WZW Criteria (Effective, Appropriate, Cost-effective)
The WZW criteria under Art. 32 KVG require that benefits of Swiss basic health insurance be effective (wirksam), appropriate (zweckmässig) and cost-effective (wirtschaftlich); effectiveness must be demonstrated by scientific methods. They are the central benefit condition of the OKP and the counterpart to the cost-effectiveness principle of § 12 SGB V in Germany.
Concept and Legal Basis
Under Art. 32 para. 1 KVG Swiss mandatory health care insurance pays for a service only if it is effective, appropriate and cost-effective. Effectiveness means that the medical benefit has been demonstrated by scientific methods; appropriateness asks whether the service is suitable and reasonable in the specific case, weighing benefits, risks and alternatives; cost-effectiveness requires a reasonable cost-benefit ratio and the choice of the cheapest among equivalent treatment options. Art. 32 para. 2 KVG requires periodic review of the criteria. Medical services are presumed to be covered; contested or new services are examined under Art. 33 KVG by the Federal Department of Home Affairs on the recommendation of the Federal Commission for Benefits and Principles and are included in Annex 1 of the KLV, excluded, or made subject to conditions.
Application in Practice
The WZW criteria operate at three levels: when services, medicines (specialities list) and devices are admitted to the catalogue; in individual cases when the insurer and its medical examiner assess the duty to pay, in particular for cost approvals of expensive or unusual treatments; and in retrospective cost-effectiveness reviews of providers under Art. 56 KVG, which allow recovery of payments in cases of over-treatment. Health technology assessments by the FOPH serve to re-evaluate existing benefits. For insured persons this means that even medically defensible treatments may remain outside basic insurance, which is a key motive for supplementary insurance.
Country Comparison
The German cost-effectiveness principle (§ 12 SGB V) states that services must be “sufficient, appropriate and economical” and must not exceed what is necessary; the Federal Joint Committee decides on the benefit and cost-effectiveness of new methods. Austria uses the equivalent formula “sufficient and appropriate, not exceeding what is necessary” in § 133 ASVG. In private and international health insurance, the contractual concept of medical necessity replaces the statutory WZW criteria.
Legal basis
- CH: Art. 32 KVG (conditions), Art. 33 KVG (designation of benefits), Art. 56 KVG (cost-effectiveness of services)
- DE: German Social Code Book V (SGB V) – § 12 Cost-effectiveness principle