Outpatient case rates

On 30 August 2018, SwissDRG AG published a feasibility study on the development of flat rate payments for outpatient treatment. This had been commissioned by its Board of Directors in response to the discussion on ‘zero night DRGs’ previously launched by H+, FMH and FmCh, three of the professional associations that represent service providers. Given the introduction of outpatient service lists by various cantons and the increasing unattractiveness of TARMED for specialists and hospital outpatient departments, these were believed to constitute a better method of reimbursing hospital outpatient services.

Although CSS is generally in favour of flat rate compensation for individual services and procedures, it takes a critical view of the results of this particular study and does not wish to see it implemented in its current form. The main point of criticism is that, at present, the proposed flat rates for certain outpatient hospital services can only be calculated on the basis of inpatient services. However, it is essential for this calculation to be based on outpatient data (sourced both from hospitals AND medical practices). Calculating these rates on the basis of inpatient service and cost data contravenes the Federal Health Insurance Act (KVG Art. 43 para.4; KVV Art. 59c) as it does not reflect the actual outpatient service and cost structure. As the report’s authors explain, where there is no suitable outpatient service and cost data available for developing a tariff structure, then such a basis must first be created. It is further intended to restrict the use of flat rates to outpatient treatment in hospitals. This would create new interfaces and lead to unfair differences in the amounts paid for outpatient treatment depending on whether it was administered in hospital or in a doctor’s practice. This situation would not only go against the principle of cost-effectiveness, it would also run contrary to the idea of “the same rates for the same services regardless of where they are provided” and create new false incentives. That is why outpatient case rates must apply to the entire spectrum of outpatient service provision.