Who earns from the pack?

In May a pharmacy customer went to the media because he had been charged a good thirteen francs extra for collecting his prescribed medicines, itemised as safety checks. The case did the rounds, the consumer protection organisation called for transparency, the pharmacists’ association pointed to the statutory duty to check. What is remarkable about it is not the outrage. What is remarkable is that it was possible at all.

Because the thirteen francs were visible. The amount that a self-dispensing medical practice earns on the same pack is not. It sits inside the medicine price set by the Federal Office of Public Health, it is identical for pharmacy, practice and hospital, and it appears on no invoice as an item of its own. The Swiss debate about who earns from medicines has for years been conducted almost exclusively over the one half of the money that can be seen.

How the price is built

The public price of a reimbursable medicine consists of three parts: the ex-factory price, the distribution share and value added tax. The distribution share compensates the logistical service, that is capital tie-up, warehousing, transport, infrastructure and staff. It is defined in law in Article 67 of the Health Insurance Ordinance and Article 38 of the Health Care Benefits Ordinance and applies equally to all providers who dispense such medicines.

A new model has applied since 1 July 2024. The price-related surcharge was reduced from twelve and seven per cent respectively to a uniform six per cent, for all medicines up to an ex-factory price of 4,720.99 francs; above that it falls away entirely. The pack-related surcharge now has three instead of six classes: nine francs at an ex-factory price of up to 7.99 francs, sixteen francs between eight and 4,720.99 francs, and three hundred francs above that, raised from the previous 240 francs. In addition, a uniform distribution share applies to preparations with the same active substance, calculated on the average ex-factory price of the generics or biosimilars. The aim was to neutralise the incentive to dispense the more expensive preparation. Savings of around sixty million francs a year were expected.

What this means concretely is shown by a simple calculation. For a preparation with an ex-factory price of twenty francs, the distribution share is 1.20 francs from the price surcharge plus sixteen francs pack surcharge, together 17.20 francs. On a pack costing twenty francs ex-works, therefore, almost as much again is accounted for by the journey from the factory to the patient’s hand. That is not profiteering but the calculated answer to the question of what logistics cost in a small market. Who receives this amount, however, is not thereby settled.

The sentence hardly anyone has read

In the Federal Office of Public Health’s explanatory report on precisely this adjustment there is a paragraph that casts the whole debate in a different light. The calculation of the distribution share, it says there, is based on a normative cost model of an average pharmacy whose representativeness and whose delimitation from other service components show deficiencies, which may lead to distortions in the remuneration structure. Future revisions would require an empirically collected, transparent and current data basis. And then follows the decisive sentence: the Confederation has no competence to generate data within the distribution share.

This puts on the record what has undermined the debate on self-dispensing for decades. The margin a medical practice receives for dispensing medicines is derived from a cost model of a pharmacy that the authority itself describes as deficient. Whether dispensing in a practice is cheaper, more expensive or equally expensive as in a community pharmacy has never been surveyed. There are no figures on it, because nobody has the competence to demand them.

That is the real finding. Not that one side receives too much. But that nobody knows exactly what is being paid for.

Two systems, one payer

From the distribution share onwards, the paths diverge. The pharmacy additionally bills through the performance-based remuneration, since 1 January 2026 in version LOA V, approved by the Federal Council on 29 October 2025 and limited until the end of 2028. The tariff point value is 1.40 francs. The medicine safety check is divided into four categories and valued at 3.63, 2.97, 2.83 and 1.44 tariff points respectively, depending on whether the medicine is new or existing and which dispensing category it falls into. The patient safety check, which covers maintaining the patient record and interaction checking across the whole record, stands at 2.75 tariff points.

For a newly prescribed category B medicine this gives 2.83 plus 2.75 tariff points, that is 5.58 tariff points or 7.81 francs before VAT. That is the amount for which the profession had to justify itself publicly in the spring.

The self-dispensing practice has no counterpart to this. It has billed its medical services since 1 January 2026 through TARDOC and the outpatient flat rates, which replaced the TARMED in force since 2004. The pharmaceutical checking service at dispensing is not tariffed separately there. It is implicitly included in the distribution share and the consultation.

Historically there is a justification for this, which crops up repeatedly in the dispute: cantons with self-dispensing tend to have lower tariff point values for medical services, so dispensing medicines compensates for part of the fee. That is an argument with a history, but without a robust current data basis, and it leads straight back to the problem of the missing cost model.

