5.2. Patient pathways

5.2.1. Pathways in traditional insurance schemes

Traditionally, freedom of choice of providers and direct access to all levels of care, including inpatient care, without need for a referral is a key characteristic of the Swiss health care system (see left-hand side of Fig5.2). Patients may freely choose ambulatory and inpatient providers in the entire country but reimbursement by MHI for care provided outside the canton of residence is usually limited to the maximum reimbursement in the home canton (see section 5.4.2). A pathway for a patient in need of hip replacement is described in Box5.1.

Fig5.2	Box5.1

5.2.2. Pathways in managed care type insurance plans

Switzerland has a relatively long tradition of managed care, when compared to other European countries. Almost 60% of Swiss residents in 2014 were insured by so-called alternative insurance plans, where they agreed to some kind of restriction of choice and to complying with gatekeeping rules in exchange for lower premiums (FOPH, 2014k). Despite the rejection of a proposed managed care reform by a public referendum in 2012 (see section 6.1), the number of insured opting for these plans has increased considerably (see section 3.3.3). There are important regional differences as regards the availability and popularity of alternative insurance plans (Reich, Rapold & Flatscher-Thöni, 2012a; FMC, 2014a; Meyer, 2009), with a much higher proportion of insured opting for these models in the German-speaking northern and eastern regions than in other parts of the country.

Different types of managed care plans

Different provision models are offered as part of the alternative insurance plans, which are often described as independent practice associations (IPAs), preferred provider organizations (PPOs) or HMOs. However, this terminology adopted from the United States-dominated international literature is often misleading when describing the Swiss provision context. In Switzerland, depending on the plan, patients either have to register with a GP, who will then act as the referral point for secondary care, or to consult with a medical call centre prior to seeking care. The degree to which plans actually coordinate and manage patient care differs considerably. Sometimes, restrictions are also imposed on the choice of secondary (referral) providers. Patient flow in alternative insurance plans is shown in the right-hand side of Fig5.2.

Fig5.2

In family doctor plans, care is usually provided by physician networks consisting mostly of primary care physicians, but they may also include ambulatory specialists and hospitals that contractually agree to cooperate in the provision of care. They may found joint stock companies or associations and usually commit to certain quality management processes, such as quality circles or the use of guidelines (Berchtold & Peytremann-Bridevaux, 2011). Networks can take different forms, ranging from rather loose networks of independent practices (similar to IPAs) that do not carry joint financial responsibility, to more integrated physician groups with a high degree of joint financial responsibility up to the point where they operate under capitation. The networks contract with insurers for the provision of care, usually agreeing on an objective for health care costs for a group of patients, and sharing gains and losses when actual costs are below or above the agreed objective (OECD/WHO, 2011).

The term HMO is mostly used in Switzerland to refer to group practices or small networks of physicians owned by insurers, where physicians are generally employed and paid a salary (FMC, 2014b). However, there are also networks of physicians operating as HMOs, which accept complete financial responsibility for their patients, including for care provided by specialists and hospitals.

Another insurance model, where patient choice is limited to only those GPs and (sometimes) specialists listed by the insurer is internationally often referred to as a PPO. In Switzerland, these models are usually called list models but are also subsumed under the term family doctor model. However, listed physicians usually do not have contracts with insurers and they do not take on financial responsibility for managing the care of their patients. Finally, call-centre models (known as Telmed in Switzerland) exist, where the insured agree to contact a call centre before consulting other health care providers (see Fig5.2 patient flows). Both models introduce gatekeeping and may limit choice but do not necessarily have much influence on how care processes are managed (Baur, 2005).

In 2013, according to national insurance statistics (FOPH, 2014k), 34.7% of insured had a family doctor plan (including both physician networks and list models) and 7.6% of insured had an HMO plan, while about 18% were insured by other alternative insurance plans (mostly call-centre models). According to other statistics (FMC, 2014a), 20.8% of all insured had either an HMO plan or a physician network plan (excluding simple list models), where they benefited from more actively managed care.