The Swiss Health Care System

1
The Swiss Health Care System

• Robert E. Leu
• University of Bern
• November 2008

2
The Swiss system in a nutshell

• Highly decentralized (26 cantons/states)
• Federal government acts mainly as regulator
  (Federal Health Insurance Law) and supervisor
• Cantons are responsible for the provision of
  medical care
• High physician and bed density with large
  regional variation
• Wide availability of up-to-date medical services
  in high quality

3
The Swiss system in a nutshell

• Good performance with respect to outcome
  indicators (life expectancy, etc.)
• Good performance with respect to equity criteria
  (health and health care utilization by income)
• High patient satisfaction
• Relatively high overall cost

4
Regulated competition in the health insurance
market

• Health insurance as individual mandate,
  independent of employment
• Universal coverage for all residents ( of
  uninsured lt 1).
• Comprehensive benefit package
• Free choice between insurance companies and
  contract options
• Free choice of physician and direct access to
  specialists in canton of residence (except for
  managed care plans)
• Free choice of hospital (with regulatory limits)

5
Regulated competition in thehealth insurance
market

• Competing, predominantly private not-for-profit
  insurance companies
• Open enrollment subject to timing rules
• Community rated premiums
• Insurers set premiums to cover costs tight
  control by the Swiss Federal Office of Health
• Premium subsidies for lower income families
• Risk equalization scheme

6
Cost sharing

• Variable deductible ( 272, 454, 907, 1361,
  1815,
• 2269) with corresponding premium reduction (
  145 to
• 1597)
• Coinsurance rate of 10, after insurance kicks
  in, up to stop loss amount of 600
• Coinsurance rate for original drugs 20 if
  generics are available and physician does not
  insist on original drug
• Coinsurance is replaced by a fixed amount of
• 9 per day for inpatient care
• Managed care plans may offer contracts without
  cost sharing

7
Cost sharing

• Available studies indicate that higher
  deductibles reduce utilization (moral hazard) by
  between 15 and 50
• Self-selection accounts for 50 to 85
  (deductible can be changed every year)

8
Main Problems

• Governance (fragmentation of responsibilities,
  multifunctional role of cantons)
• Inefficient regulation (limited selective
  contracting, etc.)
• Cantons too small as health regions
• Quality monitoring on national level
  (benchmarking)
• Incentives for disease management

9
Lessons for other countries

• Regulated competition in health insurance
• Health insurance as individual mandate
• Achieving high insurance coverage
• Cost sharing with no negative effect on access
• Premium subsidies
• Decentralized approach advantages and
  disadvantages