Kristian Schneider wants to improve the quality of health care and better manage the rising healthcare costs by means of a network that includes doctors, hospitals, insurance companies and the state. Its aim is to provide exactly those services needed for the health of patients. For the canton of Jura, which like all other cantons suffers from the fragmentation of service providers, this could be a unique opportunity to build an integrative care system – and thus become a pioneer, says the director of Hôpital du Jura.
Interview: Fabian Käser, Steffen Klatt
What brought you to the canton of Jura?
Kristian Schneider: I was asked and had 16 hours to decide and submit an application in French. The likelihood of ending up in a high-level managerial position as a nurse is relatively rare. There are only three hospitals in Switzerland that are run by people with a nursing degree.
How did your new colleagues react to a nurse becoming a hospital director?
The reactions were almost all positive. Nurses have a different understanding of the system and speak differently with the people who are supposed to produce health – because they have done it themselves.
How are you received as a German?
I have lived a large part of my life in the greater Basel region. The Jura is not far from there. When I was approached by the canton of Jura in 2012, I was living not far from Belfort, just 20 minutes from the Jura border. This creates an affinity. But I hardly knew the canton. I quickly noticed that the people here are very friendly and open. You can build up a network quickly.
How did you approach the work?
I arrived on 1 January 2013, and the budget was already prepared with a loss of CHF 4.5 million predicted. We then created an action plan to overcome the loss, starting 40 projects to increase resource efficiency and flow efficiency. We were fairly successful in the end.
How did people react?
Although we defined the action plan from above, we made an effort to implement it together with our staff. For example, we had too many operation blocks, and our specialists suggested that we concentrate all operation blocks in Delémont. People knew where we are inefficient; we only have to give them permission to change it. But this also requires a cultural shift.
Where do things stand now?
We broke even in 2013. And we’ve been balancing our accounts since then – while the canton is less and less able to be involved in the hospital. We’ve tidied many things up and have done more in certain areas than other hospitals in the French-speaking part of Switzerland. We’ve since come so far in coding cases that we can now make this service available to other hospitals, such as Neuchâtel. With respect to accounting, our accountants have confirmed that we have the highest quality in the French-speaking part of Switzerland. We were the first hospital to be REKOLE-certified (the system of revising cost accounting and assessments in accordance with the requirements of the Health Insurance Act, ed).
We’ve also better positioned ourselves in the canton. We’re in a unique situation here: as a hospital, we have a “quasi monopoly” in acute care, outpatient care, and also in neuro-rehabilitation and geriatrics. We have 28 per cent of nursing home spots. We therefore cover a good deal of health care in the canton of Jura.
What comes next?
Credit Suisse is forecasting that health insurance premiums are set to double by 2030. In the canton of Jura, this would put 60 per cent of the population below the poverty level. So this raises the question of how we can shape health care in a way that we can still pay for it.
What is driving the costs?
Primarily outpatient care and the age structure. Of course, most of these costs are in the final one or two years, but they begin to rise in the years leading up to this. To prevent this, we need a healthcare system with greater efficiency. Many of today’s costs do not contribute to improving health.
How do you plan to manage the cost drivers?
If I see my role as guiding people through a healthy life, then this also means that people consume only as many healthcare services as they need. So I have to prevent doctors from prescribing services that people don’t really need.
The only way to achieve this is by making all actors take responsibility for the quality and the costs. Doctor have to be paid for keeping their patients healthy.
What could this look like?
We have to build up a network in close cooperation with doctors and change the financing system. Let’s assume that every person has a healthcare budget of CHF 5,000 per year, for instance. Then we would have CHF 360 million for the entire canton of Jura with its 72,000 inhabitants. No more. If something is left over, then it would remain in the network and everyone would have an interest in prescribing only that which brings added value. And there would also be an interest in investing in preventative care.
How would you organise this?
You first have to create a network and regulate it through a framework contract. The most important rule is that everyone only does what is actually necessary. In this network you form a quality committee as a second level, which uses actual cases to examine if the cooperation works. Thirdly, the actors should work together in a physical sense as closely as possible. So if I build a hospital, a healthcare centre should be built right next door to it. And fourthly, the network must invest in preventative care. This can also be because money is left over.
How would you finance the network?
This would be done by the insurance companies. They have no interest in having us exhaust the maximum budget. Insurance companies would therefore sell the model to their policyholders. Insured people who decide in favour of our network would then pay somewhat less than if they had a completely open choice of doctor and hospital.
Isn’t this what Swica is already doing with its healthcare centres?
Swica only does this with primary care, without a hospital. The canton of Jura now has a unique opportunity: it is manageable and has only one hospital
What do you need to build this network?
I would need an experienced partner. And it already exists: Réseau DELTA is a network in the greater Geneva area that is active in primary care. It is very interested in trying something like this with a hospital. We are also talking with Medbase and University Hospital Basel as potential partners. In the end it also needs the canton because the financing model will be changed. But I don’t see a problem there.
Because it will be the same amount just under a new name for the canton?
Precisely. The 55 per cent, which it assumes for hospital accommodation, could be part of the overall budget. It could then show its citizens that healthcare costs no longer have to automatically increase. At least not for those who choose our network model.
When do you begin?
I’m already negotiating now. For the first time since it was founded, the canton is now writing its owner strategy. It has to explain if it has expectations of us as a hospital in regard to the overall costs of the healthcare system. And if yes, if we have the freedom to change the structures. The federal government, which is ultimately responsible for the financing, is open to such models. The canton of Jura could therefore take a step toward a completely different system. It could even establish itself as a region where well-off elderly people spend their last years. This could turn health care into an interesting economic factor in the Jura.
Will you stay in the canton of Jura until you retire?
Enjoying my work matters to me, and I have that here. But I’m unsure if this would also be good for the hospital. Only time will tell. In our past-paced world we need change at such positions, fresh impetus.
Kristian Schneider (45) was born in Frankfurt am Main. He was trained as a nurse in Basel and worked for close to 20 years at University Hospital Basel, the last five years as head of the emergency department. From 2007 to 2009 he completed a diploma programme at the University of Bern in Health Care Management. He has been the director of Hôpital du Jura since 2013. The Jura Cantonal Hospital was formed in 2002 through the merger of the hospitals in Delémont, Porrentruy and Saignelégier and employs 1,655 people.