Switzerland: The Healthcare Law Review - Edition 1

I OVERVIEW

The Swiss healthcare ecosystem is rather complex, since it combines aspects of managed competition and corporatism in a decentralised regulatory framework. The system is characterised by the allocation of decision-making or decision influencing powers to (1) the three different levels of government (the Swiss Confederation, the 26 Swiss cantons and the 2352 municipalities in Switzerland); (2) the recognised private healthcare organisations, such as Swiss Red Cross, Swiss Patient Organisation, Swiss Cancer League and the organisation of the mandatory health insurance (MHI) providers; and (3) the Swiss citizens who can veto against or demand a reform through public referenda and plebiscite.2

The Swiss Confederation (i.e., the federal state) is only permitted to act in those fields in respect of which it is granted powers to do so by the Swiss Constitution. The most important fields are (1) the funding of the health system (through the MHI and other social insurances); (2) ensuring quality and safety of medicinal products and medical devices; (3) ensuring public health (control of infectious diseases, food safety, health promotion); and (4) research and training (third-level education) of non-physician health professionals.3 The most important piece of legislation by which the Swiss Confederation steers the Swiss healthcare system is the Federal Health Insurance Act (HIA),4 which sets the legal framework of the MHI system and in particular defines which services are to be paid by such system.

The Swiss federal government, the so-called Federal Council, and the Swiss parliament enact laws and ordinances that are to be implemented by the Swiss cantons. On a governmental level, the Federal Office of Public Health (FOPH), which is part of the Federal Department of Home Affairs (FDHA), is responsible for the development of national health policies. The responsibilities of the FOPH include other tasks, such as the supervision of mandatory health insurance, decisions on the reimbursement and the prices of therapeutic products and the regulation of university-educated medical and healthcare professions. It also represents the health policy interests of Switzerland in international bodies and with regard to other states.5

The responsibility for the provision of healthcare services lies mainly with the 26 Swiss cantons. The cantons maintain and, together with the MHI, finance hospitals and nursing homes, which they also supervise. In addition, they are also competent to issue and implement certain health-related legislation. The cantons further finance a substantial part of inpatient care, provide subsidies to low-income households enabling such households to pay for insurance, and coordinate prevention and health promotion activities. The Swiss cantons work together on an institutional level through the Swiss Conference of the Cantonal Ministers of Public Health.

The competences and responsibilities of municipalities in the fields of healthcare and other social support services vary across Switzerland, depending on the related allocation of powers and tasks in the cantonal constitutions.

II THE HEALTHCARE ECONOMY

i General

Free healthcare services are available to all persons resident in Switzerland on the basis of the MHI system, irrespective of whether such residents are Swiss citizens or not, are employed or not, or work in the public or private sector. The MHI system, the basic social insurance covering the risk of illness, maternity and (if not covered by another insurance) accidents6 is regulated by the HIA, which entered into force in 1996. The basic principle set forth in the HIA provides that all persons resident in Switzerland have guaranteed access to good medical care. The basic MHI aims to ensure that the costs of required medical treatments are covered by the insurance.7

Every person employed in Switzerland is further covered by the mandatory accident insurance scheme for the health and economic consequences of work-related and non-work-related accidents, as well as occupational diseases (i.e., diseases that are caused in the course of occupational activity solely or principally by harmful substances or certain types of work according to a list issued by the federal government).8 Not covered by mandatory accident insurance are non-employed persons, such as children, students and pensioners. For these persons, coverage for accident is available as part of MHI.

Temporary non-resident visitors have to pay up front for care and must reclaim reimbursement under insurance coverage they may have in their home country.

ii The role of health insurance

Residents are legally required to insure themselves with an MHI provider. Persons moving to Switzerland have to do so within three months as from their arrival.9 Insurance is offered by about 60 competing non-profit MHI companies that are supervised by FOPH. Contrary to private insurers providing complimentary health insurance coverage, the MHI providers must accept all applicants,10 irrespective of age and irrespective of whether they are already ill or not.

