How does health insurance pay your medical costs?
Mandatory health insurance in Switzerland provides coverage for a wide range of services, including:
- Hospital inpatient services
- General practitioner (GP) and specialist services
- Comprehensive list of pharmaceuticals and medical devices
- Home care services (Spitex)
- Physiotherapy (with a prescription)
- Select preventive measures, such as vaccinations, general health examinations, and screenings for high-risk patients
- Maternity care, including prenatal checkups, childbirth, postpartum care, and breastfeeding support
- Outpatient care for mental illness, if provided or delegated by physicians
- Medically necessary long-term care
- Hospice care for patients with underlying diseases
However, certain services are not covered, such as durable medical equipment like wheelchairs. Hearing aids are only financed if not covered by old-age and disability insurance. However, children up to the age of 18 are covered by these services and supplies.
Supplementary insurance offers individuals the opportunity to expand their coverage beyond the basic health insurance provided by the mandatory insurance system. By opting for supplementary insurance, individuals can gain access to a wider range of benefits and services that may not be covered by basic insurance alone. This additional coverage can include specialized medical treatments, alternative therapies, preventive care, dental care, vision care, and more.
Switzerland has achieved nearly universal health coverage through a private insurance model introduced in 1994. Everyone is required by law to purchase insurance from nonprofit private insurers, including separate coverage for dependents.
New residents must obtain insurance within three months, while temporary nonresident visitors pay for their own care. Responsibilities for healthcare are divided among federal, cantonal, and municipal levels.
The majority of healthcare spending (62.8%) is publicly financed through mandatory insurance premiums, general taxes, and contributions to social insurance schemes. Additionally, voluntary health insurance covers services not included in mandatory insurance, accounting for 6.7% of expenditures.
How is the delivery system set up, and how are service providers compensated?
Physician education and workforce: Medical training in Switzerland involves a six-year program at public universities, followed by specialist training. The title of “specialist” is required to practice medicine independently. Increasing the capacity for training health workers is a priority, but entry restrictions may apply.
Primary care: Most individuals have free choice among self-employed private general practitioners (GPs). Primary care tends to be physician-centered, and regional medical networks are emerging. GPs are paid on a fee-for-service scale called TARMED, without specific incentives for chronic care.
Outpatient specialist care: Specialists in private practice are mostly self-employed and paid on a fee-for-service basis. They can see patients with private or mandatory insurance.
Administrative mechanisms for patient payments: Providers can invoice patients directly for reimbursement or bill the insurer directly. After-hours care: The cantons are responsible for after-hours care, organizing urgent-care networks with varying staffing patterns, and nurse triage.
Hospitals: There are publicly and privately owned hospitals, funded primarily by cantons. Services covered by mandatory insurance are billed through the diagnosis-related group (DRG) payment system.
Mental health insurance: Mental health services provided by certified physicians are covered, while services provided by nonphysician professionals require a doctor's prescription.
Long-term care and social support: Some long-term care services are covered by mandatory insurance. Nursing homes and institutions provide inpatient care, while outpatient home care is offered through specialized organizations. Coverage for palliative care, hospice care, and socio-psychiatric facilities is also available.
How quality care is ensured
Ensuring quality of care involves various strategies. Providers must obtain licenses and meet educational and regulatory standards, with compulsory continuing medical education. While professional self-regulation has traditionally been relied upon, there is a growing challenge to this approach. Local initiatives focus on developing clinical pathways, medical peer groups, and consensus guidelines to enhance quality. However, financial incentives for meeting quality targets are not explicitly provided.
Improving the quality of care is a key objective which includes the establishment of a national network for quality and implementation of national programs in areas like medication safety and hospital infections.
Switzerland has achieved near-universal health coverage through a private insurance model. Residents are legally required to purchase insurance from nonprofit private insurers, and coverage is supplemented by voluntary insurance. The healthcare system is divided among federal, cantonal, and municipal levels. Primary and specialist care is available, hospitals are funded by cantons, and mental health and long-term care services are covered. Quality of care is ensured through licensing requirements and continuing education for providers. Switzerland prioritizes accessibility and quality in its healthcare system.
