Swiss charm
Switzerland receives around eight million foreign tourists every year. Many of these pass through without incident, enjoying the country’s majestic landscape and snowy peaks, but for those that find themselves in need of medical treatment, what does the country have to offer; and what can assistance companies expect when dealing with local hospitals and clinics? Tatum Anderson finds out
First published in ITIJ 137, June 2012
Switzerland receives around eight million foreign tourists every year. Many of these pass through without incident, enjoying the country’s majestic landscape and snowy peaks, but for those that find themselves in need of medical treatment, what does the country have to offer; and what can assistance companies expect when dealing with local hospitals and clinics? Tatum Anderson finds out
Think Alpine peaks and chocolate box chalets, 250 ski resorts, raclette and Heidi. With such unmistakable national icons, it's not surprising that so many tourists visit Switzerland each year. And tourists have been flocking here for their health for a good few centuries. Switzerland has attracted the great and the good of European society: in fact, Robert Louis Stevenson was reported to have finished Treasure Island whilst taking the air at a sanatorium in the Swiss mountains.
Actually, a number of Swiss resorts, such as St Moritz and Davos, were medical destinations well before they became the luxury ski resorts they are better known for today. Now, medical tourists to the country spend as much as CHF1 billion (CHF1 = €0.83 or US$1.06) per year, according to some estimates.
Switzerland may be popular with tourists, but it is also attractive to expatriates. Almost 1.8 million have made Switzerland their permanent residence to date. In a country with 7.7 million inhabitants, that's a fair proportion of the population. Many work in the country’s international finance industry, for instance, or for the United Nations; but Switzerland is particularly attractive to such foreigners, in part, because of the high standard of living. It is one of the richest countries in the world, with a GDP of $638 billion last year, according to The Economist; and it is something of a tax haven. Unsurprisingly, then it had the highest concentration of high-net-worth individuals – one in 30 – of any country in the world in 2009.
With so much wealth sloshing around, it is not surprising that the US State Department believes that Switzerland has one of the best health systems, an accolade it reserves for very few countries indeed. Visitors and inhabitants are certainly well looked after by the health system. While there are concerns about shortages of nurses in many European countries, Switzerland has almost twice as many nurses per 1,000 of population as the average across the Organisation of Economic Cooperation and Development (OECD), a rich country’s group, and more doctors. In addition, it has a higher number of hospitals per head of population than most rich countries in the world (more than 41 hospitals per million persons compared to an OECD average of 30 hospitals per million).
Indeed, there are 314 hospitals in Switzerland – of which around 40 are major hospitals and 185 specialist centres. Interestingly, some of the best hospitals are public ones. There are five University hospitals, for instance, in Switzerland’s largest cities – Geneva, Bern, Lucerne, Zürich and Basel – that all have a good reputation. The University Hospital in Basel has over 50 clinics, polyclinics and institutes. University Hospital Zurich boasts 6,200 staff and sees around 200,000 patients a year. Other recommended public hospitals are within the cantons, Switzerland's 26 autonomous federal regions, although the spread of so-called cantonal hospitals is uneven, so some of the smaller cantons may only have one or two public hospitals to choose from.
In addition, there are a number of private specialist hospital groups such as Swiss Leading Hospitals and Hirslanden Private Hospital Group. The latter comprises 14 hospitals in 10 cantons, of which eight have emergency departments. Several of the country’s private hospitals have specialisms too: Klinik Im Park in Zurich, for example, specialises in cardiology, St Claraspital in Basel specialises in gastroenterology, and Klinik Gut, based in St Moritz and offering 24-hour emergency care and a trauma centre, specialises in orthopedics.
the US state department belives that Switzerland has one of the best health systems
Access to care
With the three official languages of Switzerland being French, German and Italian, hospitals are generally able to deal with foreign visitors and multiple languages. That includes English and Arabic in many places. As the majority of visitors to the country are from Germany, the UK, the US, France and Italy, this means that the communication channels between patients and hospital staff are made easier from the outset.
Assistance companies generally report that over-treatment and over-charging are not prevalent issues in Switzerland, and that hospitals and clinics are fairly easy to deal with. Says Philippe Geyer, business development manager Switzerland for Allianz Worldwide Care: “[In private clinics], billing and administration is perfectly compatible with international insurance companies … [However, in public hospitals], their procedures are usually not very ‘foreign friendly’, in particular billing and treatment guarantees.” He points out, though, that some public hospitals, in cantons such as Neuchâtel – which is at the heart of the micro-technology and high-tech industries, and where, since 2008, over 30 per cent of the population have been resident foreign nationals – have no problems in dealing with foreign-based insurance companies.
So, when a visitor does fall ill or sustain an injury, where are they taken? It's unusual for many assistance companies to place a patient into a private hospital unless explicitly requested. Private healthcare is bypassed largely because the quality of public health is good enough, according to Wolfgang Seeger, operations manager for medical assistance at Medicall, which provides assistance for several insurers. He says: “To be honest, there is no medical reason for focus in private hospitals for international patients.”
But even in the public sector, good quality doesn't come cheap. In Switzerland, there is no free health service. Indeed, the country's health system is one of the most expensive in the world. “[In Switzerland], costs [in public hospitals] are much lower than in private clinics, but still expensive compared to other European countries such as France and the UK“, explains Geyer.
