An unhealthy health care reform in Switzerland

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.

Info Box

A common argument against criticism of the Swiss health system is that the system is excellent and the population is satisfied. The most recent assessment by the Commonwealth Fund ranks Swiss health care overall 9th from 11 high income countries, and 3rd most expensive. Switzerland ranks poorly for administrative efficiency and access to care. Surveys of public satisfaction vary widely and do not always match with measures of quality, e.g. the National Health System in the UK rates highly in public esteem, but is considered very critically in Switzerland. On Swiss radio the UK system is explained, and compared with the US.

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 ……

The Covid Jab – a surprisingly emotional experience

The whole world is talking about it. Charts graph its progress. Touted as one of the greatest achievements of mankind. Yet many people reject it and seem to fear it even more than Covid-19.

The title of my blog is a bit of a give-away. Yes, this blog is about the Covid-19 vaccines, or rather my Covid-19 vaccine, which I got this morning, exactly one year after the Swiss government announced the “extraordinary situation” and put the nation into a semi-lockdown.

As soon as I learnt that where I live, people in my risk group could register for a vaccine, I did so. The delays in rolling out the vaccine had made me impatient. The current combination of increasing case numbers and political pressures in Switzerland to relax restrictions and open up the economy fill me with dread. In fact, compared with most other European countries, Switzerland has not imposed great restrictions on its people, and it was nice to be able to venture into the alps on several occasions this year. On the other hand, excess mortality has been high. I often felt that the wishes of the majority to go to restaurants carry relatively more weight in Switzerland, than the wishes of the minority not to get Covid-19.

I had to wait for one week before my vaccine, and it was long week. I knew that I should stay @home and keep safe, but the weather was so nice…. So, I went out, and then feared developing symptoms at the last minute. The day before the vaccine I felt happier than I had for a long time. On the day itself, I nearly got on the wrong train, nearly got out at the wrong station, thought that I’d forgotten some important documents, found I hadn’t, but still couldn’t find them in my bag, when I got to the hospital.

At the vaccination centre most people were elderly. The woman next to me in the waiting room was young and very nervous like me. A man in a white coat asked me for proof of eligibility. Then a woman in blue – her gloves exactly matching my blouse (see photo above) invited me to follow her. She was so kind! My nerves disappeared instantly. She said she had to ask me four questions, and held up five fingers. We laughed.

Seeing smiling people get the jab on TV I always thought that they were being rather brave. They were not. This jab was not just painless, I didn’t even feel it. However, the woman who vaccinated me said that I will feel it soon, just not today.

After waiting for a few minutes to make sure that I didn’t have an allergic reaction, I left the hospital. The young woman from the waiting room left with me. She started crying. I felt tears of relief as well.

One year of waiting and helplessness, of fear for oneself and loved ones, of sadness for the losses and pain of others. But it was also a year of amazement at all that we have learned about viruses, of frustration at politicians in denial, of anger about the inequalities that Covid-19 has revealed across and within nations. And finally a year of despairing at the ineptitude of leaders, who do not leave the playgrounds of party politics to collaborate for sustainable solutions for the common good.

And now something has changed. I have been the recipient of a vaccine against Covid-19. In one year we have a miracle for humanity, created by some of the most dedicated and brilliant people on the planet. Approved, produced, distributed and administered by the combined efforts of thousands more people. And the result is that today I could travel to a regional hospital in Switzerland to be vaccinated by the last person in this gigantic chain of genius, a kind woman wearing blue gloves.

With this vaccine, I am no longer in danger of becoming seriously ill, burdening the health system, or causing worry to my family and friends. In the light of the last year, I feel today that I am no longer part of the problem. Instead, in some sense I have become a part of the solution. In the UK and US people are already feeling more optimistic. As vaccination rates increase, Covid-19 case rates decrease. It’s not the whole solution, but surely a big part of it, and it’s nice to know that very soon, it will be unlikely that I will get Covid-19 and infect anybody else.

In a survey conducted in January this year on behalf of the Swiss Broadcasting Corporation 41% of the participants said they would be willing to get vaccinated immediately. That rate seems to be increasing, but it still isn’t enough. Even before the emergence of more infectious variants the WHO predicted that 60-70% immunity is necessary to break transmission. We need vaccine supplies for all, efficient logistics to administer them, but above all we need leaders with integrity and courage who can present the arguments to the public encouraging them to protect themselves and others by getting the jab.

Or, if such leaders are lacking, maybe get some stars to do this work instead, like Elton John and Michael Caine. Such fun to watch! Maybe the Swiss Council of ministers could ask Roger Federer, Lara Gut-Behrami and DJ Bobo?

Imagine that we have effective vaccines, but because of half-hearted take-up they don’t do the trick and contain the pandemic. Imagine that despite the availability of vaccines, case levels remain high, and new variants develop apace.

It’s time to speak up clearly in favour of vaccination, because vaccine hesitancy could destroy the window of opportunity that scientists have created for us in the last year.