JANUARY

SWITZERLAND
Moreover, out-of-pocket payments for services not covered by insurance (and in addition to cost-sharing)
accounted for 18.1 percent of total health expenditure. Most of these direct out-of-pocket payments were spent
on dentistry and long-term care. Providers are not allowed to charge prices higher than SHI will reimburse.
Safety net: Maternity care and some preventive services are fully covered and thus exempt from deductibles,
coinsurance, and copayments. Minors do not pay deductibles or copayments for inpatient care. Federal
government and cantons provide income-based subsidies to individuals or households to cover SHI premiums;
income thresholds vary widely by canton (Swiss Conference of Cantonal Health Ministers, 2015a). Overall, 28
percent of residents (in 2013) benefit from individual premium subsidies. Municipalities or cantons cover the
health insurance expenses of social assistance beneficiaries and recipients of supplementary old age and
disability benefits.
How is the delivery system organized and financed?
Primary care: As registering with a GP is not required, people not enrolled in managed care plans generally
have free choice among self-employed GPs. In 2014, 38.5 percent of doctors in the outpatient sector were
classified as GPs. Apart from scale-of-charge measures (see below), there are no specific financial incentives
for GPs to take care of chronically ill patients, and no concrete reforming efforts are underway to engage GPs
in “bundled payments” for chronic patients (e.g., diabetics). Primary (and specialist) care tends to be physiciancentered,
with nurses and other health professionals playing a relatively small role. In 2014, 57.2 percent of
physicians were in solo practice (Hostettler and Kraft, 2015).
Apart from some managed care plans in which physician groups are paid through capitation, ambulatory
physicians (including GPs and specialists) are paid according to a national fee-for-service scale (TARMED). While
billing above the fee schedule is not permitted, TARMED offers some incentives for less resource-intensive
forms of care. These incentives, however, are criticized by GPs as insufficient to render attractive such services
as home visits, after-hours care, and coordinating and communicating with chronically ill patients. In response,
the SFC decided to slightly increase remuneration for consultations in primary care as of October 2014, while
remuneration for some more technical services (such as computer tomography) has been slightly reduced. The
median income of primary care doctors was CHF197,500 (USD144,151) in 2009 (Künzi and Strub, 2012).
Outpatient specialist care: In the outpatient sector, 61.5 percent of doctors were classified as specialists in
2014 (Hostettler and Kraft, 2015). Residents have free access (without referral) to specialists unless enrolled
in a gatekeeping managed care plan. Specialist practices tend to be concentrated in urban areas and within
proximity of acute-care hospitals. Mostly self-employed specialists can schedule appointments in public
hospitals with both SHI and private patients.
Administrative mechanisms for direct patient payments to providers: SHI allows different methods of
payment among insurers, patients, and providers. Providers can invoice the patient, who pays up front and
claims reimbursement from the insurer, or the patient can forward the invoice to the insurer for payment.
Alternatively, providers can directly bill the insurer, who makes payment and bills any balance to the patient.
After-hours care: Cantons are responsible for after-hours care. They delegate those services (fees set by
TARMED) to cantonal doctors’ associations, which organize care networks in collaboration with their affiliated
doctors. The networks can include ambulance and rescue services, hospital emergency services, and walk-in
clinics and telephone advice lines run or contracted by insurers. There is no institutionalized exchange of
information between these services and GPs’ offices (as people are not required to register).
International Profiles of Health Care Systems, 2015 163