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The Swiss Health Care System

by Isabelle Sturny, Swiss Health Observatory

What is the role of government?

Duties and responsibilities in the Swiss health care system are divided among the federal, cantonal, and municipal levels of government. The system can be considered highly decentralized, as the cantons play a critical role. Each of the 26 cantons (including six half-cantons) has its own constitution and is responsible for licensing providers, coordinating hospital services, and subsidizing institutions and individual premiums. The federal government plays an important role in regulating the financing of the system, which is effected through mandatory health insurance (MHI) and other social insurance; ensuring the quality and safety of pharmaceuticals and medical devices; overseeing public health initiatives; and promoting research and training. The municipalities, in turn, are responsible mainly for long-term care (nursing homes and home care services) and other social support services for vulnerable groups.

The introduction of the new Federal Health Insurance Law in 1996 had three main objectives: 1) to strengthen equality by introducing universal coverage and subsidies for low-income households; 2) to expand the benefit basket and ensure high standards of health services; and 3) to contain the growing costs of the health system.1

Who is covered and how is insurance financed?

Publicly financed health insurance: There are three streams of public funding:

  1. Direct financing for health care providers through tax-financed budgets for the Swiss Confederation, cantons, and municipalities. The largest portion of this spending is given as cantonal subsidies to hospitals providing inpatient acute care.
  2. Mandatory health insurance (MHI) premiums.
  3. Social insurance contributions from health-related coverage of accident insurance, old-age insurance, disability insurance, and military insurance.

All government expenditures on health are financed by general taxation. In 2014, direct spending by government accounted for 20.1 percent of total health expenditures (CHF71.2 billion, or USD55.8 billion), while income-based MHI subsidies accounted for an additional 5.6 percent.2 Including MHI premiums (31.0% of total health expenditure, excluding statutory subsidies), other social insurance schemes (6.3%), and old-age and disability benefits (4.4%), publicly financed health care accounted for 67.4 percent of all spending.3

Mandatory MHI coverage is universal. Residents are legally required to purchase MHI within three months of arrival in Switzerland, and it then applies retroactively to the arrival date. Insurance policies typically apply to the individual, are not sponsored by employers, and must be purchased separately for dependents. There are virtually no uninsured residents. Temporary nonresident visitors pay for care up front and must claim expenses from any coverage they may hold in their home country. The absence of MHI for undocumented immigrants remains an unsolved problem acknowledged by the Swiss Federal Council (SFC), the highest governing and executive authority.

MHI is offered by competing nonprofit insurers supervised by the Federal Office of Public Health (FOPH), which sets floors for premiums calculated to cover past, current, and estimated future costs for insured individuals in a given region. Cantonal average annual premiums in 2016 for adults with the minimum deductible (CHF300, or USD235), the standard insurance model, and accident coverage range from CHF3,920 (USD3,074), for Appenzell Innerrhoden, to CHF6,547 (USD5,134), for Basel-Stadt.4 Funds are redistributed among insurers by a central fund, in accordance with a risk equalization scheme adjusted for canton, age, gender, and hospital or nursing home stays of more than three consecutive days in the previous year.

Insurers offer premiums for defined geographical “premium regions” limited to three per canton. Within every region, the criteria for variation in premiums are limited to age group, level of deductible, and alternative insurance plans (so-called managed care plans with the main characteristic of giving up free choice of first medical contact), but variations in premiums among insurers can be significant. In 2014, 63.0 percent of residents opted for basic coverage with a health maintenance organization, an independent practice association, or a fee-for-service plan with gatekeeping provisions.5

Private health insurance: Private expenditure accounted for 32.6 percent of total health expenditure in 2014, which is high by comparison with other OECD countries.6 There is complementary voluntary health insurance (VHI, 7.2% of total expenditure) for services not covered in the basic basket of MHI and supplementary coverage for free choice of hospital doctor or for a higher level of hospital accommodation. No data are available on the number of people covered by these plans.

VHI is regulated by the Swiss Financial Market Supervisory Authority (FINMA). Insurers can vary benefit baskets and premiums and can refuse applicants based on medical history. Service prices are usually negotiated directly between insurers and providers. Unlike statutory insurers, voluntary insurers are for-profit; an insurer will often have a nonprofit branch offering MHI and a for-profit branch offering VHI. It is illegal for voluntary insurers to base voluntary insurance subscription decisions on health information obtained via basic health coverage, but this rule is not easily enforced.

What is covered?

Services: The Federal Department of Home Affairs (FDHA) defines the MHI benefit basket by evaluating whether services are effective, appropriate, and cost-effective. It is supported in this task by the FOPH and by Swissmedic, the agency for authorization and supervision of therapeutic products.

MHI covers most general practitioner (GP) and specialist services, as well as an extensive list of pharmaceuticals and medical devices; home care services (called Spitex); physiotherapy (if prescribed); and some preventive measures, including the costs of selected vaccinations, selected general health examinations, and screenings for early detection of disease among certain risk groups (e.g., one mammogram per year for women with a family history of breast cancer).

Hospital services are also covered by MHI, but are highly subsidized by the cantons. Care for mental illness is covered if provided by certified physicians. The services of nonphysician professionals (e.g., psychotherapy by psychologists) are covered only if prescribed by a qualified medical doctor and provided in his or her practice. MHI covers only “medically necessary” services in long-term care. The FOPH and Swiss Conference of Cantonal Health Ministers aim to eliminate gaps that exist in the financing of hospice care. Dental care is largely excluded from MHI, as are glasses and contact lenses for adults (unless medically necessary), but these are covered for children up to age 18.

Cost-sharing and out-of-pocket spending: Under MHI, insurers are required to offer a minimum annual deductible of CHF300 (USD235) for adults and a zero deductible for children up to the age of 18, although insured persons may opt for a higher deductible (up to CHF2,500 [USD1,960] for adults and CHF600 [USD470] for children) and a lower premium. In 2014, 22.3 percent of all insured persons opted for the standard CHF300/0 deductible, 14.7 percent had a higher deductible, and 63.0 percent chose another model with a gatekeeping element.

Insured persons pay 10 percent coinsurance above deductibles for all services (including GP consultations), but it is capped at CHF700 (USD549) for adults and CHF350 (USD274) for children up to 18 in a given year. For brand-name drugs with a generic alternative, 20 percent instead of 10 percent coinsurance is charged. For hospital stays, there is an additional charge of CHF15 (USD12) per inpatient day. Cost-sharing in MHI and VHI accounted for 5.6 percent and 0.1 percent of total health expenditure in 2014.

Out-of-pocket payments for services not covered by insurance (and in addition to cost-sharing) accounted for 18.6 percent of total health expenditure. Most of these direct out-of-pocket payments were spent on dentistry and long-term care. Providers under MHI are not allowed to charge above the fee schedule.

Safety net: Maternity care and some preventive services are fully covered and thus exempt from deductibles, coinsurance, and copayments. Children or young adults in school (up to the age of 25) do not pay copayments for inpatient care. Federal government and the cantons provide income-based subsidies to individuals or households to cover MHI premiums; income thresholds vary widely by canton.7 Overall, 26.9 percent of residents in 2014 benefited from individual premium subsidies.8 Municipalities or cantons cover the health insurance expenses of social assistance beneficiaries and recipients of supplementary old age and disability benefits.

How is the delivery system organized and financed?

Primary care: As registering with a GP is not required, people not enrolled in managed care plans generally have free choice among self-employed GPs. In 2015, 38.2 percent of doctors in the outpatient sector were classified as GPs. There are no specific financial incentives for GPs to take care of chronically ill patients, and no concrete reforming efforts are under way to engage GPs in “bundled payments” for chronic patients (e.g., diabetics). Primary (and specialist) care tends to be physician-centered, with nurses and other health professionals playing a relatively small role. In 2015, 56.1 percent of physicians were in solo practice.9

Apart from some managed care plans in which physician groups are paid through capitation, ambulatory physicians (including GPs and specialists) are paid according to a national fee-for-service scale (TARMED). Billing above the fee schedule is not permitted. The introduction of TARMED in 2004 aimed to improve reimbursement for GP services by giving greater weight to nontechnical services than to technical services and by incentivizing less resource-intensive forms of care. These incentives, however, are criticized by GPs as insufficient to render desirable services like home visits, after-hours care, and coordination and communication with chronically ill patients. In response, the SFC decided to slightly increase remuneration for consultations in primary care as of October 2014, while remuneration for some more technical services (such as computer tomography) has been slightly reduced. The median income of primary care doctors was CHF190,150 (USD149,109) in 2009.10

Outpatient specialist care: In the outpatient sector, 61.8 percent of doctors were classified as specialists in 2015.11 Residents have free access (without referral) to specialists unless enrolled in a gatekeeping managed care plan. Specialist practices tend to be concentrated in urban areas and within proximity of acute-care hospitals. The public health system allows specialists to see MHI patients as well as private patients.

Administrative mechanisms for direct patient payments to providers: MHI allows different methods of payment among insurers, patients, and providers. Providers can invoice the patient, who pays up front and claims reimbursement from the insurer, or the patient can forward the invoice to the insurer for payment. Alternatively, providers can directly bill the insurer, who makes payment and bills any balance to the patient.

After-hours care: The cantons are responsible for after-hours care. They delegate those services (with fees set by TARMED) to cantonal doctors’ associations, which organize urgent-care networks in collaboration with their affiliated doctors. The networks can include ambulance and rescue services, hospital emergency services, walk-in clinics, and telephone advice lines run or contracted by insurers. There is no institutionalized exchange of information between these services and GPs’ offices, as people are not required to register.

Hospitals: In 2014, there were 289 hospitals (108 general and 181 specialized hospitals), with a total of 37,540 beds.12 Hospital care represented one-third (36.4%) of total health expenditures in 2014. For services covered by MHI and billed through a national diagnosis-related group (DRG) payment system, hospitals receive around half (45%–55%) of their funding from insurers.13,14 The other half is covered by cantons and municipalities, or, in case of additional services, by private health insurance.

The cantons are responsible for hospital planning and funding and are legally bound to coordinate plans with other cantons. In 2012, in parallel to the introduction of the DRG system, free movement of patients between cantons was allowed, reducing cantonal fragmentation. Remuneration mechanisms depend on insurance contracts; consequently, fee-for-service for inpatient services not covered under MHI is still possible. Hospital-based physicians are normally paid a salary, and public-hospital physicians can receive extra payments for seeing privately insured patients.

Mental health care: Psychiatric practices are generally private, and psychiatric clinics and hospital departments are a mix of public, private with state subsidies, and fully private. There is also a wide range of socio-psychiatric facilities and daycare institutions that are mainly state-run and state-funded.

Psychiatric hospitals or clinics normally provide a full range of medical services such as psychiatric diagnostics and treatment, psychotherapy, pharmaceutical treatment, and forensic services. Often, the socio-psychiatric facilities and daycare institutions offer the same medical services as the clinics, but normally treat patients with less acute illnesses or symptoms. The main field of activity of mental health practices is psychotherapy; psychiatrists are allowed to prescribe medication. The provision of psychiatric care is not systematically integrated into primary care. Prices for outpatient psychiatric services are calculated using TARMED, while psychiatric inpatient care prices are usually calculated as a daily rate.

Long-term care and social supports: Services are provided for inpatient care in nursing homes and institutions for disabled and chronically ill persons and for outpatient care through Spitex. In some cases, admission is possible only through a hospital or by approval from an admission authority. Palliative care provided in hospitals, in nursing homes, in hospices, or at home is not regulated separately in MHI, so coverage of services is similar to acute services in the respective provider setting. There is no provision of individual or personal budgets for patients to organize their own services.

Inpatient long-term somatic and mental services are covered by MHI but are highly subsidized by the cantons. For services in nursing homes and institutions for disabled and chronically ill persons, MHI pays a fixed contribution to cover care-related inpatient long-term care costs; the patient pays at most 20 percent of care-related costs that are not covered, and the remaining care-related costs are financed by the canton or the municipality. Long-term inpatient care costs totaled CHF12.3 billion (USD9.7 billion) in 2014, representing 17.3 percent of total health expenditures. Around one-third of these costs (31.3%) were paid by private households, one-quarter (24.1%) by old age and disability benefits, one-fifth (19.1%) by MHI and other social insurances, and the rest by government subsidies (25.4%). Of the 1,575 nursing homes in operation in 2014, 29.2 percent were state-operated and state-funded, 30.5 percent were privately operated with public subsidies, and 40.3 percent were exclusively private.15

Almost half (47.1%) of the total Spitex expenditure of CHF2.0 billion (USD1.6 billion), as of 2014, is financed by government subsidies. MHI and the other social insurances covering the cost of medically necessary health care at home made up roughly one-third (34.9%). The rest (18.0%), devoted mainly to support and household services, was paid out-of-pocket, by old age and disability benefits, by VHI, or by other private funds.16 In 2014, one-third of Spitex organizations were subsidized nonprofit organizations (36.6%), 13.6 percent were nonsubsidized for-profit companies, and almost half (49.8%) of Spitex organizations were individual health care workers.17 At the national level, there is no legal basis for financial support for informal help or family caregivers.

diagram of health care system

What are the key entities for health system governance?

Since health care is largely decentralized, the key entities for health system governance exist mainly at the cantonal level. Each of the 26 cantons has its own elected minister of public health. Supported by their respective cantonal offices of public health, the ministers are responsible for licensing providers, coordinating hospital services, subsidizing institutions, and promoting health through disease prevention. Their common political body, the Swiss Conference of Cantonal Health Ministers, plays an important coordinating role. At the cantonal and the national level, market pressure, i.e., from competition, is felt most by hospitals and by health insurers.18

The main national player is the FOPH, which, among other tasks, supervises the legal application of mandatory MHI, authorizes insurance premiums offered by statutory insurers, and governs statutory coverage (including health technology assessment) and the prices of pharmaceuticals. Other cost-control measures are shared with cantonal and municipal governments. The FDHA legally defines the MHI benefit basket. Professional self-regulation has been the traditional approach to quality improvement.

Prices for outpatient services are set using the fee-for-service scale TARMED, which defines the relative cost weights of all services covered by MHI at the national level and is authorized by the Swiss Federal Council. TARMED values can vary among cantons and service groups (e.g., physicians, outpatient hospital services). They are negotiated annually between the health insurers’ associations and cantonal provider associations or may be set by cantonal government if the parties cannot agree. For inpatient care, the Swiss national DRG system is in use as of 2012. The nonprofit corporation SwissDRG AG is responsible for defining, developing, and adapting the national system of relative cost weights per case.

In addition to the responsibilities of the FOPH and cantonal governments, Health Promotion Switzerland, a nonprofit organization financed by MHI, is legally charged with disease prevention and health promotion programs and provides public information on health. The Association of Swiss Patients and a national ombudsman for health insurance engage in patient advocacy.

What are the major strategies to ensure quality of care?

Providers must be licensed to practice medicine and are required to meet educational and regulatory standards; continuing medical education for doctors is compulsory. Local quality initiatives, often at the provider level, include the development of clinical pathways, medical peer groups, and consensus guidelines. However, there are no explicit financial incentives for providers to meet quality targets.

Increasing the quality of care is a priority of the federal strategy Health2020. The strategy includes the implementation of a national network for quality and of national quality programs in fields like medication safety and hospital infections.19 In 2008, the Swiss Inpatient Quality Indicators were introduced to monitor and evaluate the quality of care provided by acute-care hospitals. In addition, the National Association for Quality Improvement in Hospitals and Clinics (ANQ) publishes quality indicators for hospital inpatient care based on registries or patient surveys. Some registries are the result of private initiatives, while others, such as the cantonal cancer registries, are organized by the cantons themselves.

What is being done to reduce disparities?

The Swiss Federal Council’s national Health2020 strategy20 includes the explicit objective of improving the health opportunities of the most vulnerable population groups, such as children and the young, those on low incomes or with a poor educational background, the elderly, and immigrants. The aim is to prevent vulnerable population groups from being unable to make appropriate use of necessary health care services. Health and health access variations are measured and reported publicly by the Swiss Health Survey every five years.21

What is being done to promote delivery system integration and care coordination?

Care coordination is an issue, particularly in light of a projected lack of health professionals in the future and the need to improve efficiency to increase capacity. The task force Dialogue on National Health Policy discusses existing and new approaches to care. The national Health2020 strategy includes a comprehensive projection of the priorities of health care policy until the year 2020. The strategy also addresses care coordination, stating that integrated health care models need to be supported in all areas. The FOPH works on implementing concrete measures to confront these challenges.

Strategies and networks tackling emerging areas of importance, like palliative care, dementia, and mental health, have been created to improve coordination. They start at the conceptual level and design pilot projects, aiming at the practical level to encourage different types of health professionals to work together. The National Health Report 2015 discusses the growing number of case management programs for chronically ill patients, but pooled funding streams do not yet exist.22 It is also worth noting the efforts in the area of e-health, which should considerably improve care coordination.

What is the status of electronic health records?

In June 2015, a law addressing the national electronic patient record was adopted; it will come into effect in 2017 and should increase care coordination, quality of treatment, patient safety, and efficiency in the health care system. Insured persons are free to opt into such a record and to decide who is allowed to have access to specific details of their treatment-related information. The records are being stored in decentralized form. Providers will have to take part in certified communities (organizational units of health specialists and their institutions) to be able to read the records. Whereas ambulatory providers are not obliged to join such communities, hospitals and long-term care institutions are legally bound to join and to offer their services using an electronic patient record.

For some years, a national e-health coordination service called eHealth Suisse (an administrative unit of the FOPH) has been in place under the joint responsibility of the federal and cantonal governments. The confederation will provide partial funding for the development of networks constituting the infrastructure for the electronic patient record.

GP e-health is still at an early stage,23 and there are ongoing discussions about incentives for physicians to adopt new technologies. Hospitals are generally more technologically advanced; some have merged their internal clinical systems in recent years and hold interdisciplinary patient files. However, the extent of this integration varies greatly among hospitals and among cantons.

How are costs contained?

Switzerland’s health care costs are among the highest in the world. In 2014, total health expenditure represented 11.1 percent of gross domestic product.24 “Regulated competition”25 among nonprofit health insurers and among service providers is aimed at containing costs and guaranteeing high-quality health care and at establishing solidarity among the insured. Such were the objectives of MHI, introduced in 1996. While most of these objectives were achieved, there has been criticism of competition’s capacity to control health care costs.26 A global budget, however, has never been regarded as a possible remedy for this problem. Failures are ascribed largely to inadequate risk equalization, the dual funding of hospitals, and pressure on insurers to contract with all certified providers.27 In 2013, the FDHA postulated that the costs of providing mandatory benefits in the health system could be reduced by up to 20 percent.28

An overview of possible cost-reducing measures is part of the Health2020 strategy. The strategy outlines a need for further flat-rate remuneration mechanisms and revision of existing fee schedules to limit incentives for service providers. Also mentioned is the need to concentrate highly specialized medicine in fewer sites to eliminate inefficiency and duplicated infrastructure and to increase the quality of treatments through more-experienced teams of providers. SwissDRG AG was introduced to contain hospital costs. Inpatient capacity is subject to cantonal planning requirements, and there is a “necessity clause” for outpatient providers.

To control pharmaceutical costs, coverage decisions on all new medicines are subject to evaluation of their effectiveness (by Swissmedic) and cost (by the FOPH). Efforts are being made to reassess the prices of one-third of existing drugs every year. Depending on national market volume, generics must be sold for 20 percent to 50 percent less than the original brand. In addition to the aforementioned 20 percent coinsurance consumers pay for brand-name drugs, pharmacists are reimbursed flat amounts for prescriptions, so they have no financial incentive to dispense more-expensive drugs.

What major innovations and reforms have been introduced?

As discussed throughout this profile, the Health2020 strategy outlines important national topics, objectives, and measures for improving the quality of life, promoting equal opportunity and self-responsibility, ensuring and enhancing the quality of care, and creating more transparency, better governance, and closer coordination. In concrete terms, the SFC is pursuing the following 10 priorities in 201629:

  1. Adoption of the revised radiation protection regulations
  2. A decision on how to proceed with the total revision of the Federal Act on the Genetic Testing of Human Beings
  3. Adoption of the national strategy for the prevention of noncommunicable diseases
  4. Adoption of the revised regulation of risk adjustment in health insurance
  5. Consultation on the modification of the federal law on health insurance for the introduction of a reference price system
  6. Adoption of resources to create a health technology assessment unit
  7. Consultation on revision of the inclusion of complementary medical services in mandatory health insurance
  8. A decision on the introduction of the federal law on electronic patient records
  9. Adoption of the Suicide Prevention Action Plan
  10. Adoption of the dispatch on the approval and implementation of the Medicrime Convention of the Council of Europe.

