3.4 Out of pocket payments
OOP payments were responsible for about three quarters of private expenditure in 2012. The most important category of OOP payments are direct payments on services excluded from MHI or VHI coverage, which reached almost Sw.fr.14 billion (or 20.5% of THE) in 2012. One quarter of private expenditure was cost-sharing for services covered by MHI (Sw.fr.3.7 billion), while cost-sharing for services covered by VHI accounted for Sw.fr.0.05 billion, summing up to a total of Sw.fr.3.75 billion (or 5.5% of THE, see Table3.2). VHI cost-sharing is not further discussed.
3.4.1 Cost-sharing (user charges)
Table3.6 summarizes the system of user charges for different categories of MHI-covered services. The level of user charges is determined by the Department of Home Affairs in the Regulation on Health Insurance (KVV/OAMal).
All MHI policies (except for children) require a deductible, i.e. the insured have to cover a fixed amount before MHI companies begin to reimburse them for the services received. Since 2005, the minimum (standard) annual deductible for adults is Sw.fr.300 (none for children) and the maximum deductible is Sw.fr.2500 for adults (Sw.fr.600 for children, see Table3.6). There is no deductible for medical services provided to women during maternity (pregnancy and childbirth) and for a few preventive services.
After the deductible, patients have to pay 10% co-insurance on the price of all MHI-covered services they receive. This amount has to be paid directly out of pocket because complementary VHI coverage for user charges is prohibited. Furthermore, to incentivize the use of cheaper generics, there is a 20% co-insurance rate on brand drugs, for which a generic equivalent exists. The total annual amount that patients have to pay on co-insurance is capped at Sw.fr.700 for adults and Sw.fr.350 for children (2012).
For acute care hospital inpatient stays a co-payment of Sw.fr.15 per day is charged for adult patients. Young persons under 26 years are exempted as well as women in hospital for childbirth. However, the exemption does not apply to complications of pregnancy. There is no cap on the total annual amount for the inpatient co-payment.
3.4.2 Direct payments of private households
Services that are excluded from MHI coverage (and are not covered by VHI) must be paid for directly by patients or by other private funding for health. In 2012, Sw.fr.13.3 billion or 19.6% of THE were paid directly by patients and Sw.fr.662 million or 1.0% of THE by other private funding for health.3
One example of services that are not included in the MHI package (see section 3.3.1) is routine dental care. Dental care accounts for about a quarter of all direct payments in Switzerland (see Table3.2), and 90% of dental care costs were funded by direct payments and other private expenditure on health. A fifth of all direct payments are spent on outpatient services not covered by MHI or VHI. These include services provided by independent psychotherapists (i.e. psychotherapists who do not practise within the premises of a physician’s office; see section 5.11.2), some services provided by physicians, and all services (if provided without prescription from physicians) by physiotherapists, home care providers (Spitex), medical laboratories, radiation units and ambulance services.
Inpatient long-term care (i.e. nursing homes) accounts for a quarter of direct payments in Switzerland. A share of 39.2% of the total expenditure for inpatient long-term care institutions in 2012 is directly paid by households, mainly for housing and assistance. MHI only covers “medically necessary” services for long-term care. Since January 2011, MHI pays a fixed contribution to cover long-term care, the individual patient pays at most 20% of the MHI’s contribution, and the remaining costs are financed by the canton or locality.
Patients also make direct payments for medicines and pharmaceutical products not included in the positive lists (see section 2.8.4). An estimated share of 26.2% of costs of retail trade products is paid by private households.
Direct private household payments in outpatient and inpatient hospital services are for supplementary services, such as single or double rooms, or for non-essential interventions, such as plastic surgery (unless medically indicated) and in vitro fertilization. Such direct payments amounted in 2012 to about 9.9% of all hospital acute care expenditure.