EFAS unifies payment, but not the provision of care
From 2028, outpatient and inpatient services will use the same financing split. New Obsan data show how differently the cantons start out.
From 2028, EFAS will standardise who pays for outpatient and inpatient services. The reform, however, applies to 26 differently organised systems. New Obsan data show how far apart the starting points are.
The old split rewards inpatient bills
Outpatient treatment is currently financed entirely through health insurance premiums. For inpatient treatment, by contrast, the cantons cover at least 55 percent and insurers at most 45 percent. An inpatient stay can therefore look cheaper to insurers even though it costs the system as a whole more.
The uniform financing of outpatient and inpatient services, known as EFAS, is meant to remove this contradictory incentive. From 1 January 2028, the cantons will cover at least 26.9 percent of the net costs of all services under mandatory health insurance. At most 73.1 percent will be financed through premiums. Net costs are the expenses after the deductible and the co-payment share. Nursing care services follow from 2032. Voters approved the reform on 24 November 2024 with 53.31 percent.
CHF 9.2 billion – but only part of outpatient care
Obsan Bulletin 06/2026, published in September 2026, analyses the years 2017 to 2024. Over that period, the number of consultations rose by 25 percent. The amounts invoiced rose by 34 percent to around CHF 9.2 billion. Use and costs therefore grew much faster than the population.
The scope matters: the analysis covers only outpatient services provided by hospitals. Treatment in doctors' practices is not included. A high figure for a canton can therefore mean that emergency, specialist or on-call services are organised more through hospitals. A low figure can point to a larger practice-based outpatient sector. The data yield neither an efficiency ranking nor evidence of over- or underprovision.
Basel-Stadt and Nidwalden: two models, no ranking
The spread becomes visible when two cantons are compared. In 2024, users of hospital outpatient services in Basel-Stadt averaged 6.8 consultations, in Nidwalden 3.3. At the same time, an average of CHF 344 per consultation was invoiced in Basel-Stadt and CHF 698 in Nidwalden – roughly twice as much.
Because practice-based services are not included, these figures do not represent the entire outpatient care of either canton. The burdens a canton carries as a centre and the mix of treatments can also influence the comparison. Obsan does find a link between more frequent contacts and lower average amounts. But the published figures are not an age- and morbidity-adjusted efficiency ranking. They establish neither a cause nor a judgement on quality.
Even the medical specialties carry different weight from canton to canton. For 2024, Obsan calculates a share of psychiatry and psychotherapy in hospital outpatient costs of roughly 2 to 25 percent, depending on the canton. For physical medicine and rehabilitation, the reported range is about 4 to 28 percent. Behind this may lie different divisions of responsibility between hospitals and practices, centre effects or cantonal decisions about services. The analysis cannot conclusively separate these causes.
Obsan attributes only part of the growth to the politically desired shift from inpatient to outpatient care. For the 18 groups of the AvoS monitoring, it calculates roughly one third of the increase in activity. Which factors cause the remaining increase remains open with these data.
The CHF 800 million question: premiums or taxes?
EFAS does not automatically make medical services cheaper. At first, what changes is which pot pays a bill. The split was set on the basis of the years 2016 to 2019 so that the switch should be broadly cost-neutral across Switzerland.
The Federal Council links EFAS to the expectation that it will reduce misaligned incentives and make coordinated care easier. That is not a guarantee of falling total costs. The FOPH report of 29 October 2025 initially shows a shift in financing based on 2024 costs. Had EFAS already applied then, the cantons together would have borne more than CHF 800 million a year in additional costs. On paper, premium payers would have been relieved by the same amount.
This is not a forecast for 2028. The actual effect depends on the services provided then and their prices. It also differs from canton to canton. In premium approval, the FOPH intends to check whether the lower share borne by insurers is taken into account. At the same time, the cantons must fund their contributions through their budgets. For households, then, what matters is not only the trend in premiums. Equally important is how one's own canton covers additional spending.
The first test comes in 2028
The shared split can defuse the old misaligned incentive. But it replaces neither needs planning nor cost control, and it does not turn 26 cantonal systems into one. After the switch, it must therefore be made transparent whether inpatient treatments are actually avoided, how total costs develop and whether the relief for insurers reaches premiums. Only that reckoning will show whether EFAS achieves more than a shift between premium payers and taxpayers.
Sources
- Obsan: Hospital outpatient care in Switzerland, Bulletin 06/2026
- FOPH: Amendment to the Health Insurance Act – uniform financing of services
- FOPH: Financial impact of the transition to uniform financing, 2024 update
- FOPH: Federal Council opens consultation on the implementation of EFAS
- Medinside: EFAS faces 26 cantonal realities
