The Swiss Mental Health Care System

Switzerland has a permanent resident population of eight million and is structured as a federal directorial republic with 26 cantons, which are independent in all matters that are not specifically designated as the responsibility of the federal government. Switzerland has a private health care insurance system, with federally mandated insurance, and the cantons are responsible for the planning and delivery of health services, partial financing of hospitals, and provision of subsidies for insurance premiums (3). Residents can choose from about 60 different insurance companies. Every Swiss resident, including foreign citizens, is required to acquire statutory health insurance from competing insurance companies. In the case of financial hardship, local authorities will cover the expenses on the basis of income (subsidies). There is no government insurance program, such as Medicaid, for persons whose income and resources are insufficient to pay for health care. In Switzerland, the elderly, like the rest of the population, receive their care via these private insurers and do not receive any special financial considerations beyond the general subsidy (4). Swiss health insurers are required to offer comprehensive policies that cover a wide range of medical care. Employers do not provide health insurance for their workers, nor do they pay a tax for health care. However, employers must provide casualty insurance for accidents. Premiums for adults over the age of 26 do not vary by age or health status.

Table 1 presents comparative data on health care expenditures. The Swiss federal government regulates the health insurance market, including services covered and form of payment. Statutory health insurance benefit packages reimburse most primary care physicians and specialists and cover an extensive list of medications, physical therapy, and some preventive measures. Most health care providers in Switzerland stay within the reimbursement system because patients are readily able to access care and are unwilling to pay out of pocket. As a less expensive alternative (reductions up to 25%), residents can sign up for coverage with a health maintenance organization. In addition to the mandatory basic health insurance, residents may purchase complementary and supplementary premium packages to cover improved accommodation and free choice of hospital and treating physician (5).

To influence outpatient utilization and spending, the Swiss government introduced in 2004 the TARMED (French, tarif médical) tariff system for outpatient health services. It encompasses about 4,000 tariff positions, which label and assess services provided by physicians. The pricing of medical services with TARMED is calculated consistently throughout Switzerland with so-called tariff points. The canton and the health insurers negotiate the monetary value attributed to the tariff points for private and public institutional outpatient services (6). Also, in an attempt to regulate the supply side of health care, the Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care providers. The cantons have the jurisdiction to implement this law or to allow exemptions in case of a shortage of physicians in primary care or in certain specialties (7). Health insurers must provide mandatory insurance plans with different types of gatekeeping, such as health maintenance organizations, mandatory first visits to a designated primary care physician, or annual deductibles ranging from US$300 to US$2,500 a year.

The prevalence of psychiatric illnesses in Switzerland is comparable to that in other developed countries (8,9). Mental health inpatient treatment is mainly provided by public general hospitals, state psychiatric hospitals, private psychiatric hospitals, and residential facilities. The canton financially supports public and private psychiatric hospitals that are on the government hospital list, which is determined by the government and confirmed through regular audits. Table 1 presents comparative data on hospitalization rates, length of stay, and mental health expenditures. The number of private hospitals is increasing in Switzerland, but the number of patients treated in inpatient settings has remained relatively stable in recent years (9).

The direct and indirect costs of psychiatric disorders, including costs due to alcohol consumption, are lower in Switzerland than in the United States. Primary care physicians, psychiatrists, psychologists, registered nurses in private practice, psychiatric outpatient clinics, public clinics, and visiting nurse services provide outpatient treatment. Fees for outpatient psychiatric services are calculated by using the TARMED tariff system, which regulates the rates for various procedures, including continuous psychotherapy if indicated. In private practice and outpatient clinics, reimbursement varies according to the monetary value attributed to the tariff points set by TARMED by the canton and the health insurance companies. The tariff points differ depending on the profession of the provider, for example, physician, psychologist, nurse, and social worker, and the procedures. Regardless of the health insurance or the insurance plan, providers receive their payments at similar rates for equivalent medical services, which avoids preferential treatment of patients on the basis of their insurance (6).

Coverage for intermediate levels of behavioral health care differs depending on the canton. However, most services, such as visiting mental health nurses (called Spitex) and day treatment programs, are covered and regulated according to the TARMED tariff points. Some cantons choose to negotiate certain intermediate health care services, such as home treatment or crisis intervention services, directly with the insurance companies, establishing a flat rate for the services rendered.

Swiss residents can receive outpatient mental health care in a variety of facilities, including private practices and public clinics. Patients are liable for a 10% copayment for outpatient services, up to a maximum of US$700 per year (10). For example, 60 minutes of psychotherapy provided by a psychiatrist in Zurich costs approximately US$200, with a US$20 copayment. The cost of medication varies according to the choice of brand versus generic products, with a 10% copayment for generic medications and a 20% copayment for brand-name medications (11). For example, a one-month supply of escitalopram 10 mg will cost the patient approximately US$50 for the brand-name drug, with a US$10 copay. The generic medication will cost about US$20, with a US$2 copay. In the United States, the same drug can cost the patient around $250 for the brand-name drug and $120 for the generic.

The canton and the basic health insurance companies share the cost of psychiatric hospitalizations, with the amount paid by the state varying by canton and on an annual basis. The patient is responsible for a copay of 10% until the maximum deductible of US$700 is reached. The costs of inpatient psychiatric care are calculated in the form of per diem rates. The rates decline with increasing length of stay, which creates an incentive to reduce the length of stay (12). The 2012 health law reform has shifted the methods of hospital financing. Switzerland will be switching to a performance-oriented reimbursement method for psychiatric inpatient treatment (13). In 2018, the government will implement the new tariff structure (TARPSY), which will be based on diagnosis-related groups and psychiatric cost groups, taking into consideration different severity and complexity ratings. The goal is to increase transparency and comparability of services, costs, and quality. It is not the goal of the new tariff system to solve the inherent tension between medical and economic interests but to create a tariff system that is based on data provided by the institutions and is able to adjust more quickly to new changes and challenges of the health care system. This Swiss model allows for psychiatric institutions to compete in a free market for complementary and supplementary premium services without jeopardizing basic mental health services for the entire population.

In Switzerland, independent health insurance companies compete on price and services covered but with a comprehensive package of essential minimum benefits, which include comprehensive mental health and substance abuse services. Switzerland uses collective bargaining power and a national reimbursement schedule to keep health care costs in check. The Swiss mental health care system provides broad and comprehensive coverage for all residents, with readily available inpatient and ambulatory capacity. Psychiatric patients are among the most vulnerable populations, and the Swiss model ensures appropriate mental health services, with a high density of psychiatric inpatient facilities and mental health care providers, while maintaining affordable health care.