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The Swiss Health Care System

by Paul Camenzind, 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 communal levels of government. The system can be considered highly decentralized, as the cantons are given a critical role. The 26 cantons (including six half-cantons) are responsible for licensing providers, coordinating hospital services, and subsidizing institutions and organizations. Cantons are like U.S. states in that they are sovereign in all matters, including health care, that are not specifically designated as the responsibility of the Swiss Confederation by the federal constitution. Each canton and half-canton has its own constitution articulating a comprehensive body of legislation.

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 statutory health insurance (SHI) premiums.
  3. Social insurance contributions from health-related coverage of accident insurance, old-age insurance, disability insurance, and military insurance.

All government expenditures are financed by general taxation. In 2013, direct spending by government accounted for 20.2 percent of total health expenditures (CHF69.2 billion, or USD50.5 billion), while income-based SHI subsidies accounted for an additional 5.8 percent.

(Please note that, throughout this profile, all figures in USD were converted from CHF at a rate of about CHF1.37 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD, 2015 for Switzerland.)

Including SHI premiums (30.9% of total health expenditure, excluding statutory subsidies), other social insurance schemes (6.5%), and old age and disability benefits (4.4%), publicly financed health care accounted for 67.9 percent of all spending (SFOS, 2015a).

Mandatory SHI coverage is universal. Residents are legally required to purchase SHI within three months of arrival in Switzerland, which then applies retroactively to the arrival date. 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. Missing SHI for undocumented immigrants remains an unsolved problem acknowledged by the Swiss Federal Council (SFC), the highest governing and executive authority.

SHI is offered by competing nonprofit insurers supervised by the Federal Office of Public Health (FOPH), which sets floors for premiums offered to cover past, current, and estimated future costs for insured individuals in a given region. Cantonal average annual premiums in 2015 for adults range from CHF3,836 (USD2,800) to CHF6,398 (USD4,670) (Appenzell Innerrhoden; Basel-Stadt). 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 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 2013, 60.6 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 (FOPH, 2014).

Private health insurance: Private expenditure accounted for 32.1 percent of total health expenditure in 2013 (SFOS, 2015a), which is high by comparison with other OECD countries (OECD, 2011). There is complementary voluntary health insurance (VHI, 7.3% of total expenditure) for services not covered in the basic basket of SHI, 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.

VHI is regulated by the Swiss Financial Market Supervisory Authority. 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 SHI 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 SHI benefits 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.

SHI covers most general practitioner (GP) and specialist services, as well as an extensive list of pharmaceuticals, medical devices, home health care (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 SHI, but highly subsidized by cantons (see below). Care for mental illness is covered if provided by certified physicians. The services of nonmedical professionals (e.g., psychotherapy by psychologists) are covered only if prescribed by a qualified medical doctor and provided in his or her practice. SHI covers only “medically necessary” services in long-term care. The FOPH and Swiss Conference of Cantonal Health Ministers aim to eliminate the gaps in financing of hospice care. Dental care is largely excluded from SHI, as are glasses and contact lenses for adults (unless medically necessary), but these are covered for children.

Cost-sharing and out-of-pocket spending: Insurers are required to offer minimum annual deductibles of CHF300 (about USD219) for adults under SHI, although insured persons may opt for a higher deductible (up to CHF2,500 [USD1,825]) and a lower premium. In 2013, 23.5 percent of all insured persons opted for the standard CHF300 deductible; the other 76.5 percent chose a higher deductible or another model with a gatekeeping element.

Insured persons pay 10 percent coinsurance above deductibles for all services (including GP consultations), but is capped at CHF700 (USD511) for adults and at CHF350 (USD255) for minors (under age 19) in a given year. There is also a 20 percent charge for brand-name drugs with a generic alternative. For treatment in acute-care hospitals, there is a CHF15 (USD11) copayment per inpatient day. Cost-sharing in SHI and VHI accounted for 5.6 percent and 0.1 percent of total health expenditure in 2013.

Moreover, out-of-pocket payments for services not covered by insurance (and in addition to cost-sharing) accounted for 18.1 percent of total health expenditure. Most of these direct out-of-pocket payments were spent on dentistry and long-term care. Providers are not allowed to charge prices higher than SHI will reimburse.

Safety net: Maternity care and some preventive services are fully covered and thus exempt from deductibles, coinsurance, and copayments. Minors do not pay deductibles or copayments for inpatient care. Federal government and cantons provide income-based subsidies to individuals or households to cover SHI premiums; income thresholds vary widely by canton (Swiss Conference of Cantonal Health Ministers, 2015a). Overall, 28 percent of residents (in 2013) benefit from individual premium subsidies. 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 2014, 38.5 percent of doctors in the outpatient sector were classified as GPs. Apart from scale-of-charge measures (see below), there are no specific financial incentives for GPs to take care of chronically ill patients, and no concrete reforming efforts are underway 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 2014, 57.2 percent of physicians were in solo practice (Hostettler and Kraft, 2015).

