social, compulsory health insurance
(state March 05)
The social health insurance guarantees medical
treatment in case of illness or accidents, if not covered
by the accident insurance.
There exist 94 different insurers (“health insurances”),
which are not allowed to strive for profit. In case one of
the insurers becomes insolvent, the costs of governmental
services will be covered by the so-called common institution.
The insurers are not only responsible for the refund of services,
but they also support the health aid together with the cantons
(are the common leaders of the Swiss foundation for health
Every person with domicile in Switzerland has to be insured
(every person staying in Switzerland has to become insured
within 3 months). You can individually organize that. The
insured party can also choose freely his/her health insurer.
Every health insurance is compulsorily obliged to admit every
applicant, who has his/her domicile in the area of activity
of the health insurance, for the basic insurance. As far as
the additional insurance is concerned, which includes all
services exceeding the obligatory basic insurance, the insurers
are free to choose which contracts to take out with whom.
They are allowed to reject applicants and they can freely
The umbrella organisation of health insurers is called santésuisse
(siehe www.santesuisse.ch ). You can find an extensive database
with clear graphics next to current information about health
The health service of Switzerland is based
on the principle of managed care. A brief explanation:
The term “managed care” comes from the American
health system. Within this system the quality, the costs and
the access of care are controled. Demand, supply and financing
should not be separated from each other. Why? If supply, demand
and financing are completely separated from each other, every
patient is looking for the best treatment without thinking
about the costs, and every doctor offers the most luctrative
method of treatment regardless of the costs. This is possible,
as the costs are paid by the general public. If the health
insurance can not afford this anymore, it increases the premiums
for the general public. This leads to the well known cost
explosions. Therefore a “managed care” should
be offered. This plan is carried out by the payment of a retention
or through health maintenance organisations, where the treatment
is done by a net of statutory health insurance physicians.
(managed care, however, is not a secret recipe against cost
explosions within the health sector. Also here we encounter
The social health insurance provides services
in case of
· Illness = harm of physical or mental health, not
caused by an accident, calls for check-ups or medical treatment
or leading to inability to work.
· Maternity: pregnancy, birth and following time of
· certain measures of prevention
· accident = immediate and unintentional harm, which
was caused by an unusual, external event; Consequence –
physical or mental health disturbance. According to the accident
insurance law, every employee is insured for treatment costs
in case of accidents. There are:
a)the Swiss accident insurance institution (SUVA) as independent
accident insurance of the public law (www.suva.ch ).
b) accident insurances (after UVG) of private insurance companies
The employer has to insure his employees. Sometimes employees
will be only insured against accidents at work, sometimes
also against accidents in their spare time. The fees for industrial
accidents are paid by the employer, the fees for spare time
accidents by the employee. In case you are not employed, you
can take out a health insurance against accidents.
All health insurers, which offer the compulsory
health insurance, have to take care of the same governmental
compulsory range of services. They are not allowed to recompense
for a large degree of voluntary services. It is regarded as:
the compulsory health insurance covers only services, which
are effective, useful and economic. In case the operator is
carrying out services, which are not compulsory, he is obliged
to inform the patient in advance about that.
Details of offered services:
a) medical services:
There doesn’t exist a special list of actually effective,
useful and economic services. If the cost compensation of
a certain service is controversial, the “Confederate
Commission for General Services” examines (see http://www.admin.ch/ch/d/cf/ko/index_310.html),
if services can be produced or not. The decision is taken
by the “Confederate Department of the Interior”
and summarized in a list (see http://www.admin.ch/ch/d/sr/832_112_31/index.html
b) hospital treatments:
The basis of estimation for stationary treatments form contractual
regular estimated compensations. The estimated amounts are
valid for the respective canton and they cover a maximum of
50% of the costs (in the general department of a public or
public subsidized hospital). Hospitals ask for lower taxes
from locals than from foreigners (exeptions may be possible
in case of emergencies).
c) non-medical services:
It concerns the areas of physiotherapy, ergotherapy, out-patient
nursing, food consultation, diabetes consultation, speech
therapy, pharmasist services, services through chiropractors.
