Current developments in the outpatient tariff system
In 2015, the Federal Council approved four framework conditions for the revision of TARMED. These framework conditions concretise and supplement the legal provisions of the Health Insurance Act KVG. This is to ensure that the revised tariff structure can actually be approved. The four framework conditions are that:
- the tariff structure is agreed jointly by a majority of the service providers or payers.
- the calculation bases and proof of the legal requirements are documented.
no increase in costs for the compulsory health insurance may result from the same range of services. - the new tariff is adapted to current circumstances and is based in particular on new surveys of cost and service data as well as on new calculations.
Development of TARDOC
In the following years, in collaboration with various stakeholders (curafutura, FMH, H+ (until 2018) and MTK), a new fee-for-service tariff called TARDOC was drafted within the newly founded ats-tms AG. A first version 1.0 of this was submitted to the Federal Council for approval in 2019 by the insurers’ association curafutura and the Association of Swiss Doctors FMH. The other tariff partners, such as santésuisse or H+, were not involved in the development of TARDOC.
After the submission, however, the Federal Office of Public Health (FOPH) determined that the framework conditions were not met. Approval could therefore not be granted. The TARDOC versions 1.1, 1.2 and 1.3 submitted in the subsequent years 2020-2022 were also not approved.
Development of outpatient flat rates
Parallel to the development of the TARDOC, the development of a nationwide flat rate for outpatient services also began. For a future flat-rate tariff, Parliament adopted corresponding legal provisions as part of the 2021 cost containment measures in the amendment to the KVG. On the one hand, it was clear that a future flat rate must be uniform and nationwide. On the other hand, flat rates should also have priority over fee-for-service tariff. Accordingly, the Federal Council also called for the development of flat rates in 2022.
The development of an outpatient flat rate, which had already started before, really began to gain momentum after this decision. In order to create a data-based flat-rate system modelled on the SwissDRG tariff structure in the inpatient sector, the tariff partners santésuisse and H+ founded the organisation solutions tarifaires suisse AG. The grouping of an outpatient case is to be similar to the SwissDRG grouping on the basis of ICD and CHOP coding as well as demographic characteristics. A first version was already presented at the end of 2021 and submitted to the Federal Council for review. The latest version 1.0 was published in mid-2023.
In general, medicines, medical devices as well as the costs of laboratory analyses and other materials should be part of the reimbursement of a flat rate and thus not be reimbursed separately. Accordingly, all costs are covered in the reimbursement of a flat rate per case, unless explicitly defined otherwise. Simultaneously with the inpatient tariff structure SwissDRG, individual expensive medicines or medical devices are to be reimbursed separately by means of additional charges.
Outlook for the new outpatient tariff structures
The legal framework has changed since 1 January 2022. As part of the cost containment package 1a, Parliament made the following decision in June 2021 and recorded it in Art. 47a of the KVG: The associations of service providers and those of insurers must establish an organisation responsible for the development and maintenance of tariff structures for outpatient medical treatment.
This mandate was complied with on 15 November 2022: The new tariff organisation “Organisation ambulante Arzttarife AG”, or OAAT AG for short, was founded jointly by all partner organisations (curafutura, H+, FMH, MTK and santésuisse). The aim was to harmonise the two tariff structures for outpatient flat rates and TARDOC in such a way that they can be approved as new tariffs as early as 2023. The tariffs will then apply from 1 January 2025. ats-tms AG and solutions tarifaires suisse AG, the two tariff organisations, worked together to achieve this. Once work on the two tariff structures had been completed, the two organisations were liquidated and merged into OAAT AG.
At the beginning of December 2023, the TARDOC and the outpatient flat rates were jointly submitted to the Federal Council for review. Until then, the two tariffs were developed separately. ats-tms AG drove the finalisation of TARDOC and solutions tarifaires suisses AG the finalisation of the outpatient flat rates. A reciprocal right of inspection was granted, but without the possibility of direct involvement. The central business areas were transferred to OAAT AG on 1 January 2024.
In accordance with current developments, it can be assumed that in future there will be both an fee-for-service tariff and outpatient flat rates. In particular, the scope of the outpatient flat rates and the distinction from the fee-for-service tariff are open. This is where the greatest differences between the various tariff partners have existed in the past. The data basis for calculating the tariffs and the detailed design of the tariffs for individual specialties also offer scope for discussion. The main challenges for service providers are the correct coding and recording of services, as well as the technical implementation of the new case definition and the correct recording of costs.
Our offer
At eonum, we are well informed about the latest developments in outpatient tariffs. For example, solutions tarifaires suisses AG is developing the new outpatient flat rates with the help of our Casematch software. With our know-how, we are happy to support you in your questions and accompany you in various projects. Find out more about our consulting services, especially about the simulation of outpatient flat rates and the calculation of possible base rates or a starting price using your data on the following page: