The system of compulsory health insurance coverage of healthcare services must reconcile two contradictory elements. On the one hand, insurers are obliged to check that the services provided are cost-effective, i.e. that they are effective, appropriate and provide value for money (Art. 32 Health Insurance Act HIA). This means that service providers (hospitals, doctors, physiotherapists etc.) must provide all the information necessary for this assessment (cf. Arts 42 HIA and 59 Health Insurance Ordinance HIO) in particular regarding the diagnoses and treatments prescribed. On the other hand, this information is sensitive patient data, meaning that health insurers – who generally also provide supplementary insurance and other forms of non-health insurance – should only have limited access to it.
SwissDRG, data reception service and independent medical examiner
In order to reconcile these two interests, a specific system has been set up in the field of in-patient hospital care. There are three main elements to it (Art. 59a HIO) :
This is a system of remuneration based on flat-rate amounts awarded for different types of hospitalisation care; there is a predetermined flat-rate amount for each type of treatment.
Data reception service (Art. 59a HIO).
This is a certified body, independent from the insurance company, which receives invoices from service providers and makes an initial analysis of them. Each insurer must designate or establish a data reception service.
Independent medical examiner (Art. 57 HIA).
This service involves medical examiners attached to a health insurance company but practising independently whose role is to advise the insurance company on medical matters and on questions relating to remuneration and the application of flat-rate amounts.
How it works
The service provider (e.g. the hospital) sends an invoice to the insurance company, based on the SwissDRG flat rates. The insurance company's data reception service receives the invoice and makes a preliminary standard analysis to assess whether the amount of the invoice, the treatment and the diagnosis correspond, i.e. that the cost-benefit ratio is appropriate. If there is nothing untoward, the service forwards the invoice – without the medical data – to the insurance company for payment. If the service detects something unusual, the invoice must be forwarded to the insurance company for further examination, together with the data required to assess it (known as a Minimal Clinical Dataset – MCD). This is where the independent medical examiner may have a role to play. If the patient so wishes or if there are justified reasons to do so, the service provider may pass on medical information to the independent medical examiner only, and not to the insurance company (Art. 42 para. 5 HIA). When doing so, the service provider must mark the invoice as confidential and for the attention of the medical examiner. In this case, the MCD will only be read by the latter. Any additional information that the insurance company – or the medical examiner – may need to make a decision is treated as confidential in the same way. After analysing the invoice, the medical examiner makes an assessment and, if necessary, provides the insurance company with the information specified in Art. 57 para. 7 HIA, in particular the information required for payment, and explains the reason for the decision.
This system ensures that invoices are checked for cost-effectiveness of the treatments administered, while at the same time providing the best possible, two-fold protection of the patient's data, by means of the data reception service and the independent medical examiner.