Martine Ruggli discusses the evolving role of pharmacists in Switzerland's healthcare system, addressing challenges and opportunities in digitalization, drug shortages, and regulatory reforms, as well as the need to leverage pharmacists' expertise more broadly.
How is the pharmacy landscape in Switzerland currently structured, and what are the key trends shaping it?
Switzerland’s pharmacy sector is diverse, encompassing around 1840 pharmacies distributed throughout the country. A unique feature of the Swiss system is the presence of self-dispensing doctors in approximately two-thirds of the cantons. This practice, almost not seen elsewhere in Europe, leads to a lower density of pharmacists in those regions. Across various sectors, including industry, academia, hospitals, and community pharmacies, there are about 10,000 pharmacists in total.
PharmaSuisse, the umbrella association for Swiss pharmacists, represents about 85% of the profession, although membership is voluntary. The pharmacy landscape in Switzerland includes independently owned pharmacies, pharmacy groups, and chains, with chains currently accounting for approximately 35% of the community pharmacies. The regulatory environment in Switzerland is notably liberal, allowing non-pharmacists to own pharmacies and placing no restrictions on the proximity of one pharmacy to another, which contributes to a highly competitive market environment.
Pharmacies in Switzerland are authorized to bill insurance for certain services, mainly those associated with the dispensing of medications. However, a substantial portion of healthcare costs is directly borne by patients. For example, in 2022, Switzerland’s total healthcare expenditures reached CHF 92 billion, with only CHF 38 billion covered by insurance. The remaining costs were paid out-of-pocket by patients, either directly, within the scope of the deductible or through taxes and insurance premiums. This significant patient contribution to healthcare costs is a distinctive aspect of the Swiss system.
How does the ability of Swiss pharmacies to bill insurance compare with other countries, and what challenges are currently faced in this regard?
In Switzerland, pharmacies face significant limitations in their ability to bill insurance, a situation markedly different from countries like France, where almost all pharmacy services are reimbursed by insurance. Currently, Swiss pharmacies can only bill for a narrow range of services, leaving the majority of costs to be paid directly by patients. This discrepancy is particularly evident in cases such as vaccinations: if a patient receives a flu vaccine from a doctor, it is fully covered by insurance, minus the deductible. However, when the same vaccine is administered in a pharmacy, the patient must bear the entire cost, including the vaccine itself and the administration fee.
This inconsistency has led to public misunderstanding of why identical services are treated differently depending on the provider. PharmaSuisse is actively working to address these issues, advocating for legal reforms that would allow pharmacies to bill for a wider array of services, including vaccinations and comprehensive medication reviews, medication reconciliation and adherence programs. These changes are crucial for optimizing patient care and ensuring equitable access to essential health services.
However, the path to reform in Switzerland is notoriously slow and complex. Legislative changes must pass through lengthy parliamentary processes, often taking years to implement. Despite being in discussion for eight years, the proposed reforms—part of a broader legislative package aimed at reducing healthcare costs—remain uncertain due to potential political stalemates, which could jeopardize the entire package and force the process to restart from the beginning.
What are the key challenges confronting the Swiss healthcare system, and how do these affect the role of pharmacies?
The Swiss healthcare system, despite its strengths, is grappling with significant challenges, primarily due to its exorbitant costs, which are increasingly difficult for the population to sustain. While the system remains effective and qualitative, it is approaching a critical juncture where the financial strain on patients is becoming untenable. Compounding this issue is an imbalance in the medical workforce: there is an oversupply of specialists and a critical shortage of primary care providers, which places additional pressure on the system.
But, in response, there is a pressing need for task shifting, particularly to pharmacists and nurses, to alleviate the burden on primary care physicians. Swiss pharmacies have proactively prepared for this shift by enhancing their competencies, allowing them to dispense prescription-only medications and provide in-depth patient counselling. However, the significant hurdle of being unable to bill insurance for these essential services persists forcing patients to bear the full cost. This limitation poses a major obstacle to fully realizing the potential of pharmacies within the healthcare framework.
The structure of Switzerland’s insurance model further complicates access to pharmacy services. Patients must first cover a predetermined deductible out-of-pocket before insurance coverage begins, leading many—especially those with high-deductible plans—to seek care in pharmacies as a more accessible option, avoiding long waits in emergency rooms. However, the inability to bill insurance for many services remains a critical barrier.
Swiss pharmacies have already proven their value in areas such as preventive care, screening, and chronic disease management. For instance, pharmacists now have the authority to administer vaccinations in all cantons, a competency achieved through persistent advocacy. Additionally, pharmacies are playing a vital role in diagnostics and medication management, initiatives that have demonstrably reduced overall healthcare costs. Yet, the inability to secure insurance reimbursement for many of these services significantly impedes the full integration of pharmacies into the healthcare system, presenting a challenge that must be addressed to ensure the system’s sustainability and effectiveness.
What are the primary objectives of PharmaSuisse in shaping the regulatory landscape for Swiss pharmacies?
PharmaSuisse is focused on three critical areas: political advocacy, negotiations with healthcare insurers on billing practices, and the continuous advancement of educational standards within the pharmacy profession. A cornerstone of our efforts is the enhancement of pharmacy education, where Switzerland stands out as the only country in Europe to mandate post-graduate education for those leading a pharmacy. This comprehensive two-year program combines hands-on experience in pharmacies with targeted coursework, ensuring that pharmacists are equipped with the highest level of expertise and competencies.