The largest share of the health costs is funded by the MHI system. In 2015, the share covered by the MHI system amounted to 35.3 per cent of the total health costs.11 Costs are further covered by direct financing of healthcare providers through the tax-financed budgets of the Swiss Confederation, the cantons and municipalities. The largest portion of such direct financing is made in the form of cantonal subsidies to hospitals providing inpatient acute care. In 2015, the share paid by the cantons amounted to 18.2 per cent of the total health expenditure.12 A further share of the costs is covered by the contributions to other social insurances also providing coverage for health-related risks, such as accident insurance, old-age insurance, disability insurance and military insurance.13

iii Funding and payment for specific services

The healthcare services and products (medicinal products, medical devices and ancillary materials) payable by the MHI are defined by the FDHA. In doing so, it has to evaluate whether the services and products are (1) effective, (2) appropriate, and (3) cost-effective.14

The MHI system pays the costs of most general practitioners (GPs) and specialists, hospital care, home care services (Spitex), physiotherapy (if prescribed), and certain preventive services, including selected vaccinations, general health examinations and screenings for early detection of diseases for certain risk groups. Also covered are the cost of a comprehensive range of medicinal products and medical devices. Care for mental illness is paid by the MHI, if provided by certified physicians. The services of non-physician professionals, such as psychotherapy by psychologists, are only covered if prescribed by a qualified medical doctor and provided in its practice. Long-term care is only paid to the extent necessary medicinal services are concerned. Glasses, to the extent medically required, are partly paid. Procedures and methods used in complementary medicine (such as homeopathy) are covered by the MHI to some extent. Broadly excluded from the MHI is dental care.

Premiums vary for three different age categories and for different geographical regions, but are otherwise the same for every Swiss resident insured with a particular MHI company, independent of gender or health status. In addition, the premiums are not dependent on income. In principle, the insured persons have to pay the premiums themselves. There are no employer contributions. However, people with low income may request a premium reduction, which is subsidised by the Swiss Confederation and the canton of domicile.15 In 2016, cantonal average annual MHI premiums for adults with a minimum franchise of 300 Swiss francs per year and the standard insurance model with accident coverage ranged from 3,920 francs to 6,547 francs.16 The insurers offer specific insurance models, such as health maintenance organisation (HMO) models, which the insured persons may select to benefit from reduced premiums. Insured persons may also reduce the premiums by accepting a higher franchise than 300 francs (presently franchises of up to 2,500 francs for adults and up to 600 francs for children are admissible). Chosen insurance models and selected franchises can be changed every year.

The insured persons have to pay 10 per cent of the cost of services received (above the franchise), including GP consultations, on their own, up to an annual cap of 700 francs for adults and 350 francs for children up to age of 18.17 Where generic drugs are available, patients have to pay 20 per cent of the price themselves if they want the original medicinal product. For hospital stays, patients have to pay an amount of 15 francs per inpatient day.18

Supplementary health insurance plans may be concluded on a voluntary basis and cover benefits that are not paid by the MHI, such as greater freedom with respect to the choice of doctor or hospital, payment of certain methods of complementary medicine that are not reimbursed by MHI or single room accommodation in hospitals. Such complementary insurances are offered by private insurers as well as by MHI insurers.19

To read this Review in full, please click here.

Footnotes

1 Markus Wang is a partner and Jonas Bornhauser an associate at Bär & Karrer.

2 De Pietro et al, in: Quentin Wilm et al. (editors), Switzerland: Health system review, Health Systems in Transition, 2015 (cited: De Pietro et al., Switzerland: Health system review), 17(4):1–288, 19; Sturny Isabelle, in: International Profiles of Health Care Systems, The Swiss Health Care System, 2017 (cited: Sturny), 155-162, 155.

3 Articles 95, 117 and 118 of the Swiss Constitution; De Pietro et al., Switzerland: Health system review, 19.

4 De Pietro et al., Switzerland: Health system review, 19.

5 The Swiss healthcare system, Verband der forschenden pharmazeutischen Firmen der Schweiz (interpharma), accessible online at www.interpharma.ch/fakten-statistiken/4561-swiss-healthcare-system (accessed on 19 July 2017) (cited: The Swiss healthcare system).

6 Article 1a HIA.

7 The Swiss healthcare system, Financing healthcare.

8 Articles 1a and 6 of the Federal Act concerning Accident Insurance.

9 Article 3 HIA.

10 Article 4 HIA.

11 According to figures published by Federal Statistic Office, accessible online at www.bfs.admin.ch/bfs/en/home/statistics/health/costs-financing.html (accessed on 19 July 2017).

12 According to figures published by Federal Statistic Office, accessible online at www.bfs.admin.ch/bfs/en/home/statistics/health/costs-financing.html (accessed on 19 July 2017).

13 Sturny, 156.

14 Article 32 HIA.

15 The Swiss healthcare system, Financing healthcare; Sturny, 155.

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

17 Article 64 para. 2 HIA.

18 Sturny, 156.

19 The Swiss healthcare system, Financing healthcare.

Originally published by The Law Reviews.

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