Helsana Report: Care
Competition on quality: a key factor in success

Switzerland is considered to have a first-class healthcare system. But what proof is there of this perception? Nationwide tools for measuring the quality of medical services are rare. Given the freedom of choice so deeply embedded in the Swiss healthcare system, empowering patients to make an informed choice is a factor of crucial importance. That’s why it’s also important to boost transparency regarding the quality of medical treatment vis-à-vis patients. This will allow competition on quality to finally take hold in the healthcare system.

This transparency makes it possible to identify incorrect care or gaps in care, as this report shows by way of example. At the moment, health insurers cannot use these findings operationally on the grounds of data protection, that’s despite the fact that they hold the key to major added value for the care of many policyholders and thus for the healthcare system as a whole.


The following questions were selected as examples from the comprehensive «Helsana Report: Care», which is also available for download:

  • Are medical check­ups carried out in line with medical recommendations?
  • Are people living with diabetes receiving medical care in line with medical guidelines?
  • Is patient treatment with painkillers appropriate, and
  • What about the medication risks for older patients? Gastric acid suppressants are used as an example here.

1. In spite of clear evidence, far too few bowel check-ups take place

Medical check­ups can help detect bowel cancer early, improving the chances of recovery. They are recommended for men and women between the ages of 50 and 75. Despite this, only between 50% and 60% of this age group have undergone one of the recommended medical check-ups in the last ten years. This sees Switzerland fall significantly short of the target level (up to 80%) indicated for colonoscopies in studies.


An increase in the participation rate would have numerous positive effects: alongside reducing individual suffering, it would also have a financial impact on the direct medical costs of this disease, which amount to roughly CHF 90 million annually.


Brief explanation: bowel check-ups

There are two methods of bowel check-up that are predominantly used: a colonoscopy offers the advantage that it serves not only as a check-up of the entire large intestine, but also facilitates the removal of any precancerous lesions. Where the results are normal, the examination need not be carried out again for another ten years. The second method involves looking for hidden blood in the stool (FIT test). This should be repeated every two years and in the event of a positive test result, requires a colonoscopy.


Bowel cancer screening rate

  • < 50%
  • 51 – 55%
  • 56 – 60%
  • 61 – 65%
  • > 66%
Source: Helsana, projection for the whole of Switzerland (2022)

«A US simulation study calculated that boosting the screening rate for bowel cancer from 58 percent to a simulated 80 percent within five years could cut the incidence of cancer by a remarkable 22 percent and the mortality rate by 33 percent on a long-term basis. This data serves to underline the importance of coordinated efforts to promote prevention by professional medical associations and the medical profession, by authorities and insurers as well as the importance of patient education.»

Sabrina Stollberg, MD; Physician and Research Associate, Helsana Health Sciences

2. People with diabetes often do not receive care in line with medical guidelines

Diabetes is both an illness and a risk factor for other illnesses. That makes it all the more important for it to be detected early and treated in line with medical guidelines. Our analysis found that barely 40% of people with diabetes were treated in line with medical guidelines in 2022.


Brief explanation: treatment for diabetes in line with medical guidelines

Diabetes is a chronic metabolic disease with increasing global prevalence and a significant disease burden. To ensure patients with diabetes receive optimum care, their treatment should be in line with the guidelines of professional medical associations. Some of the diabetes care measures recommended by the guidelines include regular examinations of blood sugar levels, lipid profile, kidney status and eyes. Compliance with the guidelines is referred to as guideline adherence – something that constitutes a key quality characteristic for diabetes care.

Bowel cancer screening rate

Diabetic patients with guideline-adherent care

  • adherent

  • non-adherent

Source: Helsana, projection for the whole of Switzerland (2022)

Optimal coordination and continuity of care are key aspects of integrated care models. These have a positive impact on treatment compliance (referred to as adherence): for instance, the hospitalisation risk for diabetic patients in the integrated care model was 13% lower than in the standard model.


If the results of the individual diabetes quality indicators are viewed in isolation, it appears that just 73% of patients received the recommended twice-yearly blood glucose test and the annually recommended lipid profile measurement. 70% of patients underwent an annual kidney status test and approx. 60% attended a check-up by an eye specialist.

«Since there are a variety of evidence-based recommendations for monitoring and preventing diabetes complications, measures aimed at quality improvement are particularly helpful. The assessment of these values suggests room for improvement. Fortunately, a significant improvement was noted across all quality indicators in comparison with the quality measurement from earlier studies.»

Prof. Oliver Senn MPH; Deputy Institute Director, Specialist in General Internal Medicine at the Institute of Primary Care, University of Zurich and University Hospital Zurich

3. Inappropriate opioid prescriptions are alarmingly high

Opioids are used primarily as pain relief for cancer patients and during or after certain operations. Use of these drugs for prolonged chronic pain in non-cancerous cases is questionable and not recommended by the medical guidelines. Studies from the United States show that strong opioids in particular are associated with an increased risk of overdose and death. As such, quality of care must be transparent and monitored strictly where opioid prescriptions are concerned.


