Similarly to what is noticed in other countries, the Swiss population is ageing. Spending for health care in Switzerland is the third highest, after the USA and France, as expenditure per capita as well as a share of GDP amongst OECD countries. The latter cover a maximum of 50% of the costs of the inpatient treatment whereas the cantons meet the remaining costs including investments. Inpatient care for patients with basic health insurance is financed by the cantons and the health insurance companies. Acute inpatient care is provided by cantonal and publicly subsidized hospitals and to a smaller extend (25%) by private for-profit and not-for-profit hospitals. While independent private practitioners are paid fee-for-services, physicians working in networks or HMO’s may be paid either on a fee-for-service basis or by salary. Apart from patients who choose to restrict their choice of doctors in return for lower premiums (alternative-managed care-insurance models allowing patients to receive care from physician networks or HMOs), patients have direct and unrestricted access to primary care physicians and specialists. However, a growing part of primary care is provided by small group practices, as well as networks of physicians and health maintenance organizations (HMOs) acting on the principles of gatekeeping. Ambulatory care is provided by physicians working mainly independently in individual private practices. However, since the risk adjustment system has only poor performance, risk-selection remains a problem. Insurers are obliged to accept applicants, theoretically avoiding risk-selection across insurance companies. Universal access to health care is guaranteed since 1996 (mandatory health insurance), and the basic health insurance coverage includes a comprehensive package of health benefits, identical for all insured. Due to subsidiarity, responsibilities are always assigned to the lowest of these levels. Indeed, Switzerland is considered to have 26 slightly different healthcare systems, one for each canton, acting autonomously in the organization of healthcare services in their area. The main feature of the Swiss healthcare system is its decentralized structure and therefore the relatively high degree of local autonomy. Switzerland is a democratic federal state of approximately 7 million inhabitants, in which government responsibilities are divided between three levels: the federal level, the 26 cantons and the municipalities. Within and outside the physician networks, at regional and/or cantonal levels, several initiatives targeting chronic diseases have been developed, such as clinical pathways for heart failure and breast cancer patients or chronic disease management programs for patients with diabetes.
Seventy-three of the 86 networks (84%) have contracts with the healthcare insurance companies in which they agree to assume budgetary co-responsibility, i.e., to adhere to set cost targets for particular groups of patients. About 50% of all general practitioners and more than 400 other specialists have joined a physician networks. To date, an average of one out of eight insured person in Switzerland, and one out of three in the regions in north-eastern Switzerland, opted for the provision of care by general practitioners in one of the 86 physician networks or HMOs. The share of insured choosing an alternative (managed care) type of basic health insurance and therefore restrict their choice of doctors in return for lower premiums increased continuously since 1990.