Rational decisions are only possible when there is clarity on the objectives pursued in these decisions, the alternatives available, the assessment criteria and processes to be applied and the information available.

Objectives of Health Technology Assessments (HTAs) in Switzerland

HTA in Switzerland should serve two overriding objectives in particular, namely

  1. the comprehensive systematic comparative evaluation of the individual and social benefit, cost implications and cost/benefit relationship of “medical technologies”; and
  2. the management of services covered by compulsory health insurance.

HTA is expected to be useful in helping to increase efficiency (for example, by eliminating ineffective and/or uneconomical services) and to improve the quality of healthcare (for example, through the development of binding evidence-based guidelines for use based on HTA results) within the limits covered by compulsory health insurance.

The limits of the project (interfaces of the HTA process) arise partly from the marketability of a technology, in many cases thus from a prior regulatory approval (the activities of swissmedic do not fall within the scope of this project).

At the same time, HTAs should provide useful information for associated decisions for the proper use of the technologies evaluated; however, the decisions themselves fall within the remit of the FOPH.

HTA as decision support

HTAs should support decisions in keeping with objectives for a healthcare that meets the criteria of efficacy, suitability and cost-effectiveness within the limits covered by compulsory health insurance:

  1. Reimbursement and price decisions within the limits of the provisions set forth for services covered by compulsory health insurance (e.g. maximum prices for medicines [“Specialties List”] and analyses [“Analyses List”] and maximum reimbursements e.g. for equipment and appliances “Equipments and Appliances List”, etc.);
  2. Regular reviews of the range of services for conformity with the criteria of efficacy, suitability and cost-effectiveness;
  3. Identification of research needs: proper closure of evidence gaps;
  4. Fair access to effective and efficient medical care at a high level of quality.

Focus on key objectives of solidarity-based healthcare

Objectives conflicting with the solidarity principle (in particular financial sustainability and the wish of citizens for limitation of taxes and insurance contributions; the economic correlates of this are the elementary concepts of “scarcity” and “opportunity costs”) require the setting of priorities in the definition of services covered by compulsory health insurance.

In this context the following hierarchy of objectives is considered:

1. Primary normative postulate:

Paramount focus on a rights-based concept of personality, integrity and autonomy of the individual and an understanding of health as a “conditional good”, without a minimum of which it is not possible to achieve self-determined life plans (“facilitation character” of health), within the meaning of Swiss legal tradition (cf. in particular the Federal Constitution, the basic principle of equal rights, protection of children and youths, right to assistance in emergency situations and other norms), which urges desisting from primarily utilitarian approaches and is rather informed to a substantial degree by the principle of solidarity ;

2. Expectation of insured people (“social preferences”)

within the meaning of the concept of “empirical ethics”:  with a glance at the above normative premises and in view of existing Swiss studies and surveys, as well as international economic and socioeconomic studies, the following social preferences are postulated – in the sense of a working hypothesis.

  • Priority for interventions in especially acute and/or especially severe disorders (criterion of urgency and severity),
  • Special consideration of interventions for young people (who have not yet had any chance of independently realizing their individual life plans; criterion of a “fair innings”),
  • A fair chance of access to effective medical care even in the case of rare diseases and/or high costs of intervention (criterion of fairness),
  • Subordination of interventions for only minor disorders and / or in cases where self-financing by the insured person may be reasonably expected (criterion of “bagatelles”),
  • As far as possible unhindered general and prompt access to new interventions that offer demonstrable added benefit (criterion of innovations).

For this there is an express need for further research (with regard to validation, ranking and relative weighting of criteria; cf. below, “Evaluation methods, criterion of suitability”).

These target requirements are operationalized by lending concrete shape to the criteria of efficacy, suitability and cost-effectiveness:

Operationalization of the criteria of the KVG for efficacy, suitability and cost-effectiveness

The Swiss health insurance act (KVG) requires evidence of efficacy, suitability and cost-effectiveness and the periodic review of these criteria for all services covered by the basic (compulsory) insurance.

With the criteria of efficacy, suitability and cost-effectiveness, objectives are stipulated, the attainment of which is to be supported by HTAs. To meet both central normative premises and also the expectations of insured people, these criteria are operationalized with reference to the following standards:

1. Efficacy

  • Starting point (1):
    Relevant added benefit (always) compared with relevant alternatives; degree of confidence in the existing evidence
  • Starting point (2):
    Consideration of the best available evidence, the relevance of which should be clear for the reality of Swiss healthcare

2. Suitability (appropriateness to purpose and objectives)

  • Starting point (3):
    Primary normative postulate within the meaning of Swiss legal tradition (see above)
  • Starting point (4):
    Empirically demonstrable “social preferences” of insured persons (see above)

3. Cost-effectiveness

  • Starting point (5):
    Cost implications
  • Starting point (6):
    Efficiency; relation of (added) benefits to (added) costs

The underlying classification consists in the logical assignment of the individual benefits perspective to (1), the social benefits perspective to (2) and the cost perspective to (3).

This classification is an essential prerequisite for a potential seamless further development of the method with a view to possible future setting of limits justified by health economics.