The Emerging Transformation of Primary Care in Switzerland and its Financial Implications: a Qualitative Study

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Joaquim Marti, Dr. Nadia Danon, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9042346/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Rising chronic disease burdens, workforce shortages, and the limitations of traditional physician‑centered models put pressure on primary care systems. Many countries have begun transitioning toward interprofessional, team‑based care structures with mixed or value‑based financing mechanisms. Such reforms remain limited in Switzerland, where primary care still relies heavily on small, fee‑for‑service family medicine practices with minimal recognition of preventive, coordinative, or interprofessional activities. This study examines Switzerland’s emerging innovative care models, including Medical Homes 1 (MHs) and other interprofessional structures, their roles, and implementation experiences. It identifies the financial and organizational opportunities and barriers shaping their development within Switzerland’s current healthcare financing context. Methods This examination used qualitative methodologies including purposive sampling, structured interview guides, and semi‑structured interviews with representatives from MHs, care networks, and other innovative primary care practices. Results Of 19 potential participants contacted from diverse primary care settings, 16 were interviewed. Three key themes emerged: the integration of broader interprofessional teams (including nurses, advanced practice nurses, ambulatory care pathway coordinators, and social workers) despite unstable funding; local authorities’ central roles in supporting the creation and sustainability of new models through financial support (including rent reductions, guarantees, or investments) and engaging in efforts to ensure continued access to primary care; and the need to move beyond exclusive fee-for-service financing to enable these transformations. Conclusion This study reveals that multidisciplinary teams are seen as essential to transforming primary care in Switzerland; however, unclearly defined roles and unstable financing continue to limit implementation. Locally backed initiatives involving MHs appear particularly promising when supported by municipal or regional authorities committed to maintaining access to care. Sustained progress will require moving beyond purely fee‑for‑service models. Blended payment models better support coordination, prevention, and the development of new professional roles. Further applied research must identify feasible strategies for scaling up innovative primary care models within Switzerland and across similar healthcare systems. 1 “Maison de santé” in French, with no direct English equivalent Primary care Medical homes Teamwork Multidisciplinary teamwork Fee-for-service Blended payment Switzerland. Figures Figure 1 Background Over recent decades, in theory if not always in practice, primary care (PC) has played an increasingly indispensable role within healthcare systems characterized by financial constraints and the growing prevalence of chronic conditions [ 1 , 2 ]. Despite global shortages of physicians entering into general practice [ 2 ], many European healthcare systems continue to uphold traditional models centered on general practitioners (GPs). These models no longer seem to provide appropriate responses [ 3 ], and PC systems must be transformed. This will require comprehensive measures aimed at moving from isolated, single GP medical practices to collaborative interprofessional PC structures incorporating multiple GPs. As Jabbarpour asserts, “Team-based care constitutes the cornerstone of practice transformation,” since “evidence suggests that a team-based structure is essential if our PC workforce is to meet the chronic and preventive care needs of our population” [ 4 ]. New financing approaches and governance structures seem essential to supporting this transformation [ 5 ]. Some countries have indeed moved from fee-for-service systems toward mixed, value-based remuneration models combining capitation, care pathways, and incentives [ 6 – 8 ]. Each model has its own particular advantages and drawbacks, and existing studies have tended to demonstrate the importance of adopting mixed models [ 9 – 11 ]. Like many European countries, Switzerland’s healthcare system is in crisis. Despite its reputation for quality, it is also criticized for its high costs, a hospital-centered model, a lack of data, and very low investment in prevention (1.9% of total health spending vs . an OECD average of 3.4%) [ 12 , 13 ]. Furthermore, a growing shortage of GPs [ 14 , 15 ] could lead to even more fragmented care and worse access to PC [ 16 ]. The transformation of Switzerland’s PC models is still in its early stages [ 17 ]. Most family medical practices operate as small private businesses, with one or a few independent GPs. They are remunerated almost entirely through the “TarMed” fee-for-service and time-based system (or “TARDOC” as of 2026). Family practices thus depend primarily on their clinical activities and are generally organized around a two-professional model comprising a GP and a medical assistant (MA). The existing remuneration framework largely fails to acknowledge services like preventive care, care coordination, or interprofessional collaboration [ 18 , 19 ]. Against this predominantly activity-based, physician-centered backdrop, few initiatives have sought to explore new organizational models. Often implemented as pilot projects supported by public funding or in collaboration with health insurance companies, these initiatives have tested new forms of PC delivery using broader interprofessional teams [ 20 – 22 ] or, in Geneva, the first Maisons de santé or Medical Homes (MHs) [ 15 , 23 ]. There is no single definition for an MH [ 24 , 25 ], but certain elements are essential: “An MH is an interprofessional organization providing local medical services, with the aim of offering accessible, comprehensive, continuous, coordinated, and high-quality PC. It is based on a patient-centered care philosophy that promotes collaboration between several healthcare professionals (doctors, nurses, coordinators, physiotherapists, etc.) in order to meet acute and chronic needs, while incorporating preventive and health promotion measures” [ 15 , 26 ]. To the best of our knowledge, there has been no research investigating transformations to new models of PC in Switzerland and their associated financial implications. The present study’s main objective, therefore, was to explore the development of innovative PC models in Switzerland within the country’s existing healthcare financing context and better understand the financial and organizational opportunities and barriers to their implementation. As MHs, as defined above, are still very rare in Switzerland, other new models were also studied as they could provide important elements for the development of MHs or institutions with similar objectives. Methods As a qualitative study, this work drew on the in-depth experiences and insights of employees from MHs, PC networks comprising general practices, and other innovative PC settings. It primarily used data collected through individual semi‑structured interviews. Population The study population consisted of healthcare professionals (including administrative and human resources staff). Inclusion criteria required professionals working in either an existing or planned MH setting, as defined in the study, or in a PC environment that integrated a broader range of professionals, beyond GPs, secretaries, and MAs. These additional roles included ambulatory care pathway coordinators, nurses, physiotherapists, dietitians, psychologists, and social workers. We also included people representing healthcare networks that incorporated innovations in terms of funding or PC professionals. Data collection The authors developed an interview guide based on a narrative review of the literature and field visits. It was tested on two healthcare professionals and slightly adapted. To assess sociodemographic information, we began each interview with four closed questions about sex, age, occupation, and place of work. The interview grid covered the type of institution, time spent doing coordination work, new professional roles (for those other than GPs, MAs and secretaries), sources of funding for project launches and operations (including coordination and new roles), remuneration and professional status, and the new facility’s overarching philosophy, notably by allowing participants to respond to two statements regarding remuneration in PC (see interview grid in Appendix 1). Recruitment Recruitment was carried out using convenience and purposive sampling techniques. We drew on our network of expert contacts and individuals identified in the scientific and grey literature. A list of potential institutions (PC facilities, MHs, or healthcare networks) and their respective contact persons was established. Targets were contacted by email to explain the study’s objectives and invite them to an interview. About one-third of participants were already known to the principal investigator before the study. Interviews occurred between July 2024 and July 2025 in French, English, or German, according to participants’ language preference. They were performed by the principal investigator under the supervision of the second and the last authors, both senior scientists. Qualitative interviews took place either face-to-face or online, based on each participant’s preference. They continued until data saturation was reached for MH projects in Switzerland (although saturation could not be confirmed for healthcare networks incorporating innovations in the German-speaking regions of Switzerland, due to the smaller number of facilities represented). Participants received no financial compensation for their interview. Data analysis All interviews were recorded. An administrative assistant transcribed 14 of them verbatim. Two interviews were transcribed using Corv [ 27 ], secure AI-enabled software authorized by the University of Lausanne. A human then listened to them to correct mistakes or misunderstandings. A deductive approach was used to code the first four transcribed interviews and identify relevant phrases regarding the research questions, enabling us to develop a codebook. The codebook was then used to code the remaining transcripts and was slightly adapted according to new data. The last author double-coded the first two interviews. Codes were discussed, and consensus was found regarding the differing ones. The study followed the COREQ (COnsolidated criteria for REporting Qualitative research) Checklist [ 28 ]). Results Participants Of the 19 people contacted, 16 gave interviews: 6 face-to-face and 10 online. These lasted an average of 39.3 min [range: 30.1–55.5]. Each respondent represented a different institution. Two individuals never responded, despite follow-up attempts, and one institution declined to participate due to financial difficulties at the time. Table 1 APPEAR HERE Table 1 Sample characteristics. Sex Age Profession Region Type of Project