The causal effects of mandatory health insurance coverage expansion in Switzerland

Abstract

The expansion of public health insurance programs affects payers as well as the behavior of service providers. In this paper, we study the expansion of Swiss mandatory health insurance in 2012 to include complementary and alternative medicine physician services. The policy change provides a quasi-experimental design that allows us to estimate the causal effects on the payer and physician behavior using a difference-in-differences framework. First, we find that from the payer's perspective, expanding coverage to complementary and alternative medicine increases physician costs per patient by about 7 percent. Second, we find that the increase in physician service costs per patient in mandatory health insurance is almost exactly offset by a decrease in supplementary health insurance costs. Thus, suggesting that the behavior of physicians was unchanged by the coverage expansion.

Keywords: Complementary Medicine; Coverage Expansion; Difference-in-Differences; Health Care Costs; Mandatory Health Insurance; Physician Behaviour.

Fig. 1

Coverage of Complementary and Alternative Medicine in Mandatory Health Insurance. Notes: The figure shows the time line of the policy change regarding insurance coverage of complementary and alternative medicine (CAM) in mandatory health insurance. Note that the period shown corresponds to the data availability

Fig. 2

Physician Service Costs per Patient (Mandatory Health Insurance). Notes: The figure displays the evolution of average annual physician service costs per patient across the two treatment groups. Costs are measured in Swiss francs. The vertical line marks the policy change. Shaded areas represent 95% confidence intervals

Fig. 3

Physician Service Costs per Patient, by Specialty. Notes: For each specialty in complementary medicine, the figure displays the evolution of the average annual physician service costs per patient across the two treatment groups. The line in black represents the control group. The vertical line marks the policy change. Shaded areas represent 95% confidence intervals

Fig. 4

Evolution of Physician Service Costs (Individual Health Insurance). Notes: The figure displays the evolution of average annual physician service costs for the control group and the treatment group. For both groups, we show costs covered by mandatory health insurance (MHI); for the treatment group, we also show costs covered by supplementary private health insurance (SPHI) as well as the sum over both insurance types (total costs). Costs are measured in Swiss francs. The vertical line marks the policy change; the shaded areas represent the 95% confidence intervals

Fig. 5

Number of CAM diplomas issued by year. Notes: The figure displays the evolution of new diplomas issued by the Swiss Medical Association (FMH) for each CAM discipline. It includes all primary care physicians, which were registered in the Zahlstellenregister ZSR (SASIS) and/or the Medizinalberuferegister MedReg (BAG)

Fig. 6

Drug Costs per Patient. Notes: The figure displays the evolution of average annual drug costs per patient across the two treatment groups. Costs are measured in Swiss francs. The vertical line marks the policy change. Shaded areas represent 95% confidence intervals

Fig. 7

Laboratory Costs per Patient. Notes: The figure displays the evolution of average annual physician service costs per patient across the two treatment groups. Costs are measured in Swiss francs. The vertical line marks the policy change. Shaded areas represent 95% confidence intervals

Fig. 8

Evolution of Drug and Laboratory Costs (CSS Insurance data). Notes: The two figures display the evolution of average annual drug costs and laboratory costs for the control group and the treatment group. For both groups, we show costs covered by mandatory health insurance (MHI); for the treatment group, we also show costs covered by private supplementary private health insurance (SPHI) as well as the sum over both health insurance types (total costs). Costs are measured in Swiss francs. The vertical line marks the policy change; the shaded areas represent the 95% confidence intervals

Fig. 9

Evolution of Physician Service Costs for the Four Alternative Medicine Specializations. Notes: The four figures display the evolution of average annual physician service costs per patient for treatment subgroups defined by physicians’ specialization: traditional Chinese medicine (TCM), homeopathy, anthroposophic medicine, and phytotherapy. We show costs covered by mandatory health insurance (MHI); private supplementary private health insurance (SPHI) as well as the sum over both health insurance types (total costs). Costs are measured in Swiss francs. The vertical line marks the policy change; the shaded areas represent the 95% confidence intervals