Why is this model suitable for organising health insurance?

The model rests on the assumption that competition, as an organisational mechanism, brings certain advantages – efficiency, innovation and freedom of choice for the insured, to name a few. Other systems, such as the NHS in the United Kingdom, rely on tax-funded, state-provided care. In those systems, there is significantly less freedom of choice regarding service providers such as doctors and hospitals, and only one type of insurance cover. In return, greater emphasis is placed on comprehensive and uniform access to care.

So is regulated competition the perfect health insurance system?

No, there is no such thing as a perfect system. Every system reflects certain values and priorities. Some countries place greater weight on access, others on efficiency or freedom of choice. These objectives cannot all be maximised at once, as they pull in different directions. This also means that systems – even those following the principle of regulated competition – are designed quite differently in practice. The scope insurers have to tailor their offerings varies considerably from country to country; in Switzerland, it is rather limited. Under basic insurance, for instance, insurers cannot freely choose which service providers they wish to work with.

Where do you currently see the greatest challenges for the Swiss system?

By far the greatest challenge is costs. A significant driver is the lack of digitalisation and the resulting poor coordination between service providers, which leads to duplication of effort. Many processes remain fragmented and data is often not used efficiently. This is also partly down to structural and cultural factors – federalism, for instance, and a certain scepticism among the population towards centralised solutions, particularly when it comes to personal data. I see considerable potential here for improving efficiency.

And what is working very well in Switzerland?

Switzerland has a healthcare system of relatively high quality with good patient outcomes, and this standard is reflected in health insurance too. Access to care is very good; appointments and treatments are generally available quickly, albeit with variation depending on the specialist area. Overall satisfaction with the system is high – cost aside.

Where did you identify parallels between the systems of the countries you compared?

All four countries guarantee comprehensive medical care, including hospital treatment, medication and care from GPs and specialists – though there are differences in certain services, such as physiotherapy. All systems also attempt to control costs and ensure access, with funding provided through premiums and cost-sharing by the insured. In addition, all have mechanisms for risk equalisation between insurers, as well as reimbursement models that give service providers a greater share of cost responsibility.

And what were some of the key differences?

One central difference is access: in the European countries examined, health insurance is compulsory; in the US, it is partly voluntary and not universal. A second difference lies in the structure of insurers. In Europe, they are mostly independent, often non-profit organisations, whereas in the US the spectrum ranges from non-profit providers to large, profit-oriented healthcare groups. A third difference concerns cost control: the US relies more heavily on market mechanisms, while European insurers have fewer possibilities to do so. 

What can Switzerland learn from other countries?

I see potential in the Dutch model. There, insurers have more leeway than in Switzerland, such as in the selection of service providers, for example. At the same time, cooperation between the state and insurers tends to be closer and more consensus-oriented. In Switzerland, that leeway is more restricted, and it is worth asking whether greater flexibility might lead to efficiency gains.

Were there any findings from the comparison that surprised you?

I find the question of incentives for Swiss health insurers particularly interesting. Under basic insurance, they are not permitted to distribute profits, must accept all applicants and, at the same time, have only limited room for manoeuvre. There is more flexibility with supplementary insurance, but not all insurers offer this. It raises an important question: what is actually the objective of a health insurer within such a system, and what incentives exist to operate efficiently or reduce costs? This is something we would like to explore in greater depth in future research.

Interview: Katja Haas, Head of Knowledge Transfer and Communication, Faculty of Health Sciences and Medicine