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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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