Acknowledgements

The author would like to acknowledge Paul Camenzind and David Squires as contributing authors to earlier versions of this profile.30

References

1Swiss Federal Council (SFC), Botschaft über die Revision der Krankenversicherung (SFC, 1991).

2Please note that, throughout this profile, all figures in USD were converted from CHF at a rate of CHF1.28 per USD, the purchasing power parity conversion rate for GDP in 2015 reported by OECD for Switzerland: Organisation for Economic Co-operation and Development, OECD Health Statistics 2016; accessed Aug. 17, 2016.

3Swiss Federal Statistical Office (FSO), Costs and Financing of the Health Care System 2014 (FSO, 2016).

4Swiss Federal Office of Public Health (FOPH), Statistik der obligatorischen Krankenversicherung 2014 (FOPH, 2016).

5Ibid.

6FSO, Costs and Financing of the Health Care System 2014, 2016; and Organisation for Economic Co-operation and Development (OECD), Reviews of Health Systems: Switzerland, (OECD, 2011).

7Swiss Conference of Cantonal Health Ministers, http://www.gdk-cds.ch/fileadmin/docs/public/gdk/themen/krankenversicherung/praemienverbilligung/ipv_2016_df_def.pdf; accessed Aug. 17, 2016.

8FOPH, Statistik der obligatorischen Krankenversicherung 2014, 2016.

9S. Hostettler and E. Kraft, “FMH-Ärztestatistik 2015: Zuwanderung grundlegend für Versorgungssystem,” Schweizerische Ärztezeitung 2016 93(38):1371–75.

10K. Künzi and S. Strub, “Einkommen der Ärzteschaft in freier Praxis: Auswertung der Medisuisse-Daten 2009,” Schweizerische Ärztezeitung 2012 97(12–13):448–53.

11Hostettler and Kraft, FMH-Ärztestatistik 2015: Zuwanderung grundlegend für Versorgungssystem, 2016.

12Swiss Federal Statistical Office (FSO), Krankenhausstatistik—Standardtabellen 2014 (FSO, 2016).

13These include private hospitals that receive public subsidies if the cantonal governments have need of their services to guarantee a sufficient supply for the population.

14Swiss Conference of Cantonal Health Ministers, http://www.gdk-cds.ch/index.php?id=942; accessed Aug. 17, 2016.

15Swiss Federal Statistical Office (FSO), Statistik der sozialmedizinischen Institutionen—Standardtabellen 2014 (FSO, 2016).

16FSO, “Costs and Financing of the Health Care System 2014,” 2016.

17Swiss Federal Statistical Office (FSO), “Statistik der Hilfe und Pflege zu Hause—Spitex-Statistik 2014,” Neuchâtel: FSO, 2016.

18OECD, Reviews of Health Systems: Switzerland, 2011.

19Swiss Federal Council (SFC), “Mehr Patientensicherheit dank nationalen Qualitätsprogrammen,” press release, Dec. 7, 2015.

20Swiss Federal Department of Home Affairs (FDHA), The Federal Council’s Health-Policy Priorities (FDHA, 2013); accessed Aug. 17, 2016.

21Swiss Federal Statistical Office (FSO), Schweizerische Gesundheitsbefragung—Standardtabellen 2012 (FSO, 2014).

22Swiss Health Observatory (Obsan), National Health Report 2015 (Hogrefe, 2015).

23C. Mercay, Médecins de premier recours—Situation en Suisse, tendances récentes et comparaison internationale. Analyse de l’International Health Policy Survey 2015 du Commonwealth Fund sur mandat de l’Office fédéral de la santé publique (OFSP) (Observatoire suisse de la santé, 2015).

24FSO, Costs and Financing of the Health Care System 2014, 2016.

25A. C. Enthoven, “The History and Principles of Managed Competition,” Health Affairs 1993 12(1):24–48.

26OECD, Reviews of Health Systems: Switzerland, 2011.

27Ibid.

28FDHA, The Federal Council’s Health-Policy Priorities (2013).

29Swiss Federal Council (SFC), “Gesundheit2020: zehn Prioritäten für 2016,” press release, May 18, 2016.

30P. Camenzind, “The Swiss Health Care System, 2015,” in E. Mossialos, M. Wenzl, R. Osborn, and D. Sarnak (eds.), International Profiles of Health Care Systems, 2015 (The Commonwealth Fund, Jan. 2016).