Health care reforms of relevance to chronic disease

The 1996 Federal Health Insurance Act and its subsequent revisions, in particular in relation to managed care and hospital financing, form the key health reforms of importance for chronic disease management in the Swiss health care system. As mentioned above, it introduced universal access to comprehensive health care services for all Swiss residents. Its third revision, in progress since 2004, further considered, among other things, legislative modifications of managed care (see below) and hospital financing. The latter resulted in the full conversion of hospital payment to the SwissDRG system in 2012 as noted earlier. However, the proposed revision promoting managed care was rejected by popular referendum in June 2012.

Since 2007, the Federal Council has also been developing a federal law on health promotion and disease prevention, aimed at improving the conduct, coordination and evaluation, at a national level, of health promotion and disease prevention. It was expected to define the roles of the confederation, cantons and nongovernmental organizations, as well as specifying national targets for health promotion and disease prevention and the allocation of funding according to this strategy. The development of the federal law on health promotion and disease prevention was however adjourned in September 2012.

More recently, in January 2013, the Federal Council presented ‘Health2020’, a comprehensive health care strategy, which seeks to prepare the Swiss health system for ‘the challenges ahead at affordable costs’ (Federal Office of Public Health, 2013b). It identifies four priority areas: quality of health care provision, quality of life, equality of opportunity and transparency, and its strategy focuses on chronic disease prevention and care, financing and insurance transformations, data transparency and e-health, as well as education and training of health care professionals.

Reform efforts that are currently being discussed and that are likely to contribute to the prevention and care of chronic diseases include the proposed consideration of primary care medicine in the Swiss constitution, following a national vote in May 2014, and the master plan family medicine, aimed at reinforcing primary care.

Current legal, regulatory and policy frameworks

Switzerland has so far not developed a national regulatory framework targeting chronic diseases prevention and management care although national programmes and strategies targeting specific areas such as tobacco, alcohol, physical activity and diet have been in place for some time. Strategies addressing chronic diseases more generally are more recent. However, all these strategies are not binding, and cantons remain free to organize health care delivery.

Currently, managed care as set out in the Federal Health Insurance Act represents the principal regulatory and policy framework for chronic disease management in Switzerland. However, it is not obligatory to implement chronic care initiatives within that framework. Within managed care, patients enrol with a physician who acts as a gatekeeper to specialist care in return for reduced premiums. The most common forms of managed care are physician networks and health maintenance organizations (HMOs). Within HMOs, physicians work in a group practice owned by a health insurer or by physicians while physician networks bring together office-based doctors in ambulatory care, usually in the form of family physician or gatekeeper models although increasingly also involving specialists (Strehle & Weber, 2008). Throughout the following text, we will refer to physician networks only.

The development of managed care schemes in Switzerland dates from the early 1990s; by 2014, there were 75 physicians networks, four-fifths of which had agreements to share part of the financial risk (Forum Managed Care, 2014b). About 24% of residents across Switzerland are currently enrolled with physician networks although coverage varies widely, with up to one-third of the population enrolled in some cantons while other regions have yet to implement networks. About half of all primary care physicians participate in networks.

As indicated above, from 2004, the Federal Council considered a further advancement of managed care models within the third revision of the Federal Health Insurance Act, with the main objective to promote the quality of care at reasonable and appropriate cost. The proposed legislation foresaw the strengthening of managed care, broadly referred to as integrated care (networks), through, among other things, requiring health insurers to contract with at least one integrated care network to be offered to their insured population (Cassis, 2010). However, as noted, following several years of development, the ‘managed care’ proposal was considered in a popular referendum and 76% of the population and all 26 cantons rejected the proposed plans.

Individual cantons have also engaged in advancing the regulatory and policy framework for chronic disease management, with, for example, the canton of Vaud, in its 2008–2012 health policy (Rapport du Conseil d’État sur la politique sanitaire 2008–2012) aiming to adapt health care services to chronic diseases, in particular reinforcing cooperation and coordination, and to promote health, prevent diseases and conduct priority public health programmes. In that context, the Ministry of Health of the canton of Vaud developed a cantonal diabetes programme, aimed at controlling the incidence of diabetes and at improving care for diabetic patients (see below).

Diabetes disease management programme Diabaide, canton of Vaud

Diabaide (Filière de soins Diabaide; ‘diabetes care network’) was developed in 2004 in western Switzerland. The programme was mainly led by a physician (endocrinologist–diabetologist) and a diabetes nurse-specialist. It was based on an inventory of the needs of diabetic patients in the region and the creation of a working group including a range of health care stakeholders involved in diabetes care. Initially, the programme included the provision of information material and continuing education for health care professionals only. It was expanded to form a more comprehensive programme directly targeting the patient.

The programme was jointly run by the Association Réseau de Soins de la Côte (one of five care networks operating in the canton of Vaud³) and two regional hospitals (Ensemble Hospitalier de la Côte and Groupement Hospitalier de l’Ouest Lémanique). While the hospitals provided the setting for service provision within Diabaide, services were not targeted at inpatients but are community-based.

The key components of Diabaide were disease management and multidisciplinary teams (cellule multidisciplinaire diabaide). The programme is currently being reorganized (see below); in the following we describe the core components implemented originally. This included the programme’s main strategies which involved elements of self-management support, delivery system design, decision support and clinical information systems.

• Self-management support involved the provision of information material (French language), customized face-to-face self-management education and follow-up, and support by trained staff (nurse specialists, dieticians and specialist physicians). The patient’s overall situation was regularly assessed and patients were actively involved in goal setting and developing a treatment plan.
• Delivery system design included the clear definition of the roles and tasks of each participating health professional, monthly meetings of the entire team and weekly coordination or organizational meetings, and the development of care plans for typical ‘clinical situations’ such as the introduction of insulin, gestational diabetes, which were then adapted to the specific context of the individual patient. Patients were followed up (in person or by telephone) following a predetermined schedule, including telephone contact at least once a year.
• Decision support involved the use of care protocols developed according to international and Swiss guidelines, and the involvement of specialist physicians in the programme.
• Clinical information systems included the implementation of a shared electronic medical record permitting restricted information sharing among health professionals involved in the care process (‘customized‘ access). This system also included an electronic booking system.

The programme offered specialized ambulatory care, along with access to a network of specialists such as endocrinologists, dieticians, diabetes nurses and podologists (Peytremann-Bridevaux & Burnand, 2009). GPs and family physicians did not assume an active role in the programme.

Any patient with type 1 or type 2 diabetes residing in the region of Nyon-Morges in the canton of Vaud was able to join the programme. However, participation in the programme was strongly dependent on whether or not the primary care physician referred patients to the programme. In addition, patients seen once were not to be followed further.

Initially supported by health insurers and the canton of Vaud, the programme is currently funded by the canton of Vaud (around 50%) and from care activities charged to the patient and reimbursed by their health insurers (around 50%). The objective of Diabaide was to cover 30% of the estimated diabetic population in the region of Nyon-Morges (around 6000). By 2009, a total of 720 patients (12%) had been reached. This equated to 100– 150 new patients, who were seen at least once a year.

Despite these encouraging results, there has been a lack in the steering, management and organization of Diabaide and as a consequence, Diabaide has been in the process of reorganization since 2013. This reorganization is moving towards fragmentation of its activities with specialized ‘poles’ developed by local institutions in collaboration with independent health care professionals. An external evaluation is under way which aims at a better understanding of the situation and previous experiences, and to explore how experiences can be used for further cantonal developments.

Breast cancer clinical pathway, Lausanne University Hospital and University of Lausanne

The breast cancer clinical pathway in Lausanne was implemented in 2008/2009 at the initiative of clinicians and clinical managers at Lausanne University Hospital to improve the quality and efficiency of health care. It was accredited by the Swiss Cancer League and the Swiss Senology Society label for breast cancer in November 2013. The breast cancer pathway, initiated by the Medical Directors’ Board, heads of hospital departments and hospital clinicians, was designed to improve the quality of care, and developed de novo. It is hospital-based and targets adults with breast cancer who are primarily treated at Lausanne University Hospital. As such, it does not involve primary care physicians.

The key components of the breast cancer clinical pathway are coordinated and integrated care as well as multidisciplinary teams. The pathway’s main strategies involve elements of self-management support, delivery system design, decision support and clinical information systems.

• Self-management support involves information for patients using written documentation on a range of topics including the disease process as well as treatments and therapies; dedicated time during the individual consultation including information and regular reassessment of the patient’s situation; shared decision-making within a limited frame; and self-management support by trained nurses and social workers; and possible access to peer support groups. Self-management education following resection of axillary lymph nodes is also available.
• Delivery system design includes a detailed description of each step of the clinical pathway; regular meetings with staff and project leads; and planned, predetermined and structured face-to-face consultations. This component also considers regular assessments of pathway implementation (routine process indicator measures).
• Decision support involves the adaptation of (inter) national guidelines developed by the National Cancer Care Network and the Consensus of Saint-Gall (European guidelines) as well as provider education on specific components of the programme. Physicians and nurses involved in the programme also receive education in the field of senology–oncology and in communication. Hospital specialists are entirely integrated in the programme. Clinicians are further supported by written documentation detailing the diagnosis and pre-operative phase, the peri- and post-operative phase, and pre-operative chemotherapy, radiotherapy and surgical reconstruction, with additional guidance under development.
• Clinical information systems include the establishment of a database and biobank. Providers receive feedback on delays (for example between diagnosis and treatment) and the number of new cases of breast cancer per year (a target is set at 150 new cases of breast cancer included in the clinical pathway per annum). Surgeons also receive specific information relating, for example, to the number of reoperations needed because safe histological margins were not reached, or the number of times that a surgeon was the main operator in relation to the total number of breast cancer operations.

