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Switzerland! It's a gorgeous alpine nation of 8 million people. It's a parliamentary republic made up of 26 cantons. I've never been, but I hear great things about it. The country should free to fly us over so we can learn even more. But what I do know about its healthcare system, I'll be telling you in this episode of Healthcare Triage.
Those of you who want to read more and see references can go here: http://theincidentaleconomist.com/wordpress/?p=57335

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics

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 Introduction


Swiss national anthem plays in background

Switzerland! It’s a gorgeous alpine nation of 8 million people. It’s a parliamentary republic made up of 26 cantons. I’ve never been, but I hear great things about it. The country should  feel free to fly us over so we can learn even more. But what I do know about its healthcare system, I’ll be telling you today, here on Healthcare Triage. 

 Main


Like pretty much every healthcare system we've discussed, except the United States, Switzerland has universal coverage. Since 1996, the Federal Health Insurance Act has mandated that all residents buy statutory health insurance or SHI from private insurance companies. Everyone, and I mean EVERYONE, is insured. If you moved to Switzerland you have three months to buy a policy, and it's retroactive to your arrival. The country even works to cover undocumented immigrants.

SHI is offered by competing non-profit insurance companies. In 2013 the average premium for a policy with a 300 Swiss Franc deductible for an adult ranged from 3591 Swiss francs  to 6070.

Premiums can vary by geographic region and age. There are three groups: children up to 19, young adults 19 - 25, and adults over 25. Premiums can also vary by acceptance of a managed care scheme. In 2011, more than half of the Swiss chose basic coverage with a managed care insurer.

Coverage, like in most of the countries we've discussed is comprehensive. You get physician services, drugs, medical devices, home healthcare, and preventive services like screening, immunizations, and exams. Unlike some countries, dental care is not covered. Eye glasses and contact lenses are only covered for children.

Insurance is not coupled to employment. Individuals  buy policies and separate ones for their dependents. There's also voluntary health insurance or VHI, which covers stuff not in the basic plans. This can include a better choice of hospitals or doctors, or improved amenities.

Switzerland has a fairly high level of cost sharing. All plans have to have a minimum-yes, minimum-deductible of 300 Swiss Francs (or about $325) for adults. You can get a plan with a higher deductible to a maximum of 2500 Francs, which comes with the lower premiums.

Plans generally come with 10 percent coinsurance above the deductible for most services, 20% charge for most brand-name drugs and a 15 Franc copay each day you're in a hospital.

Prices are set by SHI, and doctors can't charge more. Maternity and preventive care are exempt from all co-pays, as are children who are in the hospital. There's a maximum on all out-of-pocket spending of about 700 Francs for adults and 350 Francs for kids.

Those at the low end of the socioeconomic spectrum get the same private insurance as everyone else- they just get help buying it. Subsidies are given to the poor on a sliding scale. About 29 percent of people get such subsidies to help them buy insurance.

Public hospitals are partially paid for by canton-level governments, with insurers paying for the rest. Private hospitals are paid for more by insurers (with minimal public money coming from cantons) for services that public hospitals can't provide. Government also subsidizes many other types of outpatient care, but to a lesser extent than hospitals.

In 2011, public funding covered about 65 percent of all health care spending. The rest is private. Much of it is from VHI, which unlike SHI, can be for-profit. Often, these can come from different branches of the same insurance company - a nonprofit side for SHI and a for-profit side for VHI.

Now, it's technically illegal for VHI rates and decisions to be based on information known through SHI, but it's reportedly hard to enforce this, so people can get screwed a bit.

About 9 percent of health care spending is for VHI. Another 20 percent of spending though, is for out-of-pocket payments. That's very high as countries go- almost two to three times what some other countries are paying.

The Swiss don't have to have a primary care doctor, and have a lot of choice unless they're part of certain managed care plans. In 2012, 39 percent of doctors were primary care physicians. About 60 percent of them are still in solo practices. If they're not part of a managed care plan, the Swiss have wide access to specialists. Much care is still paid for on a fee-for-service basis.

Recognizing that much of life takes place after work hours, the Swiss actually focus on after-hours care which is managed by doctors' associations. This is unlike a lot of other countries.

The Swiss system is somewhat de-centralized. Cantons, and not the federal government, are mostly in charge of health care system decisions. They are coordinated by the Swiss Conference on the Cantonal Ministers of Public Health.

Quality is mostly maintained through professional self-regulation. Some quality initiatives have been begun, but almost all at a local or provider level.

Costs in Switzerland are considered high. Of course, this is because they're only beat by the U.S., Netherlands, France, Germany, and Canada with respect to health care spending as a percentage of GDP. So, take "expensive" with a grain of salt. The Swiss are attempting to control costs with some regulated competition among the SHI insurance providers.

However, this hasn't been working out so well. Many think that the system isn't equalizing risk enough, so some insurers are getting screwed by having to cover a much sicker population. Others think that the ways in which hospitals are funded and insurers are compelled to contract with all providers adds to cost. In 2012, risk equalization was improved. This year, incentives were also modified to increase efficiency. Managed care may also help cost control in the future.

Drugs have to be evaluated for effectiveness and cost before they're covered. Older drugs are reassessed as well.

So, what do people not like about the Swiss health care system? There's a huge amount of out-of-pocket spending- more than even the United States. In fact, it's pretty much the highest in the world. There's no tax breaks for health insurance, so premiums are completely on the individual. That 20 percent copay for drugs can be pretty stiff too. There's also no special program for the elderly.

Some doctors complain that they feel pressured to keep costs down. If they're prescribing too many drugs or doing too many procedures they can be investigated by insurance companies, and if they can't justify what they've done to the satisfaction of insurers, they can be forced to pay back some of the costs themselves.

But while physicians might not like the oversight, there's much less bureaucracy on the patient side, and lots of Swiss like that.

There are plenty of physicians- with 3.8 per 1000 people, compared to an OACD average of 3.1. Unlike some countries, scanning technology is common.

Wait times are short. In fact, in a study of 11 OACD nations, Switzerland was the second of the best to see a specialist, and third best to have elective surgery. Access there is amazing.

Life expectancy at birth is 82.6, which is pretty much the highest in the world. Infant mortality, at 3.8 per 1000, beats the OACD average of 4.3 as well. Their obesity rate is 8.1 percent- that's unreal these days.

Overall, in many quality metrics, Switzerland ranks among the best. In fact, it has a legitimate claim to being one of the best health care systems in the world in terms of quality. It costs more, but the Swiss seem to think it's worth it.