Payment is effected in accordance with the nursing service
d) medical prescriptive products, analysis,
There are 4 positive lists:
· Resource- and object list (e.g. bandages, dressing
· List of analysis (only for analysis, carried out
· Drug list
· List of specialities (ready-made medication)
The lists are being reviewed regularly.
e) measures of prevention:
Overview of the measures of prevention: taken from art. 12
of the nursing service provision (KLV)
Health examination and the normal development of a child at
the pre-school age in accordance with the manual of the Swiss
society for paediatrics about “medical check-ups”
(2. edition, Bern, 1993) total of eight check-ups
Screening on phenylkentonurie, galactosamy, biotinidase deficiency,
adrenogenital syndrom, hypothyroidism of newborn babies.
Gynaecological medical check-up inclusive cancer smear test.
The first two examinations including cancer smear test in
annual intervals and after that every third year. This is
valid for normal results; if that is not the case: a check-up
interval according to clinical estimation.
HIV tests for newborn babies of HIV positiv mothers and for
persons, who are exposed to a risk of infection, connected
to a consultation, which has to be documented.
Colonoskopie in case of a family colon cancer (if a minimum
of three persons in the first relations degree is affected
or a person younger than the age of 30 ).
Vaccination and booster against diphteria, tetanus, pertussis,
poliomyelitis; vaccination against measles, mumps and German
measles for children and young people until the age of 16
as well as for adults, who are not immune, in accordance with
the “plan for routine vaccinations” of the Federal
Office of health (BAG) and the Confederate Commission for
questions of vaccinations (EKIF).
Booster vaccinations against tetanus and diphteria for persons
over the age of 16 in accordance with the “plan for
routine vaccinations” of the BAG and the EKIF.
Haemophilia influenza vaccination for young children up to
the age of five in accordance with the “plan for routine
vaccinations” of the BAG and the EKIF.
Vaccinations against influenza, annual vaccination for persons
with an underlying illness, who run the risk of bad complications
in case of the flu (in accordance with recommendations for
preventions against influenza of the BAG, the team Influenza
and the EKIF, state August 2000; supplement XIII, BAG 2000),
and for people over 65 years.
Hepatitis B vaccination 1. For newborn babies HB-Ag positive
mothers and for persons, who run the risk of infection. In
case of job-related indication the employer has to pay the
vaccination. 2. vaccination regarding the recommentation of
the BAG and the EKIF from 1997 (supplement of the bulletin
of the BAG 5/98 and addition of the bulletin 36/98) and 2000
(bulletin of the BAG 44/2000). Number 2 is valid until December
Passive vaccination with hepatitis B immuno globulin for newborn
babies of mothers, who are HbsAg positive.
Pneumo coccoid vaccination 1. with polysaccharide serum: adults
and children from the age of two years with serious chronic
illnesses, immune suppression, diabetes mellitus, immunosuppression,
cerebral liquor fistula, practical or anatomical splenectomy,
cochlea-implant or deformity at the base of the skull or before
a splenectomy or the cochlea-implant 2. with conjugate serum:
children under five years in accordance with the recommendation
of the Confederate Commission for questions of vaccinations
of 2001 and 2003 (bulletin of the BAG 29/2001 and 35/2003).
Skin examination in case of a higher risk of melanoma within
the family (melanoma at a person in the first relations degree).
Mammography 1. Diagnostic mammography: breast cancer at mother,
daugther or sister. Up to one annual preventive examination
according to clinical estimation. After an extensive educational
talk before the first mammography, which has to be documented.
The mammography has to be carried out by a doctor, who has
to be specially educated in medical radiology. The security
of the equipment has to be in accordance with the EU guidelines
of 1996. (European Guidelines for quality assurance in mammography
screening. 2nd edition) 112. Screening mammography: Every
second year over the age of 50 within the program of early
diagnosis of breast cancer in accordance with the regulation
of June 23, 1999 13 about the securing of quality for programs
of early diagnosis of breast cancer by mammography. There
is no franchise for this service. Number 2 is valid until
December 31, 2007.
Vitamin K Prophylaxis for newborn babies (3 doses)
Vitamin D administering for the rachitis prophylaxis during
the first year of life.
In vitro muscle to recognize a predisposition for malign hyperthermy
for persons after a case of anaesthesia in case of suspected
malign hyperthermy and for first degree of blood relations,
who have malign hyperthermy under anaesthesia and a documented
predisposition for malign hyperthermy in an established centre
of the European Malignant Hyperthermia Group.
