). It is therefore unclear whether the motion, if adopted, could even be implemented. At the moment, it is also uncertain if potential savings in the area of therapeutic aids actually exist. The additional costs associated with higher administrative requirements could conceivably surpass the amounts saved.
Arguments
Prioritise treatment quality and patient safety
Healthcare reforms frequently focus primarily on costs – with quality of treatment and patient benefit along the treatment pathway taking second place. These, however, should absolutely receive top priority. With this in mind, we welcome the fact that the Federal Council, like the author of the motion, is restricting implementation to a few «unproblematic» MiGeL items. In our view, however, this restriction does not go far enough. An example: approximately 45% of stoma plates for artificial bowel outlets are individually modified by the dispensing outlet to fit the patient’s specific stoma size. The question arises of how to ensure treatment quality when these products are procured abroad. Another example: equipment needed for injections (also regarded by the Federal Council[1] as unproblematic) do not constitute a monotherapy, as insured individuals also require the associated medication. It makes little sense to obtain the medication and injection equipment from different sources.
Protect insured persons from excess out-of-pocket costs
The motion provides for reimbursement if the product obtained abroad is less expensive than in Switzerland. This raises the essential question of which prices should be compared, as there is no official tariff for medical aids, either in Switzerland or abroad. Prices are governed by free market competition and can vary as a result. Should therefore the maximum reimbursement rate be applied? How will customs duties, differing VAT rates, and the generally higher costs in Switzerland be taken into account? All these variable factors make it virtually impossible for patients to determine if a product purchased abroad will actually be reimbursed in full. Incorrect assessments could lead to considerable out-of-pocket expenses for insured persons. This must be avoided at all costs.
Ensure legal equivalence of the dispensaries
To ensure treatment quality and patient safety, Swiss dispensing outlets must fulfil a number of legal requirements. For example, a cantonal license and special dispensing contract (Art. 55 KVV) with all health insurers concerned are mandatory to provide services covered by compulsory health insurance. These govern issues such as administration, services (e.g. maintenance, technical support, etc. for medical devices), and quality. In accordance with the principle of equality before the law (Art. 1 para. 3 let. C, Therapeutic Products Act (HMG)), foreign sales outlets would have to meet the same requirements in order to guarantee quality and safety. As this is virtually impossible to enforce, the result would be unequal treatment of dispensing outlets and a reduction in the quality of supply.
Analyse additional administrative costs and compare with potential savings
Swiss dispensing outlets, pharmacies, and health insurers invest a great deal in efficient invoicing practices. Clear processes and standards have been defined in order to standardize the predominantly electronic billing of medications and products, and to reduce administrative workload (keywords: Data Exchange Forum, XML Standard). The majority of billing is processed digitally; directly between service providers and payers. The MiGeL is structured generically (in product groups and without product names). For purchases abroad, it is important to determine where the assigned allocation in MiGeL for the respective product is made. It is also necessary to confirm if the potential savings in product prices are higher than the associated administrative costs on the part of the insurer.
[1] Federal Council report of 1 September 2021 entitled «Reimbursement under compulsory health insurance of funds and items obtained privately abroad.»
Swiss Medtech represents around 800 members in its role as industry association for Swiss medical technology. With 71,700 employees and a contribution of 11.9% to the positive trade balance, medical technology is an economically significant sector in Switzerland. Swiss Medtech advocates for conditions that enable the medtech industry to perform at peak capacity and provide first-class medical care.