Project Status M:8 F:8 50: 8 Medical : 7 Paramedical: 4 (Nurse, Physiotherapist, Psychologist) Administrative: 5 (Human Resources Manager, Project Manager, Accountant) French-speaking: 14 German-speaking: 2 MH: 12 Care network: 4 Operational: 14 In planning: 2 Main findings Our analysis identified three main themes that reflected emerging new PC models inspired by MHs, together with funding opportunities and barriers to their implementation: 1) innovation through teamwork and integrating underrepresented professions into PC, despite uncertain funding; 2) local anchoring and local authorities’ key role in creating and developing MHs; and 3) moving away from exclusive fee-for-service remuneration to facilitate the development of MHs (see Fig. 1 ) FIGURE 1 APPEAR HERE 1. Innovation through teamwork and integrating underrepresented professions into PC, despite uncertain funding 1.1 Medical Homes: “teams working in collaboration to improve patient care” (PARAMED2) Participants highlighted how interdisciplinary work was crucial to innovative PC projects, especially for complex patient needs: “An MH is like a medical center, but one where we take care of patients with complex needs and improve care coordination and interprofessional communication” (PARAMED2). Some saw integration as a way to manage home care: “Each doctor has two community nurses and two dedicated nursing assistants, so we are established teams” (GP2). Team composition varied: “We integrate all the necessary health and social professionals to ensure proper patient care and follow-up” (PARAMED2). Conversely, others argued that their MH was not a “true MH” due to its limited diversity: “The [mix of professions] is perhaps not quite sufficient in my view. It is more like a medical practice than an MH” (GP4). Due to financial uncertainty, multidisciplinary efforts could also regress: “The somewhat holistic approach in our MH deflated like a balloon […] we now have a nurse specialized in diabetic care one day a week, who works as an independent nurse. But for other professionals, it is difficult, due to cost coverage issues” (ADMIN2). 1.2 Inclusion of social workers is not yet implemented Participants stressed the importance of incorporating professional social workers into MHs, though such roles were mostly absent: “The question is, should there even be a social element? The answer is probably yes” (ADMIN3); “It would be very useful to have a social worker alongside me” (PARAMED1). Some projects aimed to include social and community aspects: “Not only medical care but also social care” (PARAMED4) and create spaces “for coming together and creating connections” (GP1). However, some already integrated a measure of coordination: “We also work hand in hand with the municipality’s social worker” (GP2) or briefly had local authority support: “The local authority paid part of the costs [of a social worker’s salary] for three years. But now it no longer wants to” (GP7). 1.3 Different types of nurses taking on emerging PC roles Participants described different nursing roles in PC, including advanced practice nurses (APNs), family practice nurses, home care nurses, and new functions, like ambulatory care pathway coordinators. APNs’ roles varied and remained unclear: “They are much more highly trained in diagnostics and the management of common outpatient conditions. It is not yet clear whether they will coach the team [to work in patients’] homes or have their own patients” (GP2). Coordination with physicians was debated: “The APN must specify their competencies and knowledge […] and the GP must clarify what they are willing to delegate” (GP3). APNs were also introduced amid physician shortages: “He could not find a physician to take over his PC practice but needed help with patient care […] The nurse practitioner assisted during this transition and remained in the practice with the new doctor” (GP3). Funding for APNs was mentioned as relying on the existing physician billing system: “She can always refer to the GP she works with and use that physician’s GLN number 2 for reimbursement.” However, that participant saw such action as a “legal grey area” (GP3): “Proceeding like this is not officially prohibited, but it is not encouraged either” (GP3). These funding uncertainties were sometimes described as problematic: “The main problem is APNs’ salaries […]; there is no recognized funding yet” (GP4). Initiatives to introduce family practice nurses into family medicine practices were presented as efforts to strengthen specific aspects of PC’s mission: “There is a limited cantonal project to improve the continuity of care, prevention, health promotion, and chronic disease management” (PARAMED1). However, those initiatives faced instability: “Employment stability was limited, as contracts were annual […], project directors had to negotiate next year’s budget with the canton each time” (PARAMED1). Participants also described other possibilities involving nurses in projects initiated by insurers or cantons, including them becoming ambulatory care pathway coordinators or health managers: “We call them care coordinators rather than nurses, because an ambulatory care pathway coordinator can also perform this role” (ADMIN4), adding value for complex patients: “Particularly for more complex patients; we [type of professional] provide added value by bridging the gap between the family doctor and home care” (ADMIN4). 1.4 Medical assistants evolving into ambulatory care pathway coordinators Participants noted how expanded training had helped MAs’ roles evolve: “Medical assistants wanted to progress in their profession, not just complete an apprenticeship” (GP7). Implementation varied, with differences between regions: “This support already exists to a large extent in German-speaking Switzerland but is much less common in French-speaking Switzerland” (ADMIN3). Participants mentioned an advantage over other roles: “Doctors in private practice are used to working with medical assistants, who are the professionals they work most closely with” (ADMIN3). For some, the role was still unclear: “Collaboration with the ambulatory care pathway coordinator is being established […] we need to identify what tasks she can or cannot do” (GP6). This was partly due to funding uncertainties: “It’s still being developed, because we didn’t have any certainty about financing, or rather billing [...] We’re starting to understand that things will be a bit simpler with TARDOC” (GP2). Others described this role as crucial to proper coordination, but only one canton was providing essential financial support for it: “For everything related to the coordinator, the salary actually comes from the budget of CHF 1,300 per complex patient (received from the canton). It's the biggest part of the budget, in fact. Because they play a very important role and are there to make sure that coordination works” (PARAMED2). Other participants either had no ambulatory care pathway coordinator at their workplace or the project was awaiting funding: “We have applied to the Confederation for funding to launch an ambulatory care pathway coordinator project” (ADMIN3). 2. Local anchoring and local authorities’ key role in creating and developing MHs Two main reasons were given for why local anchoring was key to the development of innovative models like MHs. 2.1 Partnerships with local authorities Participants emphasized local authorities’ key role in the creation of MHs, mainly through negotiations and financial support. The argument for maintaining healthcare services in a village was central: “He contacted the local authorities, and they supported us […] It was important for them to guarantee access to PC in the village” (ADMIN2). “At the beginning, I tried to involve the canton and the local authorities. The local authorities were naturally interested: two doctors nearing retirement were about to cease their activities, which would have meant the end of basic care in the village” (GP7). The choice of the name MH also reflected this goal: “We called it an MH [ Maison de Santé ] because it matched the senior general practitioner’s wish to ensure the continuity of PC in the village” (ADMIN2). Financial support included the local authority becoming a shareholder: “The shareholders are the future professionals of the center […] over two years, we will increase this capital and ask the local authority to invest” (ADMIN5). There were also rent reductions: “They granted us the first two months rent free and then a slightly reduced rent over the first five years” (ADMIN2); bank guarantees: “We took a loan from a local bank, which the local authority guaranteed” (ADMIN2); or property assistance: “They supported us because we converted a residential unit into a commercial space, establishing a practice in an apartment” (GP2). Some projects moved forward without waiting for extra funding: “We’re not going to wait until we find financing; we’re going ahead because we have ideas and motivation” (GP6). 2.2 Local anchoring as a foundational dimension of MH models Local anchoring was seen as central to the vision of an MH: “This community MH is part of the town” (PARAMED3). It reflected a commitment to meeting local needs: “It is a place that brings together different healthcare professionals from different professions, who work together for individuals’ well-being and health. And the local area, in fact” (GP6). A common space was seen as important: “Co-location is important [...] it can create a local network to meet the population’s needs” (GP1). However, it was not mandatory: “The MH can use something that already exists within a defined area, rather than recreating everything under the same roof" (GP6). MHs were also associated with proximity and accessibility: “The aspect of proximity is also important [...] we have left the hospital [for the MH] to get closer to the population” (ADMIN4). “I travel by bicycle, so it has to be within cycling distance. [It is also important] because we also provide home care and palliative care” (GP2). 3. Moving away from exclusive fee-for-service remuneration to facilitate the development of MHs Participants emphasized that the central missions envisioned for MHs—community care, prevention, and health promotion—appeared inadequately supported by the current fee-for-service remuneration system, which was identified as a major barrier to their development: “The MH, as we envision it, is a community care setting, partly focused on prevention, group care, therapeutic education, and other aspects of care inadequately covered by the current healthcare funding system” (PARAMED4). 