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). While billing above the fee schedule is not permitted, TARMED offers some incentives for less resource-intensive forms of care. These incentives, however, are criticized by GPs as insufficient to render attractive such services as home visits, after-hours care, and coordinating and communicating 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 CHF197,500 (USD144,151) in 2009 (Künzi and Strub, 2012).

Outpatient specialist care: In the outpatient sector, 61.5 percent of doctors were classified as specialists in 2014 (Hostettler and Kraft, 2015). 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. Mostly self-employed specialists can schedule appointments in public hospitals with both SHI and private patients.

Administrative mechanisms for direct patient payments to providers: SHI 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: Cantons are responsible for after-hours care. They delegate those services (fees set by TARMED) to cantonal doctors’ associations, which organize care networks in collaboration with their affiliated doctors. The networks can include ambulance and rescue services, hospital emergency services, and 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: About 70 percent of the 293 acute inpatient hospitals (in 2013) are public or publicly subsidized private hospitals (SFOS, 2015b). For services covered by SHI and billed through a national diagnosis-related group (DRG) payment system, hospitals (this includes private hospitals that receive public subsidies if the cantonal governments have need of their services to guarantee a sufficient supply) receive around half (45%–55%) of their funding from insurers (Swiss Conference of Cantonal Health Ministers, 2015b). The other half is covered by cantons and communes, or, in case of additional services, by private health insurance. There are no arrangements for bundled payments to include entire episodes of care are not used.

Cantons are responsible for hospital planning and funding, and are legally bound to coordinate plans with other cantons. The introduction in 2012 of free movement of patients between cantons under the DRG system has reduced cantonal fragmentation. Remuneration mechanisms depend on insurance contracts; as a consequence, fee-for-service is still possible for inpatient services not covered under SHI. 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 -funded.

Psychiatric hospitals or clinics normally provide a full range of medical services like 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 psychiatric practices is psychotherapy that can be supplemented by pharmaceutical treatment. 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 SHI, 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 SHI, but are highly subsidized by cantons. For services in nursing homes and institutions for disabled and chronically ill persons, SHI 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 commune. Long-term inpatient care costs totaled CHF12.0 billion (USD8.8 billion) in 2013, representing 17.4 percent of total health expenditures. Around one-third of these costs (32.0%) were paid by private households, one-quarter (24.1%) by old age and disability benefits, 18.4 percent by SHI and other social insurances, and the rest by government subsidies (25.5%). Of the 1,580 nursing homes (as of 2013), 29.6 percent are state-operated and -funded, 29.6 percent are privately operated with public subsidies, and 40.8 percent are exclusively private (SFOS, 2015c).

Almost half of total Spitex expenditure of CHF2.0 billion (USD1.4 billion), as of 2013 (SFOS, 2015d), is financed by government subsidies (47.5%). SHI and the other social insurances covering the cost of medically necessary health care at home made up roughly one-third (30.0%). The rest (22.6%), devoted mainly to support and household services, was paid out-of-pocket, by old age and disability benefits, by VHI, and by other private funds (SFOS, 2015a). There is no legal basis for financial support for informal help or family caregivers. Most Spitex organizations are subsidized nonprofit organizations (85% of personnel), while the remaining 15 percent are nonsubsidized for-profit organizations (SFOS, 2015d).

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, 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 the Cantonal Ministers of Public Health, 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 (OECD, 2011).

The main national player is the FOPH, which, among other tasks, supervises the legal application of mandatory SHI, 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 communal governments. The FDHA legally defines the SHI benefits basket. Professional self-regulation has been the traditional approach to quality improvement.

Prices for outpatient services are set in the fee-for-service scale TARMED, which defines the relative cost weights of all services covered by SHI on the national level and is authorized by the Swiss Federal Council. TARMED values can vary among cantons and service groups (physicians, outpatient hospital services) as negotiated annually between the health insurers’ associations and cantonal provider associations, or are set by cantonal government if the parties cannot agree. For inpatient care, the Swiss national DRG system has been in use since 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 SHI, is legally charged with disease prevention and health promotion programs and provides public information on health. A national ombudsman for health insurance and the Association of Swiss Patients engage in patient advocacy.

What are the major strategies to ensure quality of care?

Providers must be licensed in order 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.

The Quality Strategy, approved by the SFC at 2009, takes a broad conceptual approach with different fields of action, including the implementation of a national pilot program by the Swiss Foundation for Patient Security on medication safety in acute-care hospitals, a pilot program to reduce hospital infections, and the publication of quality indicators for acute-care hospitals. Quality-control mechanisms usually do not involve information from registries or patient surveys. Registries are organized by private initiatives or cantons, such as the cantonal cancer registries.

At the end of 2013, the SFC mandated a task force led by the cantons and the Swiss Confederation (the Dialogue on National Health Policy) to work out a national strategy for the prevention of noncommunicable diseases (NCDs) by 2016. The strategy aims to improve the health competence of the population and promote healthy living conditions. The National Health Report (Obsan, 2015) discusses the growing number of case management programs for chronic illnesses.

What is being done to reduce disparities?

There are several reasons why health disparities have not attracted as much political and professional interest at the national level as elsewhere: Health inequalities are not considered to be very significant in comparison to other OECD countries; it is difficult to obtain detailed statistical information about the epidemiology of health outcomes; and health inequalities are seen more as the responsibility of cantons, making them less visible at the national level.

The Swiss Federal Council’s national Health2020 agenda (FDHA, 2013) 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 (SFOS, 2014) every five years.

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 providers 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 agenda includes a comprehensive projection of the priorities of health care policy until the year 2020. The agenda also addresses care coordination, stating that integrated health care models need to be supported in all areas. The FOPH works on 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 on a conceptual level, aiming at the practical level to encourage different types of health professionals to work together. A growing number of such programs are in the works, as shown in the National Health Report (Obsan, 2015), but pooled funding streams do not exist yet. It is also worth noting the efforts in the area of e-health (see below), which should considerably improve coordination as well.

What is the status of electronic health records?

A national e-health service called eHealth Suisse (an administrative unit of the FOPH) is coordinated by the federal and cantonal governments and has three sets of responsibilities. First, all providers in Switzerland should be able to collect and store information on their patients’ treatment electronically. Second, health-related websites and online services will be required to undergo quality certification and a national health website will be constructed. Third, necessary legal changes will be made to realize these measures.

A key element of eHealth Suisse is the SHI subscription card, which encodes a personal identification number and all necessary administrative data. If allowed by the insured person, information about allergies, illnesses, and medication can be recorded on the card. The insured person also decides who is allowed access to this information (all, selected, or no providers). GP e-health is still at an early stage (Vilpert, 2012), and there are ongoing discussions about incentives for physicians to adopt new technologies.

Hospitals are generally more 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, despite efforts by eHealth Suisse to convince providers of the benefits of electronic health records for medical practice. An interoperable national patient record is not a priority for eHealth Suisse, since the principles of decentralization, privacy, and data protection are regarded as very important.

How are costs contained?

Switzerland’s health care costs are among the highest in the world. “Regulated competition” (Enthoven, 1993) among nonprofit health insurers and among service providers is aimed at containing costs and guaranteeing high-quality health care, and establishing solidarity among the insured. While most of its objectives are considered successfully achieved, academic analyses (OECD, 2011) and public perception have been critical of competition’s ability to control health care costs. 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 (OECD, 2011). The costs of providing mandatory benefits in the health system could be reduced by up to 20 percent (FDHA, 2013).

An overview of possible cost-reducing measures—in coordination of care, compensating systems, and highly specialized medicine—is part of the Health2020 agenda. The agenda outlines a need for increasing flat-rate remuneration mechanisms and revising existing fee schedules to limit incentives for service providers. Also mentioned is the need for greater concentration in sites of highly specialized medicine to eliminate inefficiency and duplication in infrastructure systems and to increase the quality of health care provision. 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.” See also the section on cost-sharing for patient cost-sharing mechanisms.

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 more frequently the prices of older drugs. Depending on national market volume, generics must be sold for 20 to 50 percent less than the original brand. In addition to the aforementioned 20 percent coinsurance for brand-name drugs, pharmacists are paid 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 agenda outlines important national topics, objectives, and measures for improving quality of life, promoting equal opportunity and self-responsibility, ensuring and enhancing quality of care, and creating more transparency, better governance, and more coordination. In concrete terms, the SFC realized the following nine priorities in 2014 (SFC, 2015):

  • Adoption of the message (i.e., official explaining text of SFC) concerning the federal law of cancer registries (implementation date of law: not before 2018;
  • Submission for public consultation of the preliminary draft of a federal law concerning a national health quality institute in SHI (new proposal made by the Swiss Federal Council, with open date for implementation);
  • Submission for public consultation of a partial revision of the federal law on SHI concerning better control of the outpatient sector, more control of health care cost, and better assurance of health care quality (implementation date of law: mid-2016);
  • Submission for public consultation of the preliminary draft of a federal law concerning non-ionizing radiation and sound waves (implementation date of law: open);
  • Submission for public consultation of the preliminary draft of a federal law concerning tobacco products (implementation date of law: open);
  • Adoption of regulation on the adjustments of tariff structures in SHI (regulation introduced: October 2014);
  • Adoption of the results of a public consultation on the federal law concerning health professionals (implementation date of law: open);
  • Adoption of the results of a report on the current state of and need for action to support caring relatives;
  • Recognition of the results of the new constitutional article concerning primary health care and plans to enact it (implementation date: open).

The Swiss Health Observatory (Obsan) is currently creating an indicator system to evaluate the effects of all measures proposed by the Health2020 agenda.

Acknowledgements

The author would like to acknowledge David Squires as a contributing author to earlier versions of this profile.

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