Meningo coccoid vaccination with conjugate serum in accordance
with the recommendations of the EKIF of 2001 (bulletin of
the BAG 46/2001). Cost coverage by the compulsory health insurance
is reduced to following situations: medical indication vaccination
of family members, who live in the same household as the probable
or certain case. Vaccination of persons, who slept in the
same room or were directly exposed to nose or throat secretion.
Vaccination of first degree family members before the age
of 20, also without contact.
Vaccination against tuberculosis with BCG serum in accordance
with the regulations of the Swiss organization against tuberculosis
and lung illnesses (SVTL) and the BAG of 1996 (bulletin of
Genetic advice, indications for genetic examinations and arranging
of the according laboratory analysis in accordance with the
list of analysis (AL) in case of suspected predisposition
for a cancer illness in the family. Patients and first degree
relatives of patients with: hereditary ovacrial breast or
cancer syndrome - Polyposis Coli/attentuative form of Polyposis
Coli– hereditary non polypotic colon cancer HNPCC–
Specialists of medical genetics or members of the «Network
for Cancer Predisposition Testing and Counseling» of
the Swiss institute for applied cancer research (SIAK), who
can prove the professional cooperation with a specialist of
Vaccination against early summer meningitis encephalitis (FSME)
for persons, who are regularly in the nature of endemic disease
areas in accordance with the recommendations of the BAG and
the EKIF of March 2003 (http://www.bag.admin.ch/infekt/ publ/wissenschaft/d/fsme_empf.pdf).
In case of job-related indication the vaccination has to be
paid by the employer.
Varicella vaccination of non-immune youth and adults as well
as specific risk groups in accordance with the recommendations
of the BAG and the EKIF of November 2004 (BAG bulletin no.
f) services in case of maternity/birth:
(art. 13-16 KLV)
· check-ups (7 in a normal pregnancy)
· 100 francs for birth preparation courses of midwives
· silent advice (maximum of 3 sessions) by midwives
or special trained nurses
· midwives: six check-ups during pregnancy. (in case
of risk pregnances the doctor and the midwife cooperate.)
The midwife can arrange a scan; she is responsible for the
g) dental treatments:
The costs for dental treatments are covered by the compulsory
health insurance in connection with:
· Serious and unavoidable illnesses or
· Illnesses of the jaw system caused by a serious general
· Accidents (if no other insurer covers the costs)
The costs for fillings in case of caries or braces to correct
the position of teeth will not be covered.
h) health cures, transport and rescue costs:
· For a medical health cure, a maximum of 10 francs
per day are paid for a maximum of 21 days a year. Requirement:
an authorized medical bath
· Transports, which are necessary because a trip by
private or public means of transport is not possible, will
be supported with a payment of half of the amount. The annual
maximum sum is 500 francs.
· As far as rescue service in Switzerland is concerned:
Half of the rescue costs will be covered, a maximum of 5000
francs per year.
i) services abroad:
If an emergency treatment abroad is necessary, i.e. the return
to Switzerland is not possible because of medical reasons;
costs of up to the double amount what would have been paid
for the treatment in Switzerland are covered. No other medical
services abroad will be covered.
j) cost sharing of insured parties:
The cost sharing consists of following parts:
· Every adult pays annually the first 300 francs for
medical and hospital costs himself, the so-called real franchise
(not paid by children and young people up to the age of 18).
It is also possible to take out insurance models with lower
insurance bonuses and a higher franchise. (see 3.)
· There is a retention rate of 10% of the remaining
invoice fee (a maximum of 700 francs a year, children and
the youth up to the age of 18 pay 350 francs).
· persons living in a single household pay 10 francs
per day themselves in case of a hospital stay (Exeption: maternity)
No cost sharing in case of a normal pregnancy (complications
are illnesses, therefore cost sharing) and special indicated
3. insurance models with premium reduction
a) eligible franchise
Within this model, the cost sharing (see 2.year) of the insured
party is changing. The covering of the operation costs stays
unchanged. The insured party pays a smaller premium than he
would have paid for the real franchise of 300 francs.
b) reduced choice of the service supplier
There is a medical collective in Switzerland, a so-called
HMO (=Health maintenance organization) (see 1.). It is possible
to get an insurance, where you only get your treatment through
this HMO or consult your GP first and he takes the decision
if you should go to a specialist or not. The insured party
practically gives away his/her right to choose a doctor freely
and therefore pays lower premiums.
c) bonus insurance:
The bonus system includes a no claims bonus. The insured party
receives an additional premium reduction with every year,
where he/she doesn’t get some costs refunded. The initial
premium is 10% over the normal one, but the reduction can
amount to 45% within 5 years.
