For a target-oriented healthcare system, we need to understand the effects of various incentives for service providers and their organisational structures.
In Switzerland, as in many other countries, there are considerable regional differences in healthcare costs. For example, a person in the canton of Basel-Stadt receives an average of ... francs per year in basic insurance, while a person in the canton of Appenzell Innerrhoden only has average costs of Y francs per year. There may be various reasons for these differences in regional costs. On the one hand, the two cantons differ greatly in terms of their population structure. On the other hand, if we look at the cantonal density of doctors in terms of full-time equivalents, according to the FMH there are 10.7 doctors per 1,000 inhabitants in the canton of Basel-Stadt, but only 1.5 in the canton of Appenzell Innerrhoden.
Selection versus control
Almost 80% of the Swiss population choose an insurance model with restricted access to service providers. These managed care models aim to reduce healthcare costs through targeted patient management. However, the correct measurement of these savings is methodologically challenging.
By switching from the standard to an alternative insurance model, insured persons in Switzerland can reduce their health insurance premiums. As the premiums ultimately reflect the average healthcare costs of the people in the corresponding model, managed care models therefore appear to have the intended cost-cutting effect. However, a superficial look at the data harbours the risk of biased conclusions.
Alternative forms of insurance tend to be less attractive for the chronically ill than for people who are less dependent on healthcare services due to the need to contact a gatekeeper. The latter are therefore more willing to switch to such a model. As a result, people with different health statuses systematically select themselves into the various insurance models. This self-selection leads to "mechanically" lower average costs for insured persons in managed care models, without the models themselves achieving an actual reduction in costs. In order to be able to determine the effect of better patient management, for example, a "randomised" allocation to an insurance model with a corresponding control group would be required. However, such randomised studies are not feasible in basic insurance for a number of reasons, which means that the correct measurement is dependent on "natural experiments" and other methods of modern econometrics.
This raises the question of the extent to which the observed demand is determined not only by patients' different health needs, but also by the available supply of healthcare services. Compared to other markets, providers play a disproportionately important role in the healthcare sector, as even consumers with the necessary willingness to pay according to the law also require the authorisation of an approved provider. It is therefore important to understand which incentives influence the supply of service providers and how.
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