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Subject: qotd: Swiss lessons on cost sharing
Date: Wed, 5 Sep 2012 11:09:15 -0700
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
In press - Draft published online August 23, 2010
High prevalence of forgoing healthcare for economic reasons in
Switzerland: A population-based study in a region with universal health
By I. Guessous, J.M. Gaspoz, J.M. Theler, H. Wolff
Health insurance is compulsory for all citizens in Switzerland and
insurance premiums are paid independently of income. Health insurance
covers the costs of medical treatment and hospitalization for the
insured. The insured person pays part of the cost of treatment: an
annual flat deductible, called the franchise, chosen by the insured
person (with premiums adjusted accordingly) and a 10% co-pay of the
costs up to a stop-loss annual amount of CHF 700 (1CHF≈1$). Between 1099
and 2010, health insurance premiums increased by 77%, coupled with
increasing out-of-pocket payments. Increasing out-of-pocket spending
may, at least in some settings, reduce the use of clinically important
services and drugs to prevent the onset and progression of chronic
disease (Paez et al., 2009).
We aimed to determine the characteristics of participants who report
forging healthcare and to describe the past 4-year trend for forgoing
healthcare for economic reasons.
To investigate the determinants and the 4-year evolution of the forgoing
of healthcare for economic reasons in Switzerland.
Population-based survey (2007–2010) of a representative sample aged
35–74 years in the Canton of Geneva, Switzerland. Healthcare forgone,
socioeconomic and insurance status, marital status, and presence of
dependent children were assessed using standardized methods.
A total of 2601 subjects were included in the analyses. Of the subjects,
13.8% (358/2601) reported having forgone healthcare for economic
reasons, with the percentage varying from 3.7% in the group with a
monthly income ≥ 13,000CHF (1CHF ≈ 1$) to 30.9% in the group with a
monthly income < 3000CHF. In subjects with a monthly income < 3000CHF,
the percentage who had forgone healthcare increased from 22.5% in 2007/8
to 34.7% in 2010 (P trend = 0.2). Forgoing healthcare for economic
reasons was associated with lower income, female gender, smoking status,
lower job position, having dependent children, being divorced and
single, paying a higher deductible, and receiving a premium subsidy.
In a Swiss region with universal health insurance coverage, the reported
prevalence of forgoing healthcare for economic reasons was high and
greatly dependent on socioeconomic factors. Our data suggested an
increasing trend among participants with the lowest income.
► Forgoing healthcare for economic reasons is frequent in a region of
► This prevalence varies with reported monthly household income category
from 3.7% to 30.9%.
► Data suggest an increasing 2007–2010 trend among participants with the
► Risk factors include gender, smoking, occupation, children, being
divorced, and insurance status.
► Forgoing healthcare is associated with worse self-rated health status.
Comment: Conservatives in the United States often praise the Swiss
health care financing system largely because it is composed of a choice
of private health plans (although they may not like the facts that it is
compulsory, that it is heavily regulated, and that it is one of the most
expensive financing systems in the world). So what is the policy lesson
from this study of the Swiss system?
The out-of-pocket deductibles and coinsurance result in a high
prevalence of forgoing health care for economic reasons. The prevalence
is inversely related to household income, but even at the highest income
levels, some do forgo health care for economic reasons. Forgoing health
care is associated with worse self-rated health status, and reduces the
use of clinically important services and drugs.
Other nations have shown that you do not have to have deductibles,
co-payments, and coinsurance to control health care spending. Since
these cost sharing measures do have the detrimental effect of reducing
the use of clinically important services and drugs, they should be
rejected as bad policy. The other measures inherent in a well designed
single payer system obviate the necessity of patient cost sharing.