Tariff intervention in Swiss physiotherapy: What's behind it?

Overview of tariff intervention

Physiotherapy has been reimbursed according to the same structural tariff for more than 20 years. In August 2023, the Federal Council has now announced that it will implement a tariff intervention and presented this in a fact sheet. 

The tariff intervention is being carried out as a direct determination and without the cooperation of the tariff parties normally involved; it is therefore an "intervention" and not a negotiation. Such interventions are provided for by law if the parties to the collective agreement - in this case the representatives of the health insurance funds and the physiotherapy sector - are unable to reach an agreement. The Federal Council now considers this to be the case.  

The Federal Council's decision stipulates that all treatments would now be time-limited, divided into different categories lasting between 20 and 75 minutes. Currently, the decision as to how long a treatment lasts within a flat rate is at the discretion of the physiotherapist providing treatment.

The Federal Council has proposed two different variants for implementing this adjustment. However, these differ only in the denomination of the permissible treatment duration. Variant 1 provides for treatments lasting 20, 30 and 45 minutes. Variant 2 provides for a basic flat rate for the first 20 minutes, followed by billing for the actual duration of treatment in blocks of five minutes. 

In addition, the possibility of billing so-called "complex physiotherapy" (tariff item 7311) is to be restricted. In addition to the presence of a listed clinical picture, in future it will also have to be shown that the treatment was actually more difficult.

Is the tariff intervention appropriate?

The factsheet shows that the Federal Council wants to improve the quality of treatment and control costs. These objectives are initially plausible and understandable. However, it is more than questionable whether the proposed tariff intervention is suitable for achieving these goals. 

The Federal Council mainly bases the quality of treatment on its duration. This is the only way to explain why, with the declared aim of quality assurance, only the duration requirements are being adjusted. 

No importance is attached to the specific type of therapy. Fango treatments, for example, whose effectiveness cannot be proven, are reimbursed in the same way as evidence-based, active exercise therapy. Incidentally, the latter also requires significantly more expensive infrastructure, which does not play a role in the remuneration - think of practice space and modern training equipment. 

It is also ignored that a central mechanism of action of physiotherapy is the instruction of healthy behavior in everyday life. Whether the personal session lasts 20, 25 or 30 minutes is irrelevant if patients can be competently instructed and motivated for the remaining 6,700 conscious minutes per week. 

In this context, the tariff intervention also fails to take into account the level of training of the treating therapist. This contradicts the politically desired academization of physiotherapy. If treatment by physiotherapists with a BSc FH, MSc FH and certificates such as the "Swiss Advanced Physiotherapy Practitioner" is remunerated in exactly the same way, this ultimately means that the Federal Council sees no medical value in further training. Of course, nobody wants to put it that way.

In addition to quality, specifying the duration of treatment is also intended to improve cost control. The Federal Council defines "costs" as the direct expenditure for physiotherapy treatment. However, a holistic and therefore meaningful assessment of the costs of physiotherapy must also take indirect cost consequences into account. For example, how do the costs of outpatient specialist consultations, diagnostic imaging, hospital stays, operations or sickness allowances change over the 12 months following therapy? The sum of the cost consequences - direct and indirect - must be considered in order to effectively control healthcare costs in Switzerland.

Focusing solely on the increase in direct costs for physiotherapy also reveals that physiotherapy treatment is tacitly regarded as not cost-effective. Expenditure is to be cut in the short term; the long-term cost consequences for the healthcare system are not considered by the tariff intervention and are unlikely to be reduced.

Overall, the tariff intervention shows an outdated understanding of physiotherapy that has little to do with the actual practice of the leading providers in Switzerland. The image of physiotherapy as a mixture of massage, esoteric methods and warm mud packs has had its day and does not do justice to Swiss physiotherapists. 

It would therefore be extremely regrettable if the current tariff intervention cemented an outdated tariff structure that does not reward evidence-based and competent treatment.