| In an era of tightening controls over growing health care costs, rationing---defined here as limiting beneficial care through price or other means (e.g., priority setting of covered benefits)---has come to the forefront of the health policy debate in many countries. This study presents Switzerland's approach to this issue following enactment of health care reform legislation in 1994, which seeks to control health care cost inflation while guaranteeing universal access to a basic benefit package. Although the legislation does not call for explicit rationing, the system put in place implicitly rations care through the functioning of private markets for health insurance and health services. A mechanism the legislation calls a rationalizing of the coverage decisionmaking process establishes a federal commission that determines whether to require or deny coverage of controversial treatments based on evidence of their "effectiveness, appropriateness, and efficiency." This study explores how Switzerland has implemented this "evidence-based" coverage decisionmaking process, including how decