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Switzerland
The
Swiss health system
Describing the Swiss health system, aside from the complications
inherent in the federalist system that permeates it, currently
presents an additional difficulty due to the fact that the largest
part of it, social sickness insurance, has been governed since 1
January 1996 by a new federal law which in certain points contrasts
radically with what has been practised up to now. In addition, the
statistics available on all the parameters to be considered are only
complete for the year 1992.
This should be taken into account by the
reader in the description that follows.The players: in 1994, the
7.037 million inhabitants of Switzerland had 21,788 practising
doctors at their disposal, or an average of one doctor per 323
inhabitants; this average hides very wide disparities from one
canton to another, between a ratio of 1:191 in Geneva and that of
1:105 7 i n Appenzel I.By only taking into consideration the density
of doctors in private practice, the proportion becomes one doctor in
practice per 596 inhabitants. As regards the 11,814 doctors in
private practice, they are distributed in the following way: 64.4
per cent specialists (regular postgraduate training between five and
seven years); 19.8 percent specialists in general medicine (specific
regular postgraduate training of five years); and 15.8 per cent
qualified doctors, without regular postgraduate training, which does
not mean to say without any postgraduate training.The proportion of
general practitioners has been in slow hul constant decline for many
years; it is too early to say today whetlii'i the new law on health
insurance will counteract this tendency. The proportion of women in
the profession, constantly increasing, is currently 23.9 per cent
with respect to the total number of doctors and 17.3 per cent of the
doctors in private practice (only eight pei cent of specialist
doctors in general medicine).
Since no numerical restriction has yet
been placed on entering medical studies, the medical population,
already high when compared internationally, is still set to increase
significantly, given that the annual number of new graduates exceeds
700.To complete the picture, let us also mention that Switzerland
has (1993) 3,839 dentists in private practices, 1,614 pharmacies, to
which should be added some 3,500 dispensing doctors (entitled to
sell medicines). The total number of persons employed in the health
sector was estimated at 358,000 for 1993.In 1993, hospitals offered
a total of 80,000 beds (115 per 10,000 inhabitants). The trend
towards eliminating beds is evident and is going to become more
pronounced over the coming years, although admissions are increasing.
Despite the fact that the average time of hospitalisation is also
tending to diminish in acute care establishments (11.7 days in 1993
as against 1 3.6 in 1988), the expenses per case of hospitalisation
have greatly increased during the same period (from SFr.9,193 to
SFr.12,194, which explains why overall hospital costs have increased
by 84.1 per cent between 1985 and 1992.In the chapter on health
indicators, we point out that the new-born mortality rate is
6/°°° for boys and 5/°°° for girls. As for life expectancy at
birth, this is 81.4 years for women and 74.7 for men;14.7 per cent
of the population are aged 65 and over, of which four per cent are
80 years old and over.The overall cost of the Swiss health system
came to 31.719 billion francs in 1992.
Out of this overall total,
15.960 billion (50.3 percent) were absorbed by the hospitals, 1 0.53
billion (32 per cent) by ambulatory [outpatient] care (including
4.772 billion for private practitioners), 3.342 billion (10.53 per
cent) for medicinal products, 0.634 billion (two per cent) for
prevention and 1.63 billion (5.13 per cent) for the administration
costs of state health insurance schemes and other insurers. The
share of the costs of the health system in the national domestic
budget came to 9.3 per cent of the Gross Domestic Product (GDP) in
1992. This level is constantly on the increase; it was only 5.2 per
cent in 1970.The direct financial burden of the whole system is
shared between the state health insurance schemes (42 per cent),
private households (27.6 per cent), the public authorities, via
subsidies to health insurance schemes and the funding of public
hospital deficits (18.7 per cent), compulsory accident and
disability insurance and army insurance (9.4 per cent) and foreign
residents (2.3 per cent).The Swiss public health system continues to
deal separately with the sphere of insurance against sickness, on
the one hand, and those of accident insurance (AA), compulsory for
all salaried employees, disability insurance (Al), compulsory for
all residents, and army insurance (AM) on the other hand. Whereas
the first, although governed by a federal law (Federal Law of
Insurance against Sickness = LAMal), is covered by decentralised
regulations in each canton (cantonal tariff agreements between care
providers and health insurance schemes), the other three are
uniformly regulated for the whole country, the member doctors of the
Swiss Medical Association (FMH) being "p.so facto linked
to the scheme under the same tariff conditions.
The financing
oftheAA and theAl takes place through deductions as percentages of
salary, jointly borne by employers and employees.The insurance
against sickness instituted by the LAMal is financed by insured
party contributions, by annual excess payments (a minimum ofSFr.150,
higher if so chosen, with a reduction in contributions) as well as
by those insured sharing in the costs up to ten per cent, with an
annual limit fixed by the federal government. Federal and cantonal
subsidies target assistance towards persons of small financial means.The
compulsory insurance against sickness offers a basic cover, either
as outpatients or in the ordinary section of hospitals meeting the
pre-established criteria laid down by the cantons; the latter are
obliged to carry out hospital planning.
The insurers cannot take on
services other than those laid down by the law. Staying in the
private and semi-private sections of hospitals belongs to the area
of supplementary insurances, according to private contracts. The
same applies to services exceeding the basic compulsory insurance
cover.Special provisions of the law ensure the economic character
and (something new) the quality of the services.In each canton, a
general tariff agreement enables those insured to exercise their
acknowledged right to choose freely their doctor and, for example,
to have direct access to a specialist practitioner. However, and
this is the main innovation of the LAMal, the insurers can make
other forms of insurance available, particularly in closed HMOsdhe
insured can only consult doctors of the HMO in question) or network
systems run by doctors of first resort (general practitioners, house
physicians, paediatricians) who are the obligatory 'gatekeepers'
before any consultation of a specialist, hospitalisation or recourse
to another care provider; insured persons entering such insurance
schemes benefit from reduced contributions and are often exempt from
accepting any excess or any other share in the costs laid down by
the general regulations.
Other insurance schemes, with equally
reduced contributions, are offered to insured persons accepting
higher excesses or not benefiting from services for a certain time
(bonus).It is too early to say whether the deregulation introduced
into the sphere of compulsory insurance against sickness, as well as
the increased competition which will inevitably result between the
care providers, will lead to the beneficial financial effects on the
health system that were expected by the legislator. The emphasis
placed on hospital planning and the breakthroughs in the direction
of 'managed care' allow us, however, to hope so. It is, in any case,
quite within the realm of possibility that the pressure of costs
exerted on private households is prompting a relatively large
proportion of insured persons to enter into forms of insurance
restricting the free choice of their doctor or at the very least
their freedom of movement within the service supply system, in
return for smaller contributions. The status of doctors of first
resort, in particular of general practitioners, could be
significantly strengthened by this. If the phenomenon becomes
widespread, it could stop the decline in the level of general
practitioners within the Swiss medical body. Wait and see!
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