In Switzerland the part of expenses, which is not paid by
insurances is very high: in accordance with OECD figures the
so-called out-of-pocket payments amount to 1085 $ per inhabitant
(adjusted purchasing power). This is 31.5% of the total costs.
There is no other OECD country with such a high self-pay burden
for patients, not even the USA (737 $).
It is rare to use high franchises for premium reduction. Only
6% of all Swiss use the maximum franchise of 2500 francs.
In 2005 45% (like in the previous year) stays with the compulsory
basic franchise. In a survey many people mentioned the lack
of financial means as a reason for not paying the costs of
such a high franchise in case of illness. However, many people
could afford a franchise of 3200 francs. It seems as a big
amount of insured parties are insured with a too high health
4. Financing of health insurances
Every insured party has to pay the health insurance himself,
the amount of premiums is not dependend on the salary. (in
contrast to the accident insurance, which is deducted from
the employees’ salary, dependend in accordance with
the amount of the salary.) The Federal Office has to approve
the amount of bonuses, which is established by the particular
health insurance of the various regions. Persons with a low
salary get a contribution to the payment of premiums.
4. Distribution in the cantons of the average
of monthly premiums for adults (from the age of 26) in francs
for 2005 (with real franchise and accident covering)
(Graphic source : http://www.bag.admin.ch/kv/analysen/f/doc/CHSS0105_5p_d.pdf
The illustration shows the amount of bonuses in the various
cantons and you can see extemes in the cantons of Geneva and
Appenzell-Innerrhoden. Furthermore, the difference of bonuses
within a single canton is big. The point shows the average.
In addition, the insurers finance themselves through the offer
of additioinal insurances but applicants can reject this offer
in case of bad risks.
5. cost development / cost explosion
Also in 2005 the health costs are increasing
by more than 4% annually, which makes them the second highest
globally. During the last decades health costs have been increasing
faster than the general rate of price increases, faster than
the GDP. There are several reasons, like in other countries.
Some are the incrasing specialization and mechanization, expensive
drugs, an increasing amount of private practising doctors,
structural development of the population, decreasing social
solidarity (self-help, honory office) and an improved access
to high quality care services. In 2003 the Swiss health service
costed almost 50 billion francs, in 2004 already more than
50 billion francs. The Federal Office for statistics reckons
with 54 billion francs in 2005 and in 2006 with 56 billion
The health insurance covers only 1/3 of these costs, private
households and the state pay the rest.
The premium income is the most important component of return,
the net profits and the administration costs are the two most
important components of expenses of the insurers. If you decrease
the cost sharing (part of the gross profits, which has to
be paid from ill persons, like franchise, retention and part
of the costs for a hospital stay) from the gross profits,
you receive the net profits - the part of the services, which
will be covered by the insurers:
( Source: Federal Office of Health http://www.bag.admin.ch/kv/aufsicht/d/2005/praemien_2005_komm_grafiken_d.pdf
The main part of the money goes to hospitals, but this contribution
is shrinking. The costs for social-medical institutions like
old people’s homes, nursing homes or facilities for
disabled people. The reason for this increase might be the
ageing of the population, among other things.
6. Effective costs in francs per insured party per month of
insurance, divided in age groups and gender in 2003
(Source: Federal Office of Health -
The ageing (especially the growing of the population over
75 years) of the population is, like in other countries, one
of the main reasons for the increasing costs. In addition
– the increase of wages in the health industry and the
increasing women’s quota in the labour force (these
women are not at home anymore to care for their relatives).
6. The unified health insurance – a way to create lower
health insurance premiums?
The Swiss population is able to vote for a unified health
insurance in a publics’ initiative (submitted in the
end of December 04). The initiative is called “for a
social unified health insurance” and asks for a single
health insurance as a basic insurance. The per capita premium
should be banned and the calculation of the premium should
instead be oriented on the particular economic productivity.
The aim is to create deeper premiums and more possibilities
to a say in a matter. Deeper premiums should be possible,
as a unified health insurance can work on a more efficient
and economic base, because administration and marketing expenses
would be considerably lower.