An old family doctor fights against the health insurance companies

Beat Fürst* is a family doctor straight out of a picture book. For decades he cared for his patients 60 or 70 hours a week. Even when he went on vacation, he stayed close by. Always available. And suddenly he was in public as a rip-off. Beat Fürst knew then: He had to fight this battle. He had to win it. And the 74-year-old won it.

Fürst is sitting in his consulting room on the ground floor of a residential building in a town in the canton of Bern, with through traffic rushing outside. You can tell from the practice that he has been doing it for decades. There is a printout of an e-mail on the table. The son of a patient criticized Fürst because he never mentioned the “serious allegations” that had been made against him. The patient’s son complained that it was part of his understanding of transparency to disclose such facts in a personal relationship of trust. “I had to listen to things like that,” says Fürst, shaking his head.

In 2018, the family doctor made the headlines, and several media reported on his case: he had to pay back the health insurance company a whopping 561,000 francs, according to the Bern administrative court. Because in 2014 and 2015, Fürst massively “over-medicated”, i.e. billed too many medical services. For the year 2016, there was also a claim for CHF 70,000. “People aren’t stupid,” says the doctor today. “You see these amounts and think: If the prince has to pay back so much, then he must be earning huge sums. Had I given up and paid the requested amount, I would have admitted that I made mistakes. But I haven’t.”

Income of over 300,000 francs

In 2014 and 2015, Fürst achieved sales of around one million Swiss francs. Even considering his long working days, these are relatively high amounts for a general practitioner. A rule of thumb says that the net income of a doctor in practice is a quarter to a third of his turnover, so in Fürst’s case that would be a good 300,000 francs. However, Fürst did not just get stuck in the economic efficiency procedures of the health insurance companies because of the absolute numbers. But also because he devotes too much time to his patients on average.

In fact, Fürst sees every patient ten times a year. With the other general practitioners in the canton, there are just a little more than four consultations. This means that Fürst’s costs per patient are almost 50 percent higher than those of his colleagues. The Bern court therefore accused him of encouraging patients to call him due to his high availability – with correspondingly high costs.

Prince no longer understood the world. It was never about earning as much as possible, he asserts. On the contrary, he always believed that his way of working saved costs. “If a patient says he has to see a cardiologist, I tell him: ‘No, come back to me in 14 days.’ If the problem is still there, he should come back two weeks later – and then maybe that’s it again good. So I have a few more consultations, but I prevented going to the expensive specialist.”

Which makes healthcare expensive

The fact that the judges accused him of “comfort benefits” because he visited patients on their deathbed hurt the family doctor. “If I hadn’t walked by, they might have taken the patients to the hospital, which would have resulted in much higher costs.” For Fürst it is also clear what has made today’s healthcare system so expensive: the focus on profit.

“In the past, if an elderly patient fell over and then had a hole in his head, I drove up to him, sewed up the wound and asked him if he was okay again. Finished. Today they send him straight to the hospital and he’ll probably have a computer tomography done, after all, you can make a lot of money with it.” Fürst harbors the suspicion that the modern health centers employ specialists who have a special task: to see that the doctors optimize their bills in such a way that they just barely do not become conspicuous in the cost-effectiveness procedures of the health insurance companies. “I know that the controls are necessary, because there are fraudsters in our ranks too. But you get used to a little family doctor like me.”

So Fürst’s story is also the story of a profession that seems to have fallen out of time: the family doctor with a private practice who tries to solve as many medical problems as possible himself.

A big risk

The CHF 560,000 that the court set as the repayment amount was more than the health insurance companies had originally requested. And it was practically his entire income for the two years in question. By appealing the verdict, Fürst took a risk. Because in a next round the amount could have been even higher. “My lawyer and the judge told me to pay.” This is also because in the past the federal court has rarely ruled in favor of doctors who were faced with repayment claims.

But Prince was lucky. In 2018, a new contract between the Medical Association FMH and the health insurance companies came into force. Since then there has been a refined method for finding black sheep among the medical profession. It is now also taken into account how sick a doctor’s customers are. If, for example, he has an above-average number of cancer patients, this can explain the higher costs.

The reform actually came too late for Fürst, as the proceedings against him related to earlier years. However, the Federal Supreme Court ruled that Fürst was right to claim that his practice was special. He has a particularly large number of elderly and frail patients, as well as an increased proportion of foreigners who, statistically speaking, are more ill than the Swiss and whose treatment is more complex due to language barriers. The two factors justified additional work, the Lausanne judges found in April 2019 – and therefore sent the case back to the Bern arbitral tribunal.

Health insurance companies give in

For the sake of simplicity, the arbitral tribunal used the new method – and with it Fürst suddenly fell below the critical threshold of over-medical treatment. Last fall, the court therefore dismissed the lawsuit brought by the health insurance companies, and Fürst was off the hook. Because Santésuisse, the association of insurers, decided not to lodge a complaint with the Federal Supreme Court.

Santésuisse spokesman Müller makes it clear that his association still does not consider Fürst’s billing practices to be legitimate. The family doctor also calculated several flat-rate travel allowances if the patients visited had lived in the same home. In addition, the procedure of the Bern arbitral tribunal is very special. “But in individual cases it is not completely absurd,” admits Müller. Only if that had been the case would moving on be justified. “Accordingly, we respect the verdict. Otherwise, enormously high court costs would arise again and time would pass. We don’t want both.”

Noteworthy in this context is a judgment by the Federal Supreme Court from January 2022 in the case of a Geneva doctor. He had resisted having to repay the basic insurance money he had received in 2016 – and also referred to the new calculation method. However, the Federal Court confirmed the judgment of the lower court and made it clear that it would be arbitrary to apply the rules that came into effect in 2017 retrospectively. And it would violate the principle of equal treatment.

Just a 50-hour week

Santésuisse could have calculated certain chances with a continuation of the judgment against Beat Fürst. But the family doctor no longer has to worry about that. He only works part-time, in his case that’s 40 to 50 hours a week. He was looking for a successor for his practice, but – like so many other retiring general practitioners – could not find it. “It’s hopeless, the boys don’t want to do that anymore.”

So Fürst just keeps practicing. For how much longer? “Who knows? Maybe I’ll do it the Hayek way.” The watch czar from Biel died in 2010 at the age of 82 – at work.

* Name changed.