One asymmetry almost always gets lost in the debate. Substituting an original with a generic is recorded in the LOA as a service: the pharmacist declares a savings share, forty per cent of the price difference goes to them, sixty per cent stays with the insurer, capped at forty francs and chargeable only the first time. For the practice this item does not exist. Furthermore, pharmacists contribute through the LOA 0.2 per cent of the distribution share to a quality and research fund. There is no medical equivalent to that either.

The third flow of money

On 12 August 2026 the Swiss Federal Audit Office published an audit report on the supervision of integrity, transparency and the duty to pass on discounts in the dispensing of medicines. It describes that part of the money that appears in neither lobby brochure.

Providers do not necessarily buy medicines at the ex-factory price. They receive discounts, rebates and other pecuniary benefits. Since 1996, Article 56 paragraph 3 of the Health Insurance Act has required that such benefits be passed on to the debtor of the remuneration, that is to the insured or the insurer. Since 2020 the revised Therapeutic Products Act and the Ordinance on Integrity and Transparency in the Therapeutic Products Sector have specified the obligations; agreements on incomplete pass-through are possible, but must ensure that the benefits are for the most part passed on and that the retained shares are demonstrably used to improve treatment quality. Supervision lies with the Federal Office of Public Health.

The Audit Office’s figures for 2024: an estimated 743 million francs in pecuniary benefits to providers, around eight per cent of medicine turnover. Of this, 88 million was passed on. For around half the total sum, the Audit Office assumes that benefits were retained in breach of duty or were not appropriate. It describes the Federal Office’s controls as barely effective; the reasons cited are the pandemic and staff cost-cutting rounds. There have been no criminal sanctions so far; proceedings are ongoing. The authority stated that it was behind schedule but was building up the structures.

Two qualifications belong with this, and in both directions. The Audit Office itself concedes that its estimate carries considerable uncertainty and that wholesalers were not included. The billion-franc figure circulating in the reporting, cumulated over six years, is an extrapolation, not a point value from the report.

And: the report addresses medical practices, hospitals and pharmacies together. Anyone wanting to argue credibly in this debate from the community pharmacy cannot avoid this finding. The discount channel is not somebody else’s problem.

Ten-year-old evidence for a debate of today

Self-dispensing has been studied economically above all in a phase that is now history. The Federal Office of Public Health commissioned a study in 2013, carried out by Polynomics together with the health sciences department of Helsana. It was completed in February 2014 and published in March 2015, and it concluded that medicine expenditure was lower among patients in the self-dispensing channel and that generics were chosen more frequently there. The physicians’ association publicly alleged at the time that publication had been withheld across the decisive phases of the revision of the Therapeutic Products Act.

Practically simultaneously, work from Bern, among others by Kaiser and Schmid as well as by Burkhard, Schmid and Wüthrich, came to the opposite conclusion and showed higher medicine costs per patient for self-dispensing. From the medical side it was objected that one of these works had been used with provisional figures in the Aargau referendum campaign. The Polynomics study’s own literature review soberly noted that the existing research delivers remarkably divergent results.

The decisive point for 2026 is a different one. All of these investigations rest on data from a pricing system that no longer exists. They predate the reduction of the price surcharge, the uniform distribution share for preparations with the same active substance, the increase of the differentiated co-payment to forty per cent, LOA V and TARDOC. Anyone arguing with these figures today is arguing about a world that was abolished in July 2024.

That is precisely what is happening. In December 2025, in Aargau – where dispensing by doctors has been restricted to exceptions since the popular vote of 2013 – a motion for self-dispensing in primary care was submitted. Its supporters cite a locational disadvantage compared with practically all other German-speaking cantons, where dispensing in the practice is permitted. The cantonal pharmacists’ association counters that the density of provision in neighbouring cantons is no better despite self-dispensing, while pharmacy density is worse, and points to the new tariff models from 2026.

The question worth asking

Who earns from medicines? All three channels earn, and they earn with very different degrees of transparency. The distribution share is published, but built on a cost model the authority itself considers deficient. The LOA is disclosed to two decimal places, verifiable, capped, equipped with monitoring and a correction mechanism – and therefore open to attack. The discounts are the largest item and were barely controlled for six years.

For the community pharmacy an uncomfortable but usable strategy follows from this. The dispute over self-dispensing cannot be won on the field of vested interests, because both sides are fencing there with figures from 2014. It can be won on the field of demonstrability. The pharmacy is the only dispensing channel whose services are individually described, tariffed, monitored and itemised on the receipt.

In May that was an imposition. It could turn out to be the profession’s strongest asset.