Beyond education, we have instituted a mandatory quality management system to uphold and improve the standards within the profession. A prime example of our proactive approach is in the area of vaccinations. Initially, we developed a specialized certification program for practicing pharmacists, which successfully led to the recognition of their right to administer vaccinations. Building on this success, we have now integrated the necessary training directly into the university curriculum for pharmacy students in Switzerland, thus eliminating the need for additional certification for new graduates. However, pharmacists trained abroad must still meet these certification requirements.
Our strategy ensures that any new competencies, such as the authority to dispense prescription-only medications without a prescription, are embedded within the foundational education at the university level. This approach guarantees that pharmacists entering the profession are fully prepared and qualified, without the need for further certification.
Could you elaborate on the recent reforms to distribution margins for generics versus innovative drugs, and how they affect pharmacies?
Switzerland has recently undertaken a significant reform in the remuneration model for pharmaceutical distribution. The previous system created disparities, where distribution fees were adequate for expensive drugs but insufficient for lower-cost medications, placing financial strain on pharmacies and other stakeholders in the distribution chain.
To rectify this imbalance, a new remuneration model was implemented on July 1st 2024. This model provides a more equitable distribution of fees, ensuring that lower-cost drugs receive better compensation, while slightly reducing the fees for high-cost medications. This change aims to create a more sustainable financial structure for pharmacies, regardless of the price of the drugs they distribute.
It’s important to distinguish between the adjustments made to distribution fees and the industrial prices set by manufacturers. While the distribution fees have been restructured, the issue of high generic drug prices in Switzerland remains a point of contention. Swiss generics are reportedly 60% more expensive than in other European countries, despite the fact that most are not produced domestically. This has led to ongoing debates, especially in the context of the current global medicine shortages, about the sustainability and fairness of the pricing model.
What are the challenges Switzerland faces with drug shortages, and how is PharmaSuisse responding to these issues?
Drug shortages are a critical global issue, and Switzerland is additionally challenged due to its small population and status outside the European Union. This situation is further complicated by the fact that, in Switzerland, the responsibility for ensuring the security of drug supply predominantly lies with the Cantons—except for a few vital medications managed by the Swiss Confederation, which is the federal government. This decentralized structure hinders effective coordination, as Cantons lack the possibility to negotiate directly with the European Union.
PharmaSuisse is actively advocating for a centralization of this responsibility, proposing that the Swiss Confederation assume control over the supply of all medications. This would enable more streamlined negotiations with European entities and other countries, essential for securing a reliable drug supply. Additionally, there is a need to avoid driving drug prices too low, as this could discourage pharmaceutical companies from maintaining a presence in Switzerland, further aggravating supply issues.
The complexity of the Swiss market, including the requirement for drug information to be provided in three languages, adds another layer of difficulty. Pharmacies are currently dedicating considerable time—sometimes up to an entire day each week—to sourcing medications, whether by compounding them in-house or seeking alternatives from Europe, mostly in close consultation with physicians. pharmaSuisse is also working closely with the Swiss Confederation to establish clear guidelines on when and how pharmacies can engage in compounding and importing medications, aiming to mitigate the impact of these shortages and ensure that patient needs are consistently met.
How is digitalization transforming the pharmaceutical sector in Switzerland, and what challenges are being faced?
Digitalization is rapidly transforming the pharmaceutical sector in Switzerland, beginning with the widespread adoption of robotic systems for drug storage in pharmacies, which has significantly enhanced operational efficiency. Although the integration of artificial intelligence is still in its nascent stages, it is poised to become increasingly influential in the near future.
However, the implementation of electronic patient records (EPR) in Switzerland has been notably problematic. The current system suffers from poor design and execution, leading to minimal adoption despite its mandatory status for hospitals. The lack of interoperability is a major obstacle, hindering the seamless exchange of patient data. Pharmacies have been proactive in supporting EPR initiatives, even establishing their own communities to promote adoption, but the overall progress has been slow, exacerbated by strict regulatory frameworks.
One area where digitalization is showing promise is in the digital management of medication plans, which is expected to be fully implemented soon. Another significant development is the advancement of electronic prescriptions, a key focus of collaboration between pharmacies and the Swiss Medical Association (FMH). This partnership is essential for fostering greater interprofessional cooperation in the ambulatory care sector, where improved data exchange and shared electronic records are crucial. By working together on electronic prescriptions, pharmacies and physicians are building a foundation for more integrated and collaborative healthcare, ultimately enhancing patient care.
What final message would you like to share with our international audience about the evolving role of pharmacists in healthcare?
The healthcare system must fully embrace and utilize the extensive expertise of pharmacists. We are highly educated, easily accessible, and uniquely positioned to act as a primary gateway into the healthcare system. The value that pharmacists bring is profound, as evidenced during the COVID-19 pandemic. Throughout this crisis, pharmacists were the constant—remaining open, administering vaccines, conducting tests, and providing essential care when other parts of the healthcare system were overwhelmed.
As I prepare to attend the World Congress in South Africa, it is clear that the role of pharmacists is being increasingly recognized and valued on a global scale. With enhanced education and expanding responsibilities, pharmacists are ready to assume even greater roles in healthcare. It is imperative that we continue to build on this progress and integrate pharmacists more deeply into healthcare systems worldwide. Investing in and empowering pharmacists is not only beneficial but essential for improving the quality, accessibility, and efficiency of healthcare.