Brief explanation: inadequate opioid prescriptions

According to the WHO, opioids are strong painkillers, some with a high risk of addiction, and, as such, should be administered with care. The quality indicators for pain patients not suffering from cancer developed by Helsana define inadequate opioid prescriptions in accordance with medical guidelines. Treatments with at least two weak opioids or at least one weak and one strong opioid within three months are classed as inadequate.

In 2022, half a million people were prescribed two or more painkillers within three months. One in four of those, that’s 125,000 people, were given an inadequate opioid prescription according to the quality indicators. That scale is alarming. Given the frequency and the potentially fatal health consequences of opioids, there is an urgent need for action.


Inadequate opioid prescriptions

500,000 people in Switzerland were prescribed at least two painkillers


25% =

125,000 people

had an inadequate* opioid prescription


*min. two weak opioids or min. one strong and one weak opioid

Source: Helsana, projection for the whole of Switzerland (2022)

«Various studies have shown that strong opioids are being increasingly prescribed. Not only are strong opioids being prescribed more frequently, but they are also being increasingly prescribed for trivial injuries. This can potentially have far-reaching consequences. For instance, the prescription of opioids after accidents was associated with a delayed recovery and worse prognosis. Analysis of prescription patterns provides important insights into the potential overuse or misuse of medical measures and treatments.»

Prof. Maria Wertli MPH; Director and Chief Physician of the Department of Internal Medicine, Baden Cantonal Hospital; Chair of the Quality Commission of the Swiss Society of General Internal Medicine.

4. Older people are particularly exposed to medication risks

The risk of health problems increases with advancing age, which is why older people are more frequently dependent on medication. Taking several medications at once poses the risk of a harmful drug interaction and may be associated with adverse events such as hospitalisation. For that reason, medication safety should be a key focus, especially in older people with increased morbidity. For instance, gastric acid suppressants, referred to as proton pump inhibitors (PPIs), are one of the most sold medications. PPIs are a form of medication designed to reduce the (excess) production of gastric acid. The increasing frequency in prescribing PPIs is deemed questionable due to the potential side effects like pneumonia or osteoporosis.


Brief explanation: quality indicators for proton pump inhibitors (PPIs)

Proton pump inhibitors (PPIs) are used for the treatment or prevention of stomach and duodenal ulcers or for heartburn. To transparently map the quality of care in primary care, the proportion of people with potentially inadequate PPI prescriptions was measured. The annual dose of 11.5 g is regarded as inadequate. For instance, that corresponds to one 40 mg tablet of pantoprazole over a period of approx. one year.

The analysis for PPI prescriptions found a significant need for action across all age groups, but particularly among people over 80: 14% of all people over 80 received a potentially inadequate PPI prescription.


Inadequate prescription of proton pump inhibitors

  • Proton pump inhibitors

  • potentially inadequate therapy with proton pump inhibitors

Source: Helsana, projection for the whole of Switzerland (2022)

Risk compensation works and creates competition on quality

The revised risk compensation method creates fair competition among health insurers. The groundwork has been laid for competition on quality among health insurers for effective and innovative care models.

Older people make more frequent use of medical services. Accordingly, the average costs per person increase significantly with age see figure without RA. Since health insurers are also in direct competition with one another when it comes to unitary premiums, efforts should be made to prevent health insurers from systematically recruiting young, healthy policyholders. That’s why «risk compensation» was created and anchored in the Swiss Federal Health Insurance Act (KVG) in 2007. These compensation payments are intended to correct the financial consequences across health insurers’ insurance portfolios, i.e. those associated with the age effect and chronic illnesses such as asthma or diabetes.


Figure with RA illustrates this correction quite clearly: the costs even out across all age groups and pathologies. Policyholders with asthma/COPD and diabetes have expenses comparable to all other policyholders. Risk compensation demonstrates the desired effect: there is no longer any incentive to attract policyholders that are healthy or ill, young or old.

Risk adjustment 2020-2021

Quelle: Helsana (2022)

This is increasingly moving the focus towards efforts aimed at improving care for policyholders while emerging as a key success factor in any health insurance. Using billing data practically in the interests of improved care offers a lot of potential here, as the analyses described illustrate.

5. Conclusion: inform and empower policyholders and improve their health

Health insurers have access to a wealth of health data relating to their policyholders and, as such, are in a position to highlight potential for improvement in medical care.


Currently, regulatory provisions prohibit health insurers from

  • informing individual policyholders of worthwhile bowel screenings;
  • alerting diabetic patients to important check-ups;
  • warning pain patients of the risks of opioid prescriptions;
  • explaining potential health risks like drug interactions or overdoses to older patients.

These provisions prevent the competition on quality desired by the legislature. Helsana is therefore advocating that information from billing data be used to aid a higher quality of care – for the good of the patient.

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