All health professionals involved in the programme are employed by Lausanne University Hospital. Specialist physicians include oncologists, surgeons, plastic surgeons, fertility specialists and geneticists, radiologists and pathologists. Nurses are represented by breast cancer nurse specialists, oncology nurse specialists and generalist nurses. Allied health professionals such as physiotherapists, psychologists and social workers are also part of the team; however, social workers are not employed by the hospital but are associated with the ligue vaudoise contre le cancer.

Currently, Lausanne University Hospital takes care of approximately 200 new breast cancer patients per year. The main objective of the programme is to reach at least 150 patients included each year, which corresponds to the minimum requested for the Swiss Cancer League label. The programme is also aimed at increasing the recruitment of patients by working in a network with regional hospitals, in order to reach 40% of new breast cancer patients in the canton of Vaud. The programme is financed by the hospital itself with the Medical Director Board and chief executive actively encouraging the continuing implementation and development of the programme as well as reaching targets.

Programme cantonal diabète, canton of Vaud

In 2008, the Ministry of Health of the canton of Vaud (Département de la santé et de l’action sociale) initiated the development of a cantonal diabetes programme within the framework of the canton’s 2008–2010 health policy strategy (Rapport du Conseil d’État sur la politique sanitaire 2008–2012) (Canton de Vaud, 2008). It involved representatives from the range of providers involved in the delivery of diabetes care and other stakeholders in the health care system, including public hospitals and health insurance funds. The cantonal programme aims to sustainably reduce the impact of diabetes on the population of Vaud by reducing its incidence through appropriate preventive measures and improving the management of those with established disease (Canton de Vaud, 2014).

The programme is principally based on the Chronic Care Model developed by Wagner (1998). It plans to emphasize quality and access to self-management education, multi/interdisciplinarity, coordination and the integration of evidence-based care, health professionals’ training and health promotion and disease prevention at the general population level. This is expected to be accompanied by some form of information system.

The programme is still under development, involving a stepwise, bottom-up and top-down approach. By the end of 2013, around 40 projects had been launched (Canton de Vaud, 2013). After a first concept and campaign for early diagnosis and targeted screening for diabetes and associated risk factors, further achievements were, among others: (i) the establishment of a cohort of patients with diabetes to monitor the quality of their care, patient needs, the knowledge and exposure to the programme and its effect on the population of patients with diabetes; (ii) the adaptation of diabetes guidelines to the Swiss context; (iii) the development of a diabetes risk assessment website; and (iv) the implementation of programmes targeting physical activity of type 2 diabetic patients, of programmes promoting self-management and of patient education programmes awareness for health care professionals. The programme cantonal is also participating in partnerships to promote healthier lifestyles and considers an implementation as well as effectiveness evaluation.

Réseau de santé Delta, canton of Geneva

The Réseau de santé Delta was developed in 1992 as a health maintenance organization (HMO), on the initiative of two physicians at the University of Geneva. Initially restricted to university staff and students, the HMO was subsequently (1994) opened to other members and transformed into a network of physicians (‘Delta’) (Werblow, 2004). It is accessible to any resident of the canton of Geneva opting for the Delta network health insurance scheme. The network also operates in the canton of Vaud.

Delta’s main strategies involve elements of delivery system design and decision support.

• Delivery system design includes the development of chronic disease management programmes for diabetes, heart failure and asthma.
• Decision support involves the organization of regular quality circles for all physicians participating in the network.

While formal self-management support strategies are not documented, patients receive regular information (two information letters per year), detailing provisions for access to health promotion and disease prevention consultations and activities. A website is also available.

Primary care physicians (GPs, generalists, internists, family physicians) act as gatekeepers and refer patients to specialists; paediatricians, gynaecologists and ophthalmologists are directly accessible. The Delta network of physicians also includes psychologists and a network of 40 pharmacies.

The Delta network is reimbursed on a capitation basis, with re-insurance for expensive cases (Schaller & Raetzo, 2002). Participating physicians continue to be paid on a fee-for-service basis, and the capitation fee per insured person is negotiated annually between the network and the health insurance funds whose members have enrolled with the Delta network. In addition to their income, physicians receive a lump sum of CHF 200 each time they participate in a quality circle.

In January 2013, the Delta network comprised some 350 primary care physicians (70-80% generalists, internists, GPs) covering about 110 000 insurance members across the cantons of Geneva and Vaud (Delta Réseau de santé, 2014).