Hospital treatments: outpatient over inpatient

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The healthcare system in Switzerland is faced with some major challenges. No-one would argue that savings need to be made. But how and where? This blog explains why “outpatient over inpatient” plays such an important role in efforts to cut costs.

The Swiss healthcare system is a complex thing. And each and every year, the Swiss population is spending more and more money on healthcare. The Swiss Federal Statistical Office reports that in 2021 the total bill topped 86 billion francs, which equates to CHF 827 per person, per month – or almost CHF 10,000 a year. That’s a whole lot of money. But how can costs be lowered without compromising the quality of healthcare overall?

More outpatient procedures

Technical advancements and minimally invasive surgical techniques mean that more and more operations can be performed as outpatient procedures. When a patient undergoes outpatient treatment, they leave the hospital on the same day of the procedure. This is medically preferable in many cases, because patients tend to heal faster in the comfort of their own home than they do in hospital. At the same time, foregoing inpatient treatment saves several thousands of francs. It was with this in mind that at the beginning of 2019 the federal government introduced a new regulation: “outpatient over inpatient (in German),” ("ambulant vor stationär" in German, abbreviated as AVS or AVOS). This regulation stipulates which operations must now be performed exclusively as outpatient procedures. Basic health insurance will only cover inpatient treatment for these operations in justified cases. The result: AVOS procedures have dropped in cost by about one third since 2019. What’s more, it’s become clear that many patients welcome the opportunity to go outpatient rather than inpatient.

Outpatient versus inpatient: advantages and disadvantages

However high the pressure to cut costs, this must never be at the cost of patient care. So what are the advantages of outpatient versus inpatient from the perspective of those affected – and vice-versa?

Advantages of outpatient treatment

If outpatient treatment is indicated for medical reasons, it offers some notable advantages:

  • Lower risk of infection: At home, there is a lower likelihood that a surgical wound may become infected (keyword: “hospital infection”).
  • Personalized care: Outpatient care can often be tailored more specifically to a patient’s individual needs.
  • Optimal rehabilitation: People recovering from an operation at home have more autonomy and flexibility in the care they receive and as a result are more actively involved in their journey back to health. This is proven to support the healing process.
  • Familiar environment: Most people value their privacy, feel more comfortable in their own home and sleep better in surroundings they are used to – a key factor in a healthy recovery.
  • Social network: Having people around who you know and trust has not only practical advantages, but also emotional benefits – making it easier to get back into your daily routine.

Advantages of inpatient treatment

More involved and complicated operations bring with them risks that require a stay in the hospital. These are the most important reasons.

  • Intensive observation: Should complications arise, they are recognized in a timely manner.
  • Extensive resources: Quick action can be taken in the event of an emergency because necessary materials and specialized staff are immediately on hand.
  • Comprehensive aftercare: Proper care and support immediately following the procedure are a given when staying in the hospital – which can be especially important for people who live on their own.

Problems after discharge?

A common fear with outpatient care is that problems may arise after discharge. What if my wound starts bleeding? How will I manage on my own? It’s important to know that all procedures that fall under the “outpatient over inpatient” regulation are minimally invasive, meaning the risk of secondary bleeding and other complications is low. Patients are only discharged if they meet a specific set of criteria. The main scenario in which problems may arise later on is due to a lack of appropriate aftercare (Spitex, home care, SRC, Pro Senectute, family members, etc.). The takeaway here is that good preparation and organization are critical throughout the entire period of recovery.

Massive potential

In France, 60 percent of hip replacements are performed outpatient – in Switzerland, by contrast, 99 percent are performed inpatient. (Source: SRF, in German)

Tips for patients

Before the operation

  1. Ask questions: Allay any uncertainties and make sure that you are familiar with the ins and outs of your procedure – also if you need to stop eating/drinking or take any specific medications before your hospital visit.
  2. Make preparations for your recovery: Prepare your home, get some comfortable clothing ready and make sure you have the aids and equipment you need. It’s important to organize not just your travel back home, but also practical support during your period of recovery.
  3. Clarify any financial issues: Get preauthorization from your health insurance provider and find out whether you are entitled to any further benefits. Also inquire about your deductible, excess and any additional costs.

After the procedure

  1. Take the prescribed medications: Follow the doctor’s instructions to the letter. If you are unsure or notice any side effects, consult a specialist.
  2. Keep up with your aftercare appointments: Set up all recommended appointments and prioritize your recovery to ensure that your path back to health is as smooth as possible.
  3. Stay alert: Be on the lookout for any unusual symptoms such as persistent pain, fever or swelling. Contact your doctor immediately if you are concerned.
  • Teaser Image
    Outpatient operating centers

    Outpatient procedures require a different infrastructure – and so increasingly they are being split off from hospitals. The Hirslanden Group, for example, operates several outpatient operation centers.

    Hirslanden OPERA (in German)

Health policy: Wherein lies the problem?

In many cases it is medically advisable to perform operations as outpatient procedures – and is also the preferred choice for many patients. This approach also saves big on costs. So why is the proportion of inpatient treatments in Switzerland still so high compared with other countries? One of the main reasons is the way treatments are billed depending on whether they are performed outpatient or inpatient:

  • Inpatient care is charged at a flat rate – with the canton footing at least 55 percent and health insurance up to 45 percent of the bill. 
  • Outpatient services are invoiced according to the TARMED pricing system – where the health insurer has to pay 100%.

Problem 1: As outpatient procedures become more commonplace, this saves money overall, but the financial burden is shifted to the health insurer. This, in turn, can lead to higher premiums. 

Problem 2: The TARMED pricing system is outdated. Under the system, hospitals don’t receive enough on some outpatient procedures to even cover their costs. This means hospitals make more revenue and more profit from inpatients than they do from outpatients. (Even though, on the flipside, this results in a lack of beds and staff.)

There needs to be a complete overhaul of the way hospital procedures are billed to resolve these contradictions and false incentives. Politicians have been debating this very topic for several years now with the EFAS (in German) project, which aims to standardize how outpatient and inpatient services are financed. Outpatient treatments will continue to increase regardless of how long these well-known problems remain unresolved – but not as fast as they could do or would be in the best interests of the healthcare system overall.

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