Re-evaluation of compulsory health insurance benefits: HTA

Health technology assessments (HTAs) are an internationally recognised tool for the systematic evaluation of medical procedures and technologies. They are acknowledged as an important component of evidence-based policy advice and decision making.

Objectives

Giving a stronger role to health technology assessments (HTAs) is one of the health policy priorities set by the Swiss Federal Council in its Health2020 initiative. HTAs facilitate transparent, evidence-based decision making, help to reduce ineffective and inefficient services, medicines and processes as well as raise the quality of healthcare and lowering costs.

In this context the federal administration has launched an HTA program to re-evaluate benefits currently paid under the compulsory health insurance; this program is to be extended and expanded progressively in the next few years.

The legal basis of the program is Article 32 of the Swiss Federal Health Insurance Act (KVG/LAMal), which specifies that medical products and services covered by compulsory health insurance must be effective, appropriate and economic efficient, and periodically reviewed to check whether these requirements are met.

The program to re-evaluate medical technologies (including pharmaceuticals) focuses on reviewing potentially obsolete technologies paid under compulsory health insurance with the goal of removing them from the catalogue of benefits or limiting insurers’ liability to pay them (disinvestment).

Process for re-evaluating current compulsory health
insurance benefits

A systematic process underlies the HTA program. It involves the following steps:

  • Identifying themes
  • Pre-scoping (determining the questions to be addressed in the HTA report)
  • Commissioning an external body to produce:
    • a scoping report
    • an HTA report.

These HTA reports will then support the relevant federal advising committees (ELGK, EAMGK and EAK):

  • in their appraisal
  • in their recommendation to the Federal Department of Home Affairs (FDHA/EDI) or Federal Office of Public Health (FOPH)

On the basis of these recommendations the FDHA, or in the case of pharmaceuticals the FOPH, will decide on whether to remove, limit or continue the liability to pay the benefit.

The schematic diagram below illustrates the process.

Schematic diagram of the process: 1. Identifying issues, 2. Scoping, 3. Assessment, 4. Appraisal/decision

1) Stakeholders = FMH, associations of health insurers and industry, patient organisations, Cantonal health directors, etc.
2) Stakeholder = various associations, patient organisations and other affected groups. It is left to the associations to invite individual manufacturers, owners of patents and/or service providers to comment.

  Stakeholder consultations
Topic prioritisation Scoping report HTA report
Prior notice 20 working days 20 working days 20 working days
Consultation duration 20 working days 15 working days 20 working days

Submitting topics

Anyone can submit themes to be addressed in the re-evaluation of current compulsory health insurance benefits at any time using the submission form.

Themes to be addressed the following year must be submitted by 30 October. From 2019 on this deadline will be the 1th of March.

The themes submitted will be included in the subsequent prioritisation process.

Themes will be prioritised in line with a range of criteria including the significance of the condition (disease burden), the budgetary relevance of the technology, any controversy concerning the efficacy or safety profile, indications of inappropriate care, the expected benefit of regulatory measures (not just economic) and the practicability of suggested improvements. Stakeholders will be consulted on the prioritisation of themes. The EDI will decide which themes are to be addressed on the basis of the recommendation of the federal consulting committees.

Further information

Strategy Health2020

Going forward the Swiss healthcare system has to maintain its high quality and remain fundable and accessible to everyone. This is the goal of the 36 measures set out in the federal administration’s Health2020 strategy. Find out more here.

Last modification 26.04.2019

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Contact

Federal Office of Public Health FOPH
Division of Health Care Services
Health Technology Assessment Section
Schwarzenburgstrasse 157
3003 Berne
Switzerland
Tel. +41 58 462 21 11
E-mail

Print contact

https://www.bag.admin.ch/content/bag/en/home/versicherungen/krankenversicherung/krankenversicherung-bezeichnung-der-leistungen/re-evaluation-hta.html