A recent documentary by RTS reveals two key weaknesses in Switzerland’s system of compulsory health insurance that make it difficult to claim for cancer drugs.
Switzerland has a system of compulsory health insurance that covers most medical care and medicines, but not everything. Optional additional insurance can be added on top, but given the high cost of basic insurance, many opt to go with only basic cover. And complementary insurance is not without it weaknesses either.
Switzerland’s health insurance system is highly regulated. The government decides what basic insurance covers and many of the rules around insurance premiums. Private insurance companies offer cover within these constraints. In addition, the law requires insurance companies to offer basic insurance to any Swiss resident who applies, reducing the scope for companies to manage risk.
What basic insurance covers is defined largely by a list of medical care and medicines covered. The government and regulators regularly add to this list as diseases and health care evolve. For example, in 2019, vaccination against tick borne encephalitis was added due to higher rates of the disease across Switzerland.
The two weaknesses revealed in the RTS documentary relate to the list of approved medications. To be sure of a successful claim and reimbursement, the medicine used must be on the list and must be medically approved for the patient taking it.
This can be a problem for children. Many of the drugs used to treat cancer, while considered effective and routinely prescribed by doctors for treating children, have not always been clinically approved for children. Drug companies sometimes avoid running clinical trials on children, partly because so few take such medications. This creates a problem. It means Swiss health insurance companies have a legal case for not reimbursing these medicines by claiming they are not medically approved for the patient. The RTS documentary follows a number of examples of parents with sick children experiencing this challenge.
The second weakness outlined in the documentary relates to a divide and conquer tactic that appears to be used sometimes by some drug companies. Getting a new medicine on the list requires an application and price negotiations. If drug companies start this process with the Federal Office of Public Health (FOPH), there is chance they’ll will end up negotiating a lower universal price for the drug. However, if the discussions and negotiations start at the insurance company level there is a chance of negotiating higher prices with each insurer. A spokesperson from Santé suisse, a health insurance industry association, told RTS that he suspects in order to improve their negotiating hand some pharmaceutical companies prefer to negotiate with insurance company separately rather than directly with the FOPH. According to him one way to reduce this problem would be to allow health insurance companies and patient advocate groups to initiate the process of adding drugs to the list rather than leaving it to drug makers.
Another well known weakness in the system relates to deductibles. Many opt for a higher deductible to lower their premiums. However, this means paying a greater portion of medical bills out of your own pocket. Because some with high deductibles will opt out of treatment for financial reasons the system is unsuited to delivering procedures or medicines aimed at protecting collective public health. Actions to halt the spread of infectious disease fall into this category.
This weakness was displayed during the early phase of the Covid pandemic. On 4 March 2020, the government announced Covid-19 tests were to be covered by health insurance, leaving in place a financial disincentive for many to test. On 24 June 2020, after experiencing the first wave, the government removed the financial barrier by deciding to directly cover the full cost of Covid-19 tests. In the same vein the government has provided Covid-19 vaccinations at no cost outside the health insurance system.