Figure 4
Percentage of Total Health Spending Out of Pocket
Greece
Switzerland
Spain
Portugal
Italy
Japan
Norway
Canada
United States
Germany
France
Netherlands
0
5
10
15
20
25
30
35
40
45
Source: OECD, "OECD Health Data 2007: Statistics and Indicators for 30 Countries."
Data for France from Simone Sandier, Valerie Paris, and Dominique Polton, Health Care Systems in Transition: France
(Copenhagen: European Observatory on Health Systems and Policies, 2004).
Data for Greece from the World Health Organization.
tons, individuals with only the basic insur-
receive some form of subsidy, and approxi-
ance plan must use public hospitals; supple-
mately 19 percent of all health insurance pre-
miums are paid with government funds.265
mentary insurance (see below) is required for
admission to private hospitals.
Swiss insurers operate as cartels to negotiate
Because
Recently some providers have begun oper-
provider reimbursements on a cantonal basis.
employers do
ating outside the negotiated fee schedules. A
Providers must accept the negotiated payment,
not pay for
separate supplemental insurance market is
and balance-billing is prohibited. If insurers and
starting to develop to cover the cost of these
providers are unable to reach agreement on a fee
workers' health
providers, which are presumed to offer higher
schedule, canton governments are empowered to
insurance, the
quality or more advanced services. Supple-
step in and impose an agreement. There are no
Swiss are exposed
mentary insurance also allows access to pri-
restrictions on where physicians may set up prac-
vate hospitals in those cantons that do not
tice, so to some degree providers can vote with
to the full cost of
permit access under the basic insurance plan.
their feet, moving to cantons that offer higher
their insurance
Even within public hospitals, supplementary
reimbursements, a practice that has led to physi-
cian shortages in some areas.267
insurance can be used to pay for services such
purchases.
as private rooms that are not covered under
The system includes both public and pri-
As a result,
vate hospitals.268 Private hospitals negotiate
the basic plan. By some estimates as many as
many Swiss have
40 percent of Swiss citizens have purchased
reimbursement with insurance cartels and
supplemental insurance.269
physicians in the same manner. Public hospi-
opted for
tals are operated by cantons, which negotiate
The Swiss do not impose a global budget
high-deductible
reimbursement rates with insurers and pro-
on their health care system and have therefore
vide subsidies to the hospitals. In some can-
avoided the waiting lists common in other sys-
insurance.
27