The Swiss Federal Council plans to ration health care as part of health system reform. The immediate purpose of rationing is to reduce costs. As a patient advocate, I am adding my voice to a broad coalition who criticise this proposal as misguided.
Will rationing health care reduce financial health costs?
And how will rationing affect the costs in terms of human suffering, if it reduces the quality of care?
If you are interested to learn more, please read on…
In Switzerland health care is considered excellent, but it is also very expensive. In addition, the cost contributions for patients are high which make the system regressive: those disadvantaged by illness or low-income bear a relatively higher burden of cost than the healthy wealthy. (The wealthy are per se healthier than the poor: partly because they have the means to buy healthy food, practise sports, and visit doctors at the onset of a health problem rather than wait until it becomes more serious.)
The Swiss health system is highly commercialised – it even drives children’s hospitals towards profit-making – and fragmented, with responsibility for providing health care largely delegated to the local cantons, resulting in 26 different health systems. These systems are governed and organised by various public and private entities (Confederation, cantons, municipalities, health insurers and service providers) each of which assumes different tasks. As a result, the Swiss health system is complicated needing a costly administration to help both patients and doctors negotiate the system.
Effective governance of this complex system is further compromised by the inherently slow decision making of the Swiss political system, as well as the undue influence of private industry. For example, members of the Commissions for Social Security and Health in both the upper and lower houses of parliament attract an impressive list of lobbyists; who work in the interests of the private industries they represent, not in the interest of the public, whom the commission members are mandated to represent. Many Commission members are also active in the governing boards of health industry players creating a conflict of interest with their parliamentary mandate.
Finally, there is no independent public health institution such as the Robert Koch-Institut, as exists in Germany. The Federal Office of Public Health (FOPH) is pressured to serve political decision-makers. As an example, the responsible FOPH medical doctor for Sars-CoV-2 stated early in the pandemic that masks were unnecessary and would not protect the public. Many thought the real explanation was that there were not enough masks even for hospital workers, because regulations for reserving stockpiles had not been adhered to. Whatever the reason, the credibility of the FOPH was compromised.
Given these characteristics, I will argue that despite the passion and dedication of most health professionals, the Swiss health system primarily serves the industries that benefit from it, and not the people it should be there for: the public and specifically, patients.
The Swiss health system primarily serves the industries that benefit from it, and not the people it should be there for: the public and specifically, patients.
In 2019 the government published a health strategy called Health2030 which identified many of the issues faced not only by Switzerland but also by health systems worldwide: digitalisation, demographic changes, the increase of non-communicable diseases (NDCs), and rising costs of health care.
One of the proposed measures suggested by an Expert Group is legislation to enable the government to limit the growth of healthcare costs by using “expenditure targets,” i.e. budget restraints on outpatient care. The result is essentially that a target is set for the number of illnesses that can be treated in a given time period, e.g. one year, on an outpatient basis. When expenditures reach the set limit during that year, either services must be cut, waiting times must be introduced, or patients must be shifted from out-patient to in-patient care. A system of budget restrictions has been adopted in other countries e.g., in the UK and more recently in Germany.
This proposal has met with united criticism from all health partners, including the patients, medical clinicians’ association FMH, insurers and industry representatives. Consultation with patient advocacy groups has been cursory, and patients do not have the resources to campaign, which are available to other players. Here I present the patient perspective about these proposed measures. The views are my own but have been discussed with other patients and the Swiss Patients’ Organisation SPO.
Expenditure targets in health care assume that costs can be controlled and predicted. However, illness or accident are by their very nature unwelcome and unplannable events, as the Covid-19 pandemic has clearly shown. Accordingly, treatment costs can only be precisely predicted or regulated, if there is an explicit decision not to treat beyond a set target. (Stefan Felder of Basel University shows the impossibility of this approach and other shortcomings, which I do not explain here.) Nonetheless, this is the strategy: the government proposes to set a budget constraint for medical outpatient care.
Such a strategy opens frightening perspectives for patients. If one day you receive the diagnosis of cancer, you will want to be treated immediately and not wait. 10% of women worldwide suffer from breast cancer some time in their lifetime. Currently in Switzerland, when a woman is suspected of having breast cancer based on mammography, she will get a biopsy and begin treatment within two weeks of the suspected diagnosis. What if she gets a suspicious mammography in October, but the budget for that year is exhausted? Will she have to wait until January to get the biopsy or out-patient lumpectomy or radiotherapy? I, who have personally benefited from prompt care, would not want other women to be delayed because of budget restraints.
Delays in treatment may lead to poorer outcomes. As an analogy, in Switzerland (and in other countries) the Covid pandemic led to the postponement of many treatments. The future losses in years or quality of life are unknown. The consequences in terms of poorer outcomes have yet to be evaluated. The ethical dilemmas for medical staff – having to choose which patients to prioritize – were enormous. What will be the effect on the morale of medical staff when such dilemmas are built into the system, not just the result of a worldwide catastrophe?
Apart from the consequences for those needing health care, it seems unlikely that this measure will achieve long-term sustainable cost savings. Let us assume that budget constraints are introduced, medical costs reach the cost ceiling and the rationing of care kicks in. This will lead to other health care costs. In the case of cancer, it is well understood that any delay increases the risk that the cancer will spread and cannot be cured at all, or only at greater cost. In fact, this will be true for most other chronic diseases. Delaying or postponing appropriate care may or may not save costs in the short run, but it seems hard to believe that it will not reduce the quality of care and lead to poorer outcomes with costs in human suffering.
Delaying or postponing treatment may or may not save costs in the short run, but it seems hard to believe that it will not reduce the quality of care and lead to poorer outcomes with high costs in human suffering.
The government strategy also overlooks many other opportunities to save costs and improve the quality of care. The cost-saving opportunities presented by listening to patients – something that I have written about in this and other blogs – are enormous, if the right incentives and structures are made available.
Finally, chronic non communicable diseases like mine are the biggest cost factor in the Swiss health system, as the strategy Health2030 acknowledges. It seems likely that the chronically sick will be most adversely affected by this reform, perhaps creating new systemic inequities in access to health care.
In my next blogs I will examine how the chronically sick will be affected by this reform, and how patients could contribute to a health system which reducing costs without leading to poorer care outcomes.
To be continued ……