Along with Norway, Switzerland spends more on health per citizen than any other country apart from the US – around $5,000 per capita in 2009. And tourists must pay their share. Those with an EHIC are covered for emergency treatment in the public ward of a public hospital (no semi-private or private wards are covered). However, there is an excess, or deductible, to pay for every 30-day period – CHF92 for adults and CHF33 for children. This sum is not refundable in Switzerland, although different countries will make their own arrangements to reimburse travellers when they return home. Up-front payment for visiting a doctor (general practitioner) registered within the Swiss health system is expected from those using an EHIC. Patients must pay the full cost for treatment and services and claim a refund at the Gemeinsame Einrichtung KVG, the Swiss government office that coordinates sickness payments, or once they return to their home country.
It's unusual for many assistance companies to place a patient into a private hospital unless explicitly requested
In addition to these costs, tourists covered by the EHIC are expected to stump up half the cost of ambulances, both land and air. There is a maximum, however: CHF500 per year is allowed for land ambulances and CHF5,000 for air ambulances, according to the UK’s Department of Health. Neither is refundable in Switzerland. Importantly, there are no upfront costs for emergency transportation. Emergency ambulance services are organised by each canton, which tends to operate autonomously. That means some may use public as well as private companies. Emergency services can be reached by the telephone number 144.
Insuring the cost of care
All Swiss citizens are expected to purchase a mandatory health insurance package. By law, expats must too. Specifically, any non-resident earning money in Switzerland or who is employed by a company whose headquarters are located in Switzerland must buy an insurance package. The law regulating such packages, called Loi Fédérale sur l’Assurance Maladie or LAMal, came into force in 1996.
LAMal-based packages are guided by a strict set of rules. Citizens can only buy packages provided by insurers within their own canton, and the insurers are prohibited from making profits, must take all applicants, and cannot vary costs or reject applicants on the basis of existing conditions. The cost of a basic policy varies only by age. The age ranges of 0-18; 19-25; 26 and above, are defined in law.
Usually, anyone with such a package must pay an excess of CHF300 and then 10 per cent of all costs up to an annual maximum of CHF700 for adults, CHF350 for a child, and CHF1,000 for a family. Some variations are allowed, however: special packages with lower premiums are allowed for those who opt for a larger excess, which is also called a deductible or franchise à option. Some packages offer deductibles as high as CHF2,500. Insurers also offer the health equivalent of a no-claims bonus, where prices reduce annually if no claims for reimbursement are made. And, finally, with some insurance policies, if patients agree to go to a specified set of service providers they can also receive a discount – a policy type that is growing in popularity in the country. “[In the last few years], such insurance plans have become more and more popular and are combined with an attractive deduction on your insurance premium,” confirms Seeger.
Given that packages vary by age and that patients can opt for different deductibles and services covered, there are an enormous variety of health insurance packages on offer. And because each canton runs its own hospitals, prices for treatment vary widely too. This means that exactly the same procedure can cost different prices both within and between cantons. For instance, an outpatient colposcopy in canton Schwyz costs CHF617 but in canton Waadt, the cost is higher at CHF748. Similarly, an inpatient appendectomy at the University Hospital in Zurich will cost CHF3,480, whereas at another hospital in the same canton as Zurich, the Cantonal Hospital in Winterthur (canton Zurich), this procedure costs just CHF2,900. The same procedure in canton Jura, at the Cantonal Hospital Jura in Delémont costs just CHF2,768.
It is obvious from the excess expected that Swiss patients and those without EHIC or other cover face relatively high out-of-pocket payments for healthcare. A recent OECD report on health systems in Switzerland estimates that 31 per cent of all health expenditure is out-of-pocket. That is a significant source of financing for the Swiss health system.
And even with the variety of mandatory packages on offer and co-payments required, the Swiss often opt for supplementary healthcare cover. These packages, by law, cannot cover the same services as or provide cost-sharing with mandatory health insurance, however. Instead, they may consist of a daily cash-benefit insurance. This type of supplementary package is often taken by employers on behalf of their employees to assist with their obligation to pay wages in the event of illness or hospitalisation. Individuals can also buy supplementary packages that offer private rooms in hospitals, dental care and alternative medicines. A whopping 88 per cent of Switzerland’s insured population had at least one supplementary insurance contract in 2007.
But despite the wealth of different health insurance packages, patients don’t necessarily get value for money, says a recent report from the OECD. In addition, patients rarely switch packages, which means there is little competition and correspondingly higher prices. Things are changing, however. The average number of insurers operating in each canton has risen from 38 in 1997 to 59 in 2011. Swiss citizens are now allowed to use inpatient services outside their home cantons.The way in which hospitals are reimbursed for interventions is also changing from per diem (charges per day) to charges per case. This new policy, called Swiss DRG, was introduced this year and is supposed to increase the incentive for shorter stays in hospital and ensure that more cases are treated. In other words, it promises to encourage hospitals to become more efficient.
despite the wealth of different health insurance packages, patients don't necessarily get value for money
Swiss DRG has certainly sparked a debate about the pros and cons of these charges in Switzerland, but according to assistance companies like Medicall, it's unclear whether the policy has improved healthcare efficiencies or changed prices for patients. “At the moment, there is no impact on premiums and co-payments. The impact will be seen in a few years,” says Seeger.