3.1 Challenging the exclusively fee-for-service model Interviewees challenged Switzerland’s current billing system: “I am convinced that Switzerland needs a new model—a more human model that integrates the patient, not a healthcare system built around pricing” (GP7). Fee-for-service was also described as introducing bad incentives and being wasteful: “Fee-for-service encourages consumption [...] the more you do, the happier everyone is [...] And to get out of that, you need capitation. In my opinion, capitation means asking ourselves how much we need to treat patients in Switzerland today. And, in my opinion, we would need to do a little less than half of what we are doing today [...] while doing just as well and wasting less” (GP2). Proposed alternatives included integrated cost packages: “What we need is to keep the pricing but also integrate cost packages [...] it would be possible to create one” (GP7); and mixed funding: “Ideally, for it to work well, it needs to have some public funding, a mixed insurance system” (GP1). Some cantons already provide annual payments for complex patients: “The public health authority will give us [amount] francs per complex patient per year” (GP1), used to cover non-billable services like coordination. “The money is used to finance all medical services that cannot be billed through the existing billing systems, typically hours spent coordinating [...] or, for example, as a physiotherapist or ambulatory care pathway coordinator, we have no way of billing for any work done [when the patient is not physically present]”(PARAMED2). 3.2 Concerns about flat fees and changes to remuneration methods Participants expressed caution about package payments or capitation, mainly due to new financial expenditure responsibilities: “My first concern is financial responsibility, which is currently borne by insurance [...] And I’m not sure it’s fair that it should be doctors” (ADMIN3). Concerns also included team-based fees: “If it helps to limit deliberate overbilling, okay [...] But if it’s done to limit what healthcare professionals can charge for, then no; I have a problem with that” (PARAMED2). Finally, while teamwork was valued, it was not seen as a potential substitute for doctors: “A doctor may be very well supported by a team [...] But no, teams of people are not going to replace doctors” (ADMIN4). 3.3 “Saint George and the Dragon” Trying to change the funding model to enable the development of MHs was mentioned as a protracted struggle: “We continue to fight because we are convinced that fee-for-service is not the right solution at all [...] the incentive biases are enormous and do not encourage prevention” (ADMIN4). This struggle over funding for MHs was perceived as challenging and complex: “I am glad that someone is finally daring to take on this monster, like Saint George and the dragon!” (GP7). Discussion Synthesis Our findings provide new insights into the opportunities and barriers to implementing new PC models, like the MHs in Switzerland, where fee-for-service remuneration to GPs dominates, undervaluing prevention and coordination activities. Three main themes emerged: the need for teamwork for complex patients, the importance of local roots and support, and the need to change remuneration methods and visions of PC. Participants advocated mixed remuneration models, cost packages, or capitation, though concerns remained about being financially responsible and limits on billing. Structural reforms and sustained negotiations were seen as essential for progress. Interpretation Our findings clearly aligned with three, perhaps even four, key components of Bodenheimer’s Chronic Care Model [ 30 ]. Firstly, the Delivery System Design component, which promotes the creation of multidisciplinary teams with clearly defined roles and emphasizes the need for coordinated care for chronic and complex conditions, resonates strongly with the commitment to teamwork reported in our results. Secondly, the intention to integrate social and community elements and the strong local anchoring envisioned for MHs closely aligns with the Community Resources and Policies component. Thirdly, we could mention the model’s Clinical Information Systems component, as participants also addressed issues related to whether information technology systems were adequately adapted to coordination work. Finally, the most significant connection between the Chronic Care Model and our findings seems to be its Health Care Organization component, which emphasizes the reimbursement environment’s impact on sustaining improvements in chronic care: “If purchasers and insurers fail to reward chronic care’s quality, improvements are difficult to sustain”[ 31 ]. This reflects the slow development of MHs in Switzerland and participants’ interests in moving beyond an exclusively fee-for-service model in PC. This observation varied from region to region because there can be significant differences in health policy (and thus the implementation of new health models) between Switzerland’s cantons, despite their being bound by national federal laws. A 2016 Swiss Health Observatory report [ 18 ] proposed adapting the remuneration model, including introducing a capitation component to encourage a more population-based perspective to medical practice and increase the time dedicated to prevention and health promotion. Our findings indicated that this perspective was keenly advocated by the professionals actively engaged in transforming PC. Indeed, shifting from a fee-for-service model to a hybrid one (part fee-for-service, part capitated) is one of the American National Academies of Sciences’ main recommendations for PC [ 32 ] because “there is probably no single ideal method for remunerating healthcare professionals” [ 33 ]. The potential for a shift to a capitation model was also widely debated in France. However, for many reasons, including fee-for-service’s defense by the main independent physicians’ associations, an alternative emerged: a continuation of the fee-for-service model for physicians accompanied by nurses employed by public authorities (the Asalée experience). Indeed, this solution was also adopted in Quebec, with its Family Medicine Groups [ 34 ]. Following our findings, this approach could also represent an interesting option for Switzerland. Capitation has been criticized for difficulties regarding risk adjustment, for historically low payment levels based on fee‑for‑service formulas, and for its inherent risk of underutilization [ 35 ]. Blended payment models, however, could reduce the respective shortcomings of fee‑for‑service and capitation [ 35 , 36 ]. Thus, there is indeed a response to the Swiss Medical Journal’s 2010 question [ 37 ] of whether the Chronic Care Model can be transferred to Switzerland’s healthcare system. The emergence of new professional roles in PC (e.g., APNs, family medicine nurses) could enable the gradual integration of some of the model’s key elements, with the limits of unsecured funding. That funding usually encourages local health authorities to retain only one of those professional roles in their teams—usually the least expensive—although there is a place for them all in PC, and roles should always be adapted to the local context. Our findings showed, however, that at the broader level, particularly at the Health Care Organization level that encompasses public policies and reimbursement strategies that prioritize chronic care, things have evolved very slowly in Switzerland [ 38 ]. There have been some notable exceptions, with a few cantonal projects supported financially by local authorities or some innovative models created in collaboration between healthcare networks and health insurers—collaborations that already exist elsewhere in Europe. For example, one of the earliest alternative payment models for care by GPs began in 2014 through a partnership between the Dutch insurer Menzis and the PC organization Arts en Zorg (AEZ). Under this agreement, those two parties shared the savings in total healthcare costs resulting from a blended payment model for Arts en Zorg ’s patients, including specialist and hospital care, thus encouraging GPs to take responsibility for the broader impacts of their decisions. One evaluation showed a 2% reduction in costs with no fall in quality [ 39 ]. This could also be a new payment method for Switzerland, but it also raises concerns—notably around population-level coverage—because patients in Switzerland must choose from among 39 different health insurers [ 40 ]. Recommendations Our findings highlight the need for policies addressing the Health Care Organization component of Bodenheimer’s model, particularly the reimbursement environment. Although there is strong interest in multidisciplinary collaboration, the absence of stable funding for emerging roles—such as primary care nurses and social workers—and the insufficient financial support for chronic care activities (e.g., care coordination) within redesigned PC teams remain major barriers to developing MHs in Switzerland. A radical overhaul of the financing system appears unlikely in the short term; nevertheless, establishing sustainable funding mechanisms to replace the exclusively fee-for-service model seems essential. Finally, even within current financing frameworks, close collaboration and support from local authorities can enable innovations as they share the objective of maintaining access to quality care within their communities. Valuable lessons can be drawn from the few Swiss initiatives supported by cantonal and/or local authorities and from international experiences like France’s Azalée project. Limitations Because our interviewees were drawn predominantly from Switzerland’s French-speaking regions, their perspectives may not reflect the complete diversity of experiences in German and Italian-speaking regions. Other aspects could have been explored in more detail, such as how time spent coordinating care is used in different projects, how it is financed, and what types of information technology are used and financed. The few models explored in German-speaking regions largely found similar findings, nevertheless. Finally, given our inclusion criteria, this work did not represent physicians in private practice and healthcare professionals who were not interested in (or opposed to) PC’s transformation. Conclusion Our findings indicate that multidisciplinary collaboration is widely regarded as a key strategy for transforming primary care (PC). However, uncertainties persist surrounding how this will be financed, and the delineation of new professional roles remains a significant barrier to implementing new ideas in Switzerland. In this context, the local introduction of Maisons de santé —Medical Homes—facilitated through negotiated agreements with local and regional authorities that wish to prioritize the maintenance of access to PC, particularly in rural areas (and to a lesser extent in urban settings), appears to be a critical means of advancing such initiatives. There are also some opportunities to ensure this using innovative models created in collaboration between healthcare networks and health insurers. However, our analysis underscored that robust support for chronic care management and the facilitation of innovative PC initiatives, such as Medical Homes, will require a reform of cost-reimbursement rules. The findings indicated an urgent need to shift away from Switzerland’s exclusive reliance on fee-for-service models while remaining attentive to healthcare professionals’ concerns about changes to their remuneration. Further research should examine how such reforms would be perceived across Switzerland’s healthcare workforce. Additionally, action-oriented studies on innovative PC models could help to refine implementation strategies and support their broader dissemination across Switzerland and in similarly financed healthcare systems where the development of new PC models remains challenging or has stalled. Abbreviations PC Primary Care GP General Practitioner MA Medical Assistant MH Medical Home APN Advanced Practice Nurse AEZ Arts En Zorg Declarations Ethics considerations The Human Research Ethics Committee of the Canton of Vaud authorized this research project as it did not fall within the scope of Switzerland’s Human Research Act. All our procedures followed the Declaration of Helsinki’s ethics guidelines. All the interviewees gave written informed consent. Consent for publication Not applicable Potential competing interests All the authors have completed and submitted the International Committee of Medical Journal Editors form for the disclosure of potential conflicts of interest. No potential conflict of interest was disclosed. Funding This work was carried out as part of the main author’s medical studies at Unisanté, with 30% of the funding over 18 months coming from a start-up grant from the CRMF (Collège Romand de Médecine de Famille). Authors’ contributions Interviews were carried out by the principal investigator under the supervision of the second and the last authors. The principal investigator wrote the initial draft, and all the authors provided scientific input, read, revised and approved the final version for publication. Acknowledgements The author gratefully acknowledges the academic support provided by Unisanté and the financial support provided by a start-up grant from the Collège Romand de Médecine de Famille (CRMF). The author also extends heartfelt thanks to his wife and three children for their patience and understanding during the many additional hours devoted to this work. References WHO. WHO. The world health report 2008: primary health care now more than ever. 2008. McInnes S, Peters K, Bonney A, Halcomb E. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. J Adv Nurs. 2015;71:1973–85. https://doi.org/10.1111/jan.12647 . De Maeseneer J, Kendall S. Primary health care 40 years after Alma Ata 1978: addressing new challenges in a changing society. Eur J Public Health. 2018;28:983. https://doi.org/10.1093/eurpub/cky217 . Jabbarpour Y, Jetty A, Dai M, Magill M, Bazemore A. 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OECD. 2025. https://www.oecd.org/en/publications/how-do-health-system-features-influence-health-system-performance_7b877762-en.html . Accessed 23 May 2025. Balthasar A, Oetterli M, Romanova A, Käppeli P, Mantwill S, Health. 2040, soins ambulatoires de base durables en Suisse. Projet de recherche/Plan d’action. Université de Lucerne et Interface Politikstudien Forschung Beratung AG; 2024. Sommer J, Haller-Hester D, Cohidon C, Senn N. Demain, une maison de santé ? Rev Med Suisse. 2023;826:883–883. Bischof T, Kaiser B. Who cares when you close down? The effects of primary care practice closures on patients. Health Econ. 2021;30:2004–25. https://doi.org/10.1002/hec.4287 . Cohidon C, Senn N. Nouveaux modèles de soins en médecine de famille. Rev Med Suisse. 2023;826:885–8. Senn N, Ebert ST, Cohidon C, Revue OBSAN. La médecine de famille en Suisse. 2016. OCDE. Panorama de la santé 2025 : Suisse. 2025. https://www.oecd.org/fr/publications/panorama-de-la-sante-2025_3e997212-fr/suisse_534b9779-fr.html . Accessed 4 Dec 2025. Schütz Leuthold M, El-Hakmaoui F, Senn N, Cohidon C. General Practitioner’s Experience of Public-Private Partnerships to Develop Team-Based Care: A Qualitative Study. Int J Public Health. 2023;68:1606453. https://doi.org/10.3389/ijph.2023.1606453 . Mussard L, Chappot M, El Hakmaoui F, Martin S. Expérience d’un médecin assistant dans un cabinet de médecine de famille interprofessionnel. Rev Med Suisse. 2023;826:911–4. Lauber E, Kindlimann A, Nicca D, Altermatt-von Arb R, Sgier C, Staudacher S, et al. Integration of an advanced practice nurse into a primary care practice: a qualitative analysis of experiences with changes in general practitioner professional roles in a Swiss multiprofessional primary care practice. Swiss Med Wkly. 2022;152:w30199. https://doi.org/10.4414/smw.2022.w30199 . Perone N, Gillabert C, Van Leemput M-C, Meynard A, Vilao B, Junod-Perron N, et al. Projet pilote de maison de santé à Genève. Rev Med Suisse. 2023;826:906–10. Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, et al. The patient centered medical home. A systematic review. Ann Intern Med. 2013;158:169–78. https://doi.org/10.7326/0003-4819-158-3-201302050-00579 . Fournier C, Morize N, Moyal A. Multidisciplinary Primary Care Groups (Maisons de Santé Pluriprofessionnelles, MSPs) and the Long Path to Team Practice. Handbook of Integrated Care. Cham: Springer; 2024. pp. 1–21. https://doi.org/10.1007/978-3-031-25376-8_111-1 . Senn N, Bourgueil Y, Breton M, Cohidon C. al. Imaginer les soins primaires de demain, un livre basé sur les preuves scientifiques actuelles | Unisanté. RMS. 2025. Corv. le nouvel outil de transcription audio et vidéo pour les données de recherche - News du Ci. https://wp.unil.ch/newsci/ . https://wp.unil.ch/newsci/corv-le-nouvel-outil-de-transcription-audio-et-video-pour-les-donnees-de-recherche/. Accessed 21 Nov 2025. Consolidated criteria for reporting qualitative research (COREQ). a 32-item checklist for interviews and focus groups | EQUATOR Network. https://www.equator-network.org/reporting-guidelines/coreq/ . Accessed 27 July 2025. Registre des professions médicales - MedReg. https://www.bag.admin.ch/fr/registre-des-professions-medicales-medreg . Accessed 7 Feb 2026. Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12:166–71. https://doi.org/10.1370/afm.1616 . Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775–9. https://doi.org/10.1001/jama.288.14.1775 . Phillips RL Jr, McCauley LA, Koller CF. Implementing High-Quality Primary Care: A Report From the National Academies of Sciences, Engineering, and Medicine. JAMA. 2021;325:2437–8. https://doi.org/10.1001/jama.2021.7430 . Kidd M, President of WONCA (World Organization of Family Doctors). The Contribution of Family Medicine to Improving Health Systems: A Guidebook from the World Organization of Family Doctors. Wonca. London: Radclife publishing; 2013. Bras P-L. Paiement à l’acte/capitation : une réforme ébauchée mais avortée. Trib Santé. 2017;57:71–89. https://doi.org/10.3917/seve.057.0071 . Berenson RA, Rich EC. US approaches to physician payment: the deconstruction of primary care. J Gen Intern Med. 2010;25:613–8. https://doi.org/10.1007/s11606-010-1295-z . Tan S, Farmer J, Roerig M, Allin S. Primary Care Governance and Financing: Models and approaches. Steurer-Stey C, Frei A, Rosemann T. Le « Chronic care model » en médecine de famille en Suisse. Rev Med Suisse. 2010;249:1016–9. Peytremann-Bridevaux I, Ebert ST, Senn N. Involvement of family physicians in structured programs for chronic diseases or multi-morbidity in Switzerland. Eur J Intern Med. 2015;26:150–1. https://doi.org/10.1016/j.ejim.2015.01.007 . Lindner L, Hayen A. Value-based payment models in primary care: An assessment of the Menzis Shared Savings programme in the Netherlands. OECD Health Working Papers. 2023. https://doi.org/10.1787/0810f2ba-en Checkall. Liste des assurances maladie en Suisse 2024. https://www.checkall.ch/fr/caisse-maladie/liste-assurances-maladie-suisse . Accessed 14 Dec 2025. Footnotes 2. Doctors registered in the official Swiss medical register ( MedReg ) are assigned a GLN , which serves as their public identification number [ 29 ]. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor invited by journal 16 Mar, 2026 Editor assigned by journal 12 Mar, 2026 Submission checks completed at journal 12 Mar, 2026 First submitted to journal 05 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9042346","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631258703,"identity":"12cb07e1-29c7-4cec-9032-689fbeeb3ab8","order_by":0,"name":"Luc Mussard","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBACPiS24QMGBgkY5wBOLWxIbGMDiBZm4rWYQa0gpEUi+QHTzbY6e/7Zh7dV8+6wADL6Dz5gqLmDR0uaAXNu2+HEGefSym7znpFInHHnMLMBw7FneLTkMAC1HEhgOMNjdpu3TSKB4UYymwRjw2FCWurs5YFaioFa7OVvJLP/IEILM+MGoBZmoBbGDUBbGPBq4XlmcDjn3OHEjWfYiiXntkkkbryRbCyRcAy3Fn725IePc8rq7OXOMG/88BboQrkbiQ8/fKjBrQUEDmAKJeDVMApGwSgYBaOAEAAAaZVOEVxCFgMAAAAASUVORK5CYII=","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Luc","middleName":"","lastName":"Mussard","suffix":""},{"id":631258705,"identity":"58ba73d4-50f6-457a-95b9-714aee4b5f72","order_by":1,"name":"PD Dr. Christine Cohidon","email":"","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":false,"prefix":"","firstName":"PD","middleName":"Dr. Christine","lastName":"Cohidon","suffix":""},{"id":631258709,"identity":"9ea66f28-cc0c-4b72-a95c-333d83b02808","order_by":2,"name":"Pr. Joaquim Marti","email":"","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Pr.","middleName":"Joaquim","lastName":"Marti","suffix":""},{"id":631258711,"identity":"cb1a827f-552e-45d4-b07b-0219a9994e0d","order_by":3,"name":"Dr. Nadia Danon","email":"","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":false,"prefix":"Dr.","firstName":"Nadia","middleName":"","lastName":"Danon","suffix":""},{"id":631258716,"identity":"38a50b7c-0e22-4692-a600-7680c86c3b03","order_by":4,"name":"Prof. Nicolas Senn","email":"","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Prof.","middleName":"Nicolas","lastName":"Senn","suffix":""},{"id":631258718,"identity":"a118d30f-842e-4cd1-bff1-a31129c1734d","order_by":5,"name":"PD Dr. Christina Akre","email":"","orcid":"","institution":"Centre universitaire de médecine générale et santé publique, Lausanne","correspondingAuthor":false,"prefix":"","firstName":"PD","middleName":"Dr. Christina","lastName":"Akre","suffix":""}],"badges":[],"createdAt":"2026-03-05 16:10:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9042346/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9042346/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108385048,"identity":"71601943-0c52-428b-8ce2-a97719433c32","added_by":"auto","created_at":"2026-05-04 06:00:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53986,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMain Themes and subthemes\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9042346/v1/fd92ef0ba3409e1ef5acba6a.png"},{"id":108494670,"identity":"6bb006eb-b6f1-4b50-8bfc-fad7c6f3e120","added_by":"auto","created_at":"2026-05-05 10:06:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":312423,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9042346/v1/4987c4c5-d485-4f07-a677-04a1358206c6.pdf"},{"id":108492909,"identity":"5c7d3222-fa2c-428d-aecd-66a100b08bf2","added_by":"auto","created_at":"2026-05-05 09:58:57","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":90796,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9042346/v1/6f2ff01b1087186ca8b99ac1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Emerging Transformation of Primary Care in Switzerland and its Financial Implications: a Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eOver recent decades, in theory if not always in practice, primary care (PC) has played an increasingly indispensable role within healthcare systems characterized by financial constraints and the growing prevalence of chronic conditions [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite global shortages of physicians entering into general practice [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e], many European healthcare systems continue to uphold traditional models centered on general practitioners (GPs). These models no longer seem to provide appropriate responses [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e], and PC systems must be transformed. This will require comprehensive measures aimed at moving from isolated, single GP medical practices to collaborative interprofessional PC structures incorporating multiple GPs. As Jabbarpour asserts, “Team-based care constitutes the cornerstone of practice transformation,” since “evidence suggests that a team-based structure is essential if our PC workforce is to meet the chronic and preventive care needs of our population” [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. New financing approaches and governance structures seem essential to supporting this transformation [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Some countries have indeed moved from fee-for-service systems toward mixed, value-based remuneration models combining capitation, care pathways, and incentives [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Each model has its own particular advantages and drawbacks, and existing studies have tended to demonstrate the importance of adopting mixed models [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLike many European countries, Switzerland’s healthcare system is in crisis. Despite its reputation for quality, it is also criticized for its high costs, a hospital-centered model, a lack of data, and very low investment in prevention (1.9% of total health spending \u003cem\u003evs\u003c/em\u003e. an OECD average of 3.4%) [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, a growing shortage of GPs [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e] could lead to even more fragmented care and worse access to PC [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. The transformation of Switzerland’s PC models is still in its early stages [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Most family medical practices operate as small private businesses, with one or a few independent GPs. They are remunerated almost entirely through the “TarMed” fee-for-service and time-based system (or “TARDOC” as of 2026). Family practices thus depend primarily on their clinical activities and are generally organized around a two-professional model comprising a GP and a medical assistant (MA). The existing remuneration framework largely fails to acknowledge services like preventive care, care coordination, or interprofessional collaboration [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAgainst this predominantly activity-based, physician-centered backdrop, few initiatives have sought to explore new organizational models. Often implemented as pilot projects supported by public funding or in collaboration with health insurance companies, these initiatives have tested new forms of PC delivery using broader interprofessional teams [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] or, in Geneva, the first \u003cem\u003eMaisons de santé\u003c/em\u003e or Medical Homes (MHs) [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is no single definition for an MH [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e], but certain elements are essential: “An MH is an interprofessional organization providing local medical services, with the aim of offering accessible, comprehensive, continuous, coordinated, and high-quality PC. It is based on a patient-centered care philosophy that promotes collaboration between several healthcare professionals (doctors, nurses, coordinators, physiotherapists, etc.) in order to meet acute and chronic needs, while incorporating preventive and health promotion measures” [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, there has been no research investigating transformations to new models of PC in Switzerland and their associated financial implications. The present study’s main objective, therefore, was to explore the development of innovative PC models in Switzerland within the country’s existing healthcare financing context and better understand the financial and organizational opportunities and barriers to their implementation. As MHs, as defined above, are still very rare in Switzerland, other new models were also studied as they could provide important elements for the development of MHs or institutions with similar objectives.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eAs a qualitative study, this work drew on the in-depth experiences and insights of employees from MHs, PC networks comprising general practices, and other innovative PC settings. It primarily used data collected through individual semi‑structured interviews.\u003c/p\u003e\u003cp\u003ePopulation\u003c/p\u003e\u003cp\u003eThe study population consisted of healthcare professionals (including administrative and human resources staff). Inclusion criteria required professionals working in either an existing or planned MH setting, as defined in the study, or in a PC environment that integrated a broader range of professionals, beyond GPs, secretaries, and MAs. These additional roles included ambulatory care pathway coordinators, nurses, physiotherapists, dietitians, psychologists, and social workers. We also included people representing healthcare networks that incorporated innovations in terms of funding or PC professionals.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eThe authors developed an interview guide based on a narrative review of the literature and field visits. It was tested on two healthcare professionals and slightly adapted. To assess sociodemographic information, we began each interview with four closed questions about sex, age, occupation, and place of work. The interview grid covered the type of institution, time spent doing coordination work, new professional roles (for those other than GPs, MAs and secretaries), sources of funding for project launches and operations (including coordination and new roles), remuneration and professional status, and the new facility’s overarching philosophy, notably by allowing participants to respond to two statements regarding remuneration in PC (see interview grid in Appendix 1).\u003c/p\u003e\u003cp\u003eRecruitment\u003c/p\u003e\u003cp\u003eRecruitment was carried out using convenience and purposive sampling techniques. We drew on our network of expert contacts and individuals identified in the scientific and grey literature. A list of potential institutions (PC facilities, MHs, or healthcare networks) and their respective contact persons was established. Targets were contacted by email to explain the study’s objectives and invite them to an interview. About one-third of participants were already known to the principal investigator before the study.\u003c/p\u003e\u003cp\u003eInterviews occurred between July 2024 and July 2025 in French, English, or German, according to participants’ language preference. They were performed by the principal investigator under the supervision of the second and the last authors, both senior scientists. Qualitative interviews took place either face-to-face or online, based on each participant’s preference. They continued until data saturation was reached for MH projects in Switzerland (although saturation could not be confirmed for healthcare networks incorporating innovations in the German-speaking regions of Switzerland, due to the smaller number of facilities represented). Participants received no financial compensation for their interview.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eAll interviews were recorded. An administrative assistant transcribed 14 of them verbatim. Two interviews were transcribed using Corv [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], secure AI-enabled software authorized by the University of Lausanne. A human then listened to them to correct mistakes or misunderstandings.\u003c/p\u003e\u003cp\u003eA deductive approach was used to code the first four transcribed interviews and identify relevant phrases regarding the research questions, enabling us to develop a codebook. The codebook was then used to code the remaining transcripts and was slightly adapted according to new data. The last author double-coded the first two interviews. Codes were discussed, and consensus was found regarding the differing ones.\u003c/p\u003e\u003cp\u003eThe study followed the COREQ (COnsolidated criteria for REporting Qualitative research) Checklist [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eOf the 19 people contacted, 16 gave interviews: 6 face-to-face and 10 online. These lasted an average of 39.3 min [range: 30.1\u0026ndash;55.5]. Each respondent represented a different institution. Two individuals never responded, despite follow-up attempts, and one institution declined to participate due to financial difficulties at the time.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e APPEAR HERE\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eType of Project\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProject Status\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM:8\u003c/p\u003e \u003cp\u003eF:8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026nbsp;30: 0\u003c/p\u003e \u003cp\u003e30\u0026ndash;50: 8\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026nbsp;50: 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMedical : 7\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eParamedical: 4\u003c/b\u003e (Nurse, Physiotherapist, Psychologist)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAdministrative: 5\u003c/b\u003e (Human Resources Manager, Project Manager, Accountant)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrench-speaking: 14\u003c/p\u003e \u003cp\u003eGerman-speaking: 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMH: 12\u003c/p\u003e \u003cp\u003eCare network: 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOperational: 14\u003c/p\u003e \u003cp\u003eIn planning: 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMain findings\u003c/p\u003e \u003cp\u003e Our analysis identified three main themes that reflected emerging new PC models inspired by MHs, together with funding opportunities and barriers to their implementation: 1) innovation through teamwork and integrating underrepresented professions into PC, despite uncertain funding; 2) local anchoring and local authorities\u0026rsquo; key role in creating and developing MHs; and 3) moving away from exclusive fee-for-service remuneration to facilitate the development of MHs (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e APPEAR HERE\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e1. Innovation through teamwork and integrating underrepresented professions into PC, despite uncertain funding\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Medical Homes: \u0026ldquo;teams working in collaboration to improve patient care\u0026rdquo; (PARAMED2)\u003c/h2\u003e \u003cp\u003eParticipants highlighted how interdisciplinary work was crucial to innovative PC projects, especially for complex patient needs: \u0026ldquo;An MH is like a medical center, but one where we take care of patients with complex needs and improve care coordination and interprofessional communication\u0026rdquo; (PARAMED2). Some saw integration as a way to manage home care: \u0026ldquo;Each doctor has two community nurses and two dedicated nursing assistants, so we are established teams\u0026rdquo; (GP2). Team composition varied: \u0026ldquo;We integrate all the necessary health and social professionals to ensure proper patient care and follow-up\u0026rdquo; (PARAMED2). Conversely, others argued that their MH was not a \u0026ldquo;true MH\u0026rdquo; due to its limited diversity: \u0026ldquo;The [mix of professions] is perhaps not quite sufficient in my view. It is more like a medical practice than an MH\u0026rdquo; (GP4). Due to financial uncertainty, multidisciplinary efforts could also regress: \u0026ldquo;The somewhat holistic approach in our MH deflated like a balloon [\u0026hellip;] we now have a nurse specialized in diabetic care one day a week, who works as an independent nurse. But for other professionals, it is difficult, due to cost coverage issues\u0026rdquo; (ADMIN2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Inclusion of social workers is not yet implemented\u003c/h2\u003e \u003cp\u003e Participants stressed the importance of incorporating professional social workers into MHs, though such roles were mostly absent: \u0026ldquo;The question is, should there even be a social element? The answer is probably yes\u0026rdquo; (ADMIN3); \u0026ldquo;It would be very useful to have a social worker alongside me\u0026rdquo; (PARAMED1). Some projects aimed to include social and community aspects: \u0026ldquo;Not only medical care but also social care\u0026rdquo; (PARAMED4) and create spaces \u0026ldquo;for coming together and creating connections\u0026rdquo; (GP1). However, some already integrated a measure of coordination: \u0026ldquo;We also work hand in hand with the municipality\u0026rsquo;s social worker\u0026rdquo; (GP2) or briefly had local authority support: \u0026ldquo;The local authority paid part of the costs [of a social worker\u0026rsquo;s salary] for three years. But now it no longer wants to\u0026rdquo; (GP7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Different types of nurses taking on emerging PC roles\u003c/h2\u003e \u003cp\u003eParticipants described different nursing roles in PC, including advanced practice nurses (APNs), family practice nurses, home care nurses, and new functions, like ambulatory care pathway coordinators. APNs\u0026rsquo; roles varied and remained unclear: \u0026ldquo;They are much more highly trained in diagnostics and the management of common outpatient conditions. It is not yet clear whether they will coach the team [to work in patients\u0026rsquo;] homes or have their own patients\u0026rdquo; (GP2). Coordination with physicians was debated: \u0026ldquo;The APN must specify their competencies and knowledge [\u0026hellip;] and the GP must clarify what they are willing to delegate\u0026rdquo; (GP3). APNs were also introduced amid physician shortages: \u0026ldquo;He could not find a physician to take over his PC practice but needed help with patient care [\u0026hellip;] The nurse practitioner assisted during this transition and remained in the practice with the new doctor\u0026rdquo; (GP3). Funding for APNs was mentioned as relying on the existing physician billing system: \u0026ldquo;She can always refer to the GP she works with and use that physician\u0026rsquo;s GLN number\u003csup\u003e2\u003c/sup\u003e for reimbursement.\u0026rdquo; However, that participant saw such action as a \u0026ldquo;legal grey area\u0026rdquo; (GP3): \u0026ldquo;Proceeding like this is not officially prohibited, but it is not encouraged either\u0026rdquo; (GP3). These funding uncertainties were sometimes described as problematic: \u0026ldquo;The main problem is APNs\u0026rsquo; salaries [\u0026hellip;]; there is no recognized funding yet\u0026rdquo; (GP4).\u003c/p\u003e \u003cp\u003e Initiatives to introduce family practice nurses into family medicine practices were presented as efforts to strengthen specific aspects of PC\u0026rsquo;s mission: \u0026ldquo;There is a limited cantonal project to improve the continuity of care, prevention, health promotion, and chronic disease management\u0026rdquo; (PARAMED1). However, those initiatives faced instability: \u0026ldquo;Employment stability was limited, as contracts were annual [\u0026hellip;], project directors had to negotiate next year\u0026rsquo;s budget with the canton each time\u0026rdquo; (PARAMED1).\u003c/p\u003e \u003cp\u003eParticipants also described other possibilities involving nurses in projects initiated by insurers or cantons, including them becoming ambulatory care pathway coordinators or health managers: \u0026ldquo;We call them care coordinators rather than nurses, because an ambulatory care pathway coordinator can also perform this role\u0026rdquo; (ADMIN4), adding value for complex patients: \u0026ldquo;Particularly for more complex patients; we [type of professional] provide added value by bridging the gap between the family doctor and home care\u0026rdquo; (ADMIN4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Medical assistants evolving into ambulatory care pathway coordinators\u003c/h2\u003e \u003cp\u003eParticipants noted how expanded training had helped MAs\u0026rsquo; roles evolve: \u0026ldquo;Medical assistants wanted to progress in their profession, not just complete an apprenticeship\u0026rdquo; (GP7). Implementation varied, with differences between regions: \u0026ldquo;This support already exists to a large extent in German-speaking Switzerland but is much less common in French-speaking Switzerland\u0026rdquo; (ADMIN3). Participants mentioned an advantage over other roles: \u0026ldquo;Doctors in private practice are used to working with medical assistants, who are the professionals they work most closely with\u0026rdquo; (ADMIN3). For some, the role was still unclear: \u0026ldquo;Collaboration with the ambulatory care pathway coordinator is being established [\u0026hellip;] we need to identify what tasks she can or cannot do\u0026rdquo; (GP6). This was partly due to funding uncertainties: \u0026ldquo;It\u0026rsquo;s still being developed, because we didn\u0026rsquo;t have any certainty about financing, or rather billing [...] We\u0026rsquo;re starting to understand that things will be a bit simpler with TARDOC\u0026rdquo; (GP2). Others described this role as crucial to proper coordination, but only one canton was providing essential financial support for it: \u0026ldquo;For everything related to the coordinator, the salary actually comes from the budget of CHF 1,300 per complex patient (received from the canton). It's the biggest part of the budget, in fact. Because they play a very important role and are there to make sure that coordination works\u0026rdquo; (PARAMED2). Other participants either had no ambulatory care pathway coordinator at their workplace or the project was awaiting funding: \u0026ldquo;We have applied to the Confederation for funding to launch an ambulatory care pathway coordinator project\u0026rdquo; (ADMIN3).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2. Local anchoring and local authorities’ key role in creating and developing MHs\u003c/h3\u003e\n\u003cp\u003e Two main reasons were given for why local anchoring was key to the development of innovative models like MHs.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Partnerships with local authorities\u003c/h2\u003e \u003cp\u003e Participants emphasized local authorities\u0026rsquo; key role in the creation of MHs, mainly through negotiations and financial support. The argument for maintaining healthcare services in a village was central: \u0026ldquo;He contacted the local authorities, and they supported us [\u0026hellip;] It was important for them to guarantee access to PC in the village\u0026rdquo; (ADMIN2). \u0026ldquo;At the beginning, I tried to involve the canton and the local authorities. The local authorities were naturally interested: two doctors nearing retirement were about to cease their activities, which would have meant the end of basic care in the village\u0026rdquo; (GP7). The choice of the name MH also reflected this goal: \u0026ldquo;We called it an MH [\u003cem\u003eMaison de Sant\u0026eacute;\u003c/em\u003e] because it matched the senior general practitioner\u0026rsquo;s wish to ensure the continuity of PC in the village\u0026rdquo; (ADMIN2). Financial support included the local authority becoming a shareholder: \u0026ldquo;The shareholders are the future professionals of the center [\u0026hellip;] over two years, we will increase this capital and ask the local authority to invest\u0026rdquo; (ADMIN5). There were also rent reductions: \u0026ldquo;They granted us the first two months rent free and then a slightly reduced rent over the first five years\u0026rdquo; (ADMIN2); bank guarantees: \u0026ldquo;We took a loan from a local bank, which the local authority guaranteed\u0026rdquo; (ADMIN2); or property assistance: \u0026ldquo;They supported us because we converted a residential unit into a commercial space, establishing a practice in an apartment\u0026rdquo; (GP2). Some projects moved forward without waiting for extra funding: \u0026ldquo;We\u0026rsquo;re not going to wait until we find financing; we\u0026rsquo;re going ahead because we have ideas and motivation\u0026rdquo; (GP6).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Local anchoring as a foundational dimension of MH models\u003c/h2\u003e \u003cp\u003eLocal anchoring was seen as central to the vision of an MH: \u0026ldquo;This community MH is part of the town\u0026rdquo; (PARAMED3). It reflected a commitment to meeting local needs: \u0026ldquo;It is a place that brings together different healthcare professionals from different professions, who work together for individuals\u0026rsquo; well-being and health. And the local area, in fact\u0026rdquo; (GP6). A common space was seen as important: \u0026ldquo;Co-location is important [...] it can create a local network to meet the population\u0026rsquo;s needs\u0026rdquo; (GP1). However, it was not mandatory: \u0026ldquo;The MH can use something that already exists within a defined area, rather than recreating everything under the same roof\" (GP6). MHs were also associated with proximity and accessibility: \u0026ldquo;The aspect of proximity is also important [...] we have left the hospital [for the MH] to get closer to the population\u0026rdquo; (ADMIN4). \u0026ldquo;I travel by bicycle, so it has to be within cycling distance. [It is also important] because we also provide home care and palliative care\u0026rdquo; (GP2).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e3. Moving away from exclusive fee-for-service remuneration to facilitate the development of MHs\u003c/h3\u003e\n\u003cp\u003eParticipants emphasized that the central missions envisioned for MHs\u0026mdash;community care, prevention, and health promotion\u0026mdash;appeared inadequately supported by the current fee-for-service remuneration system, which was identified as a major barrier to their development: \u0026ldquo;The MH, as we envision it, is a community care setting, partly focused on prevention, group care, therapeutic education, and other aspects of care inadequately covered by the current healthcare funding system\u0026rdquo; (PARAMED4).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Challenging the exclusively fee-for-service model\u003c/h2\u003e \u003cp\u003eInterviewees challenged Switzerland\u0026rsquo;s current billing system: \u0026ldquo;I am convinced that Switzerland needs a new model\u0026mdash;a more human model that integrates the patient, not a healthcare system built around pricing\u0026rdquo; (GP7). Fee-for-service was also described as introducing bad incentives and being wasteful: \u0026ldquo;Fee-for-service encourages consumption [...] the more you do, the happier everyone is [...] And to get out of that, you need capitation. In my opinion, capitation means asking ourselves how much we need to treat patients in Switzerland today. And, in my opinion, we would need to do a little less than half of what we are doing today [...] while doing just as well and wasting less\u0026rdquo; (GP2). Proposed alternatives included integrated cost packages: \u0026ldquo;What we need is to keep the pricing but also integrate cost packages [...] it would be possible to create one\u0026rdquo; (GP7); and mixed funding: \u0026ldquo;Ideally, for it to work well, it needs to have some public funding, a mixed insurance system\u0026rdquo; (GP1). Some cantons already provide annual payments for complex patients: \u0026ldquo;The public health authority will give us [amount] francs per complex patient per year\u0026rdquo; (GP1), used to cover non-billable services like coordination. \u0026ldquo;The money is used to finance all medical services that cannot be billed through the existing billing systems, typically hours spent coordinating [...] or, for example, as a physiotherapist or ambulatory care pathway coordinator, we have no way of billing for any work done [when the patient is not physically present]\u0026rdquo;(PARAMED2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Concerns about flat fees and changes to remuneration methods\u003c/h2\u003e \u003cp\u003eParticipants expressed caution about package payments or capitation, mainly due to new financial expenditure responsibilities: \u0026ldquo;My first concern is financial responsibility, which is currently borne by insurance [...] And I\u0026rsquo;m not sure it\u0026rsquo;s fair that it should be doctors\u0026rdquo; (ADMIN3). Concerns also included team-based fees: \u0026ldquo;If it helps to limit deliberate overbilling, okay [...] But if it\u0026rsquo;s done to limit what healthcare professionals can charge for, then no; I have a problem with that\u0026rdquo; (PARAMED2). Finally, while teamwork was valued, it was not seen as a potential substitute for doctors: \u0026ldquo;A doctor may be very well supported by a team [...] But no, teams of people are not going to replace doctors\u0026rdquo; (ADMIN4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 \u0026ldquo;Saint George and the Dragon\u0026rdquo;\u003c/h2\u003e \u003cp\u003eTrying to change the funding model to enable the development of MHs was mentioned as a protracted struggle: \u0026ldquo;We continue to fight because we are convinced that fee-for-service is not the right solution at all [...] the incentive biases are enormous and do not encourage prevention\u0026rdquo; (ADMIN4). This struggle over funding for MHs was perceived as challenging and complex: \u0026ldquo;I am glad that someone is finally daring to take on this monster, like Saint George and the dragon!\u0026rdquo; (GP7).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSynthesis\u003c/p\u003e \u003cp\u003eOur findings provide new insights into the opportunities and barriers to implementing new PC models, like the MHs in Switzerland, where fee-for-service remuneration to GPs dominates, undervaluing prevention and coordination activities. Three main themes emerged: the need for teamwork for complex patients, the importance of local roots and support, and the need to change remuneration methods and visions of PC. Participants advocated mixed remuneration models, cost packages, or capitation, though concerns remained about being financially responsible and limits on billing. Structural reforms and sustained negotiations were seen as essential for progress.\u003c/p\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003cp\u003eOur findings clearly aligned with three, perhaps even four, key components of Bodenheimer\u0026rsquo;s Chronic Care Model [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Firstly, the Delivery System Design component, which promotes the creation of multidisciplinary teams with clearly defined roles and emphasizes the need for coordinated care for chronic and complex conditions, resonates strongly with the commitment to teamwork reported in our results. Secondly, the intention to integrate social and community elements and the strong local anchoring envisioned for MHs closely aligns with the Community Resources and Policies component. Thirdly, we could mention the model\u0026rsquo;s Clinical Information Systems component, as participants also addressed issues related to whether information technology systems were adequately adapted to coordination work.\u003c/p\u003e \u003cp\u003eFinally, the most significant connection between the Chronic Care Model and our findings seems to be its Health Care Organization component, which emphasizes the reimbursement environment\u0026rsquo;s impact on sustaining improvements in chronic care: \u0026ldquo;If purchasers and insurers fail to reward chronic care\u0026rsquo;s quality, improvements are difficult to sustain\u0026rdquo;[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This reflects the slow development of MHs in Switzerland and participants\u0026rsquo; interests in moving beyond an exclusively fee-for-service model in PC. This observation varied from region to region because there can be significant differences in health policy (and thus the implementation of new health models) between Switzerland\u0026rsquo;s cantons, despite their being bound by national federal laws.\u003c/p\u003e \u003cp\u003eA 2016 Swiss Health Observatory report [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] proposed adapting the remuneration model, including introducing a capitation component to encourage a more population-based perspective to medical practice and increase the time dedicated to prevention and health promotion. Our findings indicated that this perspective was keenly advocated by the professionals actively engaged in transforming PC. Indeed, shifting from a fee-for-service model to a hybrid one (part fee-for-service, part capitated) is one of the American National Academies of Sciences\u0026rsquo; main recommendations for PC [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] because \u0026ldquo;there is probably no single ideal method for remunerating healthcare professionals\u0026rdquo; [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The potential for a shift to a capitation model was also widely debated in France. However, for many reasons, including fee-for-service\u0026rsquo;s defense by the main independent physicians\u0026rsquo; associations, an alternative emerged: a continuation of the fee-for-service model for physicians accompanied by nurses employed by public authorities (the Asal\u0026eacute;e experience). Indeed, this solution was also adopted in Quebec, with its Family Medicine Groups [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Following our findings, this approach could also represent an interesting option for Switzerland. Capitation has been criticized for difficulties regarding risk adjustment, for historically low payment levels based on fee‑for‑service formulas, and for its inherent risk of underutilization [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Blended payment models, however, could reduce the respective shortcomings of fee‑for‑service and capitation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Thus, there is indeed a response to the Swiss Medical Journal\u0026rsquo;s 2010 question [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] of whether the Chronic Care Model can be transferred to Switzerland\u0026rsquo;s healthcare system. The emergence of new professional roles in PC (e.g., APNs, family medicine nurses) could enable the gradual integration of some of the model\u0026rsquo;s key elements, with the limits of unsecured funding. That funding usually encourages local health authorities to retain only one of those professional roles in their teams\u0026mdash;usually the least expensive\u0026mdash;although there is a place for them all in PC, and roles should always be adapted to the local context.\u003c/p\u003e \u003cp\u003eOur findings showed, however, that at the broader level, particularly at the Health Care Organization level that encompasses public policies and reimbursement strategies that prioritize chronic care, things have evolved very slowly in Switzerland [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. There have been some notable exceptions, with a few cantonal projects supported financially by local authorities or some innovative models created in collaboration between healthcare networks and health insurers\u0026mdash;collaborations that already exist elsewhere in Europe. For example, one of the earliest alternative payment models for care by GPs began in 2014 through a partnership between the Dutch insurer \u003cem\u003eMenzis\u003c/em\u003e and the PC organization \u003cem\u003eArts en Zorg\u003c/em\u003e (AEZ). Under this agreement, those two parties shared the savings in total healthcare costs resulting from a blended payment model for \u003cem\u003eArts en Zorg\u003c/em\u003e\u0026rsquo;s patients, including specialist and hospital care, thus encouraging GPs to take responsibility for the broader impacts of their decisions. One evaluation showed a 2% reduction in costs with no fall in quality [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This could also be a new payment method for Switzerland, but it also raises concerns\u0026mdash;notably around population-level coverage\u0026mdash;because patients in Switzerland must choose from among 39 different health insurers [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecommendations\u003c/p\u003e \u003cp\u003eOur findings highlight the need for policies addressing the Health Care Organization component of Bodenheimer\u0026rsquo;s model, particularly the reimbursement environment. Although there is strong interest in multidisciplinary collaboration, the absence of stable funding for emerging roles\u0026mdash;such as primary care nurses and social workers\u0026mdash;and the insufficient financial support for chronic care activities (e.g., care coordination) within redesigned PC teams remain major barriers to developing MHs in Switzerland. A radical overhaul of the financing system appears unlikely in the short term; nevertheless, establishing sustainable funding mechanisms to replace the exclusively fee-for-service model seems essential. Finally, even within current financing frameworks, close collaboration and support from local authorities can enable innovations as they share the objective of maintaining access to quality care within their communities. Valuable lessons can be drawn from the few Swiss initiatives supported by cantonal and/or local authorities and from international experiences like France\u0026rsquo;s Azal\u0026eacute;e project.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eBecause our interviewees were drawn predominantly from Switzerland\u0026rsquo;s French-speaking regions, their perspectives may not reflect the complete diversity of experiences in German and Italian-speaking regions. Other aspects could have been explored in more detail, such as how time spent coordinating care is used in different projects, how it is financed, and what types of information technology are used and financed. The few models explored in German-speaking regions largely found similar findings, nevertheless. Finally, given our inclusion criteria, this work did not represent physicians in private practice and healthcare professionals who were not interested in (or opposed to) PC\u0026rsquo;s transformation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e Our findings indicate that multidisciplinary collaboration is widely regarded as a key strategy for transforming primary care (PC). However, uncertainties persist surrounding how this will be financed, and the delineation of new professional roles remains a significant barrier to implementing new ideas in Switzerland. In this context, the local introduction of \u003cem\u003eMaisons de sant\u0026eacute;\u003c/em\u003e\u0026mdash;Medical Homes\u0026mdash;facilitated through negotiated agreements with local and regional authorities that wish to prioritize the maintenance of access to PC, particularly in rural areas (and to a lesser extent in urban settings), appears to be a critical means of advancing such initiatives. There are also some opportunities to ensure this using innovative models created in collaboration between healthcare networks and health insurers.\u003c/p\u003e \u003cp\u003e However, our analysis underscored that robust support for chronic care management and the facilitation of innovative PC initiatives, such as Medical Homes, will require a reform of cost-reimbursement rules. The findings indicated an urgent need to shift away from Switzerland\u0026rsquo;s exclusive reliance on fee-for-service models while remaining attentive to healthcare professionals\u0026rsquo; concerns about changes to their remuneration. Further research should examine how such reforms would be perceived across Switzerland\u0026rsquo;s healthcare workforce. Additionally, action-oriented studies on innovative PC models could help to refine implementation strategies and support their broader dissemination across Switzerland and in similarly financed healthcare systems where the development of new PC models remains challenging or has stalled.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Assistant\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Practice Nurse\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAEZ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eArts En Zorg\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics considerations\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe Human Research Ethics Committee of the Canton of Vaud authorized this research project as it did not fall within the scope of Switzerland\u0026rsquo;s Human Research Act. All our procedures followed the Declaration of Helsinki\u0026rsquo;s ethics guidelines. All the interviewees gave written informed consent.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003ePotential competing interests\u003c/h2\u003e\n\u003cp\u003eAll the authors have completed and submitted the International Committee of Medical Journal Editors form for the disclosure of potential conflicts of interest. No potential conflict of interest was disclosed.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was carried out as part of the main author\u0026rsquo;s medical studies at Unisant\u0026eacute;, with 30% of the funding over 18 months coming from a start-up grant from the CRMF (Coll\u0026egrave;ge Romand de M\u0026eacute;decine de Famille).\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eInterviews were carried out by the principal investigator under the supervision of the second and the last authors. The principal investigator wrote the initial draft, and all the authors provided scientific input, read, revised and approved the final version for publication.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe author gratefully acknowledges the academic support provided by Unisant\u0026eacute; and the financial support provided by a start-up grant from the \u003cem\u003eColl\u0026egrave;ge Romand de M\u0026eacute;decine de Famille\u003c/em\u003e (CRMF). The author also extends heartfelt thanks to his wife and three children for their patience and understanding during the many additional hours devoted to this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. WHO. The world health report 2008: primary health care now more than ever. 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcInnes S, Peters K, Bonney A, Halcomb E. 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Primary Care Governance and Financing: Models and approaches.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteurer-Stey C, Frei A, Rosemann T. Le \u0026laquo; Chronic care model \u0026raquo; en m\u0026eacute;decine de famille en Suisse. Rev Med Suisse. 2010;249:1016\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeytremann-Bridevaux I, Ebert ST, Senn N. Involvement of family physicians in structured programs for chronic diseases or multi-morbidity in Switzerland. Eur J Intern Med. 2015;26:150\u0026ndash;1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejim.2015.01.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ejim.2015.01.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindner L, Hayen A. Value-based payment models in primary care: An assessment of the Menzis Shared Savings programme in the Netherlands. OECD Health Working Papers. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1787/0810f2ba-en\u003c/span\u003e\u003cspan address=\"10.1787/0810f2ba-en\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheckall. Liste des assurances maladie en Suisse 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.checkall.ch/fr/caisse-maladie/liste-assurances-maladie-suisse\u003c/span\u003e\u003cspan address=\"https://www.checkall.ch/fr/caisse-maladie/liste-assurances-maladie-suisse\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 14 Dec 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003cp\u003e\u003cspan\u003e 2. Doctors registered in the official Swiss medical register (\u003cb\u003eMedReg\u003c/b\u003e) are assigned a \u003cb\u003eGLN\u003c/b\u003e, which serves as their public identification number [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary care, Medical homes, Teamwork, Multidisciplinary teamwork, Fee-for-service, Blended payment, Switzerland.","lastPublishedDoi":"10.21203/rs.3.rs-9042346/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9042346/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eRising chronic disease burdens, workforce shortages, and the limitations of traditional physician‑centered models put pressure on primary care systems. Many countries have begun transitioning toward interprofessional, team‑based care structures with mixed or value‑based financing mechanisms. Such reforms remain limited in Switzerland, where primary care still relies heavily on small, fee‑for‑service family medicine practices with minimal recognition of preventive, coordinative, or interprofessional activities. This study examines Switzerland’s emerging innovative care models, including Medical Homes\u003csup\u003e1\u003c/sup\u003e(MHs) and other interprofessional structures, their roles, and implementation experiences. It identifies the financial and organizational opportunities and barriers shaping their development within Switzerland’s current healthcare financing context.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eThis examination used qualitative methodologies including purposive sampling, structured interview guides, and semi‑structured interviews with representatives from MHs, care networks, and other innovative primary care practices.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eOf 19 potential participants contacted from diverse primary care settings, 16 were interviewed. Three key themes emerged: the integration of broader interprofessional teams (including nurses, advanced practice nurses, ambulatory care pathway coordinators, and social workers) despite unstable funding; local authorities’ central roles in supporting the creation and sustainability of new models through financial support (including rent reductions, guarantees, or investments) and engaging in efforts to ensure continued access to primary care; and the need to move beyond exclusive fee-for-service financing to enable these transformations.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis study reveals that multidisciplinary teams are seen as essential to transforming primary care in Switzerland; however, unclearly defined roles and unstable financing continue to limit implementation. Locally backed initiatives involving MHs appear particularly promising when supported by municipal or regional authorities committed to maintaining access to care. Sustained progress will require moving beyond purely fee‑for‑service models. Blended payment models better support coordination, prevention, and the development of new professional roles. Further applied research must identify feasible strategies for scaling up innovative primary care models within Switzerland and across similar healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e “Maison de santé” in French, with no direct English equivalent\u003c/p\u003e","manuscriptTitle":"The Emerging Transformation of Primary Care in Switzerland and its Financial Implications: a Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 06:00:46","doi":"10.21203/rs.3.rs-9042346/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-13T13:15:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192389348024580550184015213923319646360","date":"2026-04-28T17:34:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162309133313319934935840491083735643468","date":"2026-04-23T09:51:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T08:45:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T09:20:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-12T08:11:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-12T08:11:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2026-03-05T16:02:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba728a38-259e-463e-a7af-b5da9fbd3d4a","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-13T13:15:48+00:00","index":52,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T06:00:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 06:00:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9042346","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9042346","identity":"rs-9042346","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}