Outpatient flat rates – Tariff
From 2025, outpatient flat rates are to replace the current fee-for-service tariff for outpatient services, TARMED. This is to take place together with a new fee-for-service tariff, TARDOC. The development of outpatient flat rates (also known as patient flat rates) is being driven forward by the hospital association H+ and the health insurance association santésuisse in the joint tariff organisation solutions tarifaires suisses AG (German).
Brief overview of the development history of the new tariff system to date
Basic considerations for an outpatient flat-rate system were already presented to the public in October 2021. At that time, this system was still based on a preliminary project by santésuisse and the Federation of Surgical Societies FMCH. In the course of these initial public discussions, the hospital association H+ was also won over as a supporter of an outpatient flat-rate system. Thus, in 2021, the tariff organisation solutions tarifaires suisses AG was jointly founded by santésuisse, FMCH and H+. At the end of 2021 and 2022, tariff versions 0.2 and 0.3 were submitted to the Federal Council for review. The tariff is being developed with the help of software from eonum. You can read more about this in our blog post (in German or French only) on the topic.
At the beginning of 2022, the legal framework changed as a result of the parliamentary cost containment package 1a. This included the requirement that service providers and payers must establish a joint tariff organisation for outpatient tariffs. As a result, all tariff partners (curafutura, H+, FMH, MTK and santésuisse) launched the “Organisation ambulante Arzttarife AG” OAAT AG. This also created the prerequisite for jointly introducing the outpatient flat rates and TARDOC as a holistic tariff system and replacing TARMED. However, the financing of the two tariff structures is still to take place completely in the previous organisations ats-tms AG and solutions tarifaires suisses AG.
In June 2023, tariff version 1.0 of the outpatient flat rates could be published. The current goal is to submit tariff version 1.0 together with TARDOC to the Federal Council for approval as a coherent tariff system at the end of 2023. The introduction of both tariffs should then be completed in 2025.
You can find out more about current developments in the outpatient tariff system and various milestones in recent years on our knowledge page on the topic:
Structure and functioning of the outpatient flat rates
Flat rates are particularly suitable for highly standardised and cost-intensive services. Accordingly, diagnostics and treatments in resource-intensive infrastructures (such as in an operating theatre) are the focus of the outpatient flat-rate system. Less cost-intensive services performed in simple infrastructures will continue to be charged via the fee-for-service tariff (e.g. consultation in the consulting room of a doctor’s office).
Within the framework of the introduction of outpatient flat rates, the case definition in the outpatient setting will also change. We now speak here of so-called patient contacts, which are billed separately. In the simplest case, a patient contact corresponds to a single day. So if a patient has several consecutive appointments, these are billed as individual patient contacts. This case definition applies both to the outpatient flat rates and to the TARDOC.
In the case of an operation, all services performed on the day of the operation are thus combined in one outpatient flat rate. Other services such as initial consultations, follow-up treatments and other interventions that are performed on a different day than the operation itself are billed separately. A large part of these services will continue to be charged via the fee-for-service tariff (new TARDOC). The exact distinction between the outpatient flat-rate system and the fee-for-service tariff still has to be defined.
Equivalent to the inpatient flat rates, the individual patient contacts are also assigned to a so-called case group in the flat-rate patient tariff on the basis of various characteristics such as diagnoses, procedures carried out, age and sex, etc. The diagnosis is coded using the ICD catalogue. Diagnoses are coded using the ICD catalogue. The procedures are coded using the CHOP catalogue. Here, too, the same structures are used as in the inpatient sector. You can find out more about coding in the Swiss health system and the two catalogues CHOP and ICD on the following knowledge pages:
The outpatient flat rate system is divided into:
- Capitula (example: Capitulum 2: “Eye” – analogous to MDC 02 in SwissDRG).
- Basic flat rates (example: C02.20: “Intravitreal injection”)
- Flat rates (example: C02.20B: “Intravitreal injection, unilateral”)
Each individual flat rate is assigned a relative cost weight (also simultaneously to the inpatient sector). Real outpatient, case-related cost and service data from various service providers serve as the basis for calculating the cost weights. A total of 70 data sets from different hospitals and different data years were used to develop Version 1.0. Service and cost data from doctors in private practice could not yet be taken into account for the development. In future, however, they will also be integrated into the calculation.
The relative cost weights are then multiplied by a base rate in CHF to obtain the actual reimbursement. Since the introduction of the new outpatient tariff systems is to be cost-neutral by law (from an economic point of view), the total remuneration must correspond to the current total remuneration of these cases. Based on this, the starting prices should be set separately for hospitals and general practitioners at the cantonal level. Service providers with a broad range of services can apply for an individually calculated starting price.
We can provide you with excellent support in calculating a possible starting price (with the help of your current data and in accordance with the specifications of solutions tarifaires suisses AG) or other questions regarding the upcoming introduction of the new tariff. Find out more about our advisory services on outpatient flat rates under the corresponding offers page: