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Tue Jul 28 13:00:43 BST 2009

As you asked about international experience, I'll explain what I know of the workings of the system here in Switzerland from the standpoint of a consumer.

Here basic health insurance is mandatory and is provided by multiple private insurance companies in competition with each other. The price of the obligatory insurance is regulated (capped, I think, with the costs reevaluated and premiums adjusted once a year), but does vary substantially from company to company. Any insurer I apply to must accept me for the mandatory coverage, and there are no exclusions allowed from the mandatory coverage for preexisting conditions. The companies all offer supplemental insurance plans beyond the mandatory coverage, and there they are allowed to reject and exclude more or less as they see fit. The insurance contracts are for one year, all expiring at the same time, at which it is possible to change to any other company. Prescribed medication is included in the coverage. With the basic insurance plan, I am free to see any provider I choose for covered expenses. Many insurance companies also offer more restricted plans at
 reduced premiums.

AFAIK, there is no special provision for providing health care to those of limited financial means. They get the same basic insurance and have access to the same health care providers as everyone else, and their premiums are covered all or in part by their local government, just as other necessary expenses, such as rent and utilities, are.

Perhaps it happens here, but I am not aware of any complaints of systematic denial of covered expenses by the insurance companies. In the 10+ years that I have been here, I have only had a claim rejected for legitimate reasons (i.e. it really wasn't covered by the policy), but that is admittedly a very tiny, anecdotal sample. Indeed, my insurance company is extremely easy to deal with. The provider bills me and includes a copy of the bill for me to submit to my insurance company. I pay the provider, and within a few days of my submitting the bill, the covered portion appears in my bank account via direct deposit from my insurer. The few times I have had questions, the insurance company has been easy to reach by phone and email, and has provided competent answers very quickly.

They system works fairly well - certainly for primary care much better than in the US, I think, but is not without it's own problems.

As in many countries, health care costs here are rising a several times the rate of inflation, and the government is debating how to deal with that. I suspect, but do not know, that a part of the problem is that consumers are too well shielded from costs they generate. That causes the supply and demand forces that would normally serve to set prices to be out of whack, so demand grows beyond where the market would limit it, which, in turn, drives prices up beyond where the market would set them. This, I suspect, is a basic problem with universal access systems, and a good solution has yet to be found. The government does set prices guidelines for health care services, which many or most providers adhere to, but they don't t seem to be able to keep those prices low enough to keep the costs in check.

Another problem is that it is becoming increasingly difficult to find physicians to cover primary care practices in rural areas. Specialists working in large, urban facilities can make twice what a rural primary care doc makes while working 25 - 50% fewer hours. There is no solution to this growing problem, yet, either. I suspect that some people will have to travel further to see their doctor than they have had to in the past, but telemedicine and specialist physicians who work part time in primary care may also be part of the solution. Time will tell.

One last, major difference here is that Swiss providers don't have the fear of being sued that permeates US health care. My impression is that that single fact changes the risk / benefit balance of almost every patient care decision made, which I suspect helps a lot to keep systemic costs down, but I'm not aware of anyone having made a study of this issue, so this is purely conjecture on my part.

I expect there are others on the list with substantially more knowledge of the Swiss system than I, and I would invite you to expand on or correct my comments, as you see fit.

That's how it works here.

Cheers,
John Annen

________________________________
From: "Bjorn, Pret" <pbjorn at emh.org>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Monday, July 27, 2009 10:53:36 PM
Subject: RE: [MailServer Notification]Content Filtering Notification

Basic healthcare cannot be sustained in a for-profit model.  Neither
can/should basic education, or basic law enforcement.  Selectively
underserving any class or individual is socially, politically,
economically, and ethically untenable.  It's a wonder to me that
Americans have taken so long to admit as much.  

Wait.  We still HAVEN'T.

Of course, emergency care must also be provided without regard to
ability to pay; but that's established in statute already.  (Recall that
there were circumstances within our lifetimes when these patients could
be denied access to certain hospitals.  Be proud of the solution.)  

Now consider how providing global basic health insurance would
decompress our ED's and free them for their intended purpose.  

And how much less expensive and more effective it is to treat most
common ailments when the patient has a regular doctor and doesn't have
to tolerate early symptoms for fear of the cost.  

And how much more compliant patients will be when the pharmacy bill
doesn't get deferred in favor of rent or groceries.

Funny: the Trauma-List is a richly international venue; yet I've not
seen a single message from Canada or Great Britain or Spain or France to
the effect of "NO!  Don't do it!  Keep your system the way it is!
Public health insurance doesn't work.  We wish our system was more like
YOURS."

Or maybe I've missed it.

Regards,

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, July 27, 2009 3:20 PM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: [MailServer Notification]Content Filtering Notification

"Let's instead imply that people who can't afford or qualify for
insurance are inherently undeserving and/or insufferable whiners."

I don't believe I (or anyone else on this site) ever said that.  But
just for laughs and giggle, lets imply that - now what?  We still
haven't come to the essential of the question - just exactly what is
this "miracle cure" that Mr. Obama has proposed and that you and others
are supporting sight unseen.  What are the details?  What are the
numbers? Who are the players?  And exactly how will this new gift from
Obama get all of my inherently undeserving and/or insufferable whiners
covered so that they can get anything they want, supposedly just like
you and Rob and I could get today?

Sorry, but if it seems too good to be true, it probably is.

And Pret, you are so right......this is indeed tiresome and
unsatisfactory.

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Bjorn, Pret
Sent: Monday, July 27, 2009 3:05 PM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: [MailServer Notification]Content Filtering Notification

I haven't been able to keep up.

Okay.  I haven't really tried.  It's tiresome and unsatisfying.  (Sorry,
it is.)

But this one caught in my throat.

I'm used to the cynicism (and generally encourage it, if only for the
entertainment value); but I'm shocked at how NARROW the assertion seems.
Do you really believe that healthcare is nothing more or less than a
commodity?

I suppose it shouldn't be surprising that this mindset would come from a
trauma care provider.  Your customers (and mine, and those of the
hundreds of nurses and paramedics and surgeons EM physicians on the
List) float in a flood-stage risk pool that has been long abandoned by
the commercial insurance industry.  (See also MEDICARE and MEDICAID.)
Thus they are disproportionately more expensive to treat and less likely
to pay.  

The commercial insurance industry is not beholden to society, but to
executives and investors who measure success not by excellent
evidence-based services -- much less the enhanced health of the customer
-- but by financial profit.  The commercial interests have already
signed up all the responsible citizens who are aware of their morbidity
and protective of their fortunes (provided they could afford the
premiums).  

And with the focus off actual disease control (which would regrettably
run counter to marketing), then the quickest way to amplify the
quarterly net revenue is sadly predictable: by denying the illness or
delaying its treatment.  Every month a policy goes unclaimed is another
incremental accrual of capital.

These guys've got a business to run, after all.

But that's America, ain't it?  God forbid we should criticize
capitalism.  Let's instead imply that people who can't afford or qualify
for insurance are inherently undeserving and/or insufferable whiners.

Sigh.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Sunday, July 26, 2009 6:59 PM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: FW: [MailServer Notification]Content Filtering Notification

...

Now, look at the rest of the labor force - yeah, the very same folks
that we provide health care to - and tell me how many of those that
demand and expect health care as a God given right have earned their
paychecks, and have earned the right to the same quality care that you
and I pay for.  Sorry to sound so damn cynical, but therein lay the
basic problem that has rotted the infrastructure of our society as we
know it today.  I am tired of looking at the elephant in the room and
calling it a G*$-D@*$#!' mouse!

OK - fire away.

Ron

Ronald I. Gross, MD, FACS
Chief of Trauma & Emergency Surgery Services
Baystate Medical Center
Assistant Professor of Surgery
Tufts University School of Medicine
759 Chestnut Street
Springfield, MA  01199
413-794-4022  phone
413-794-0142  fax
ronald.gross at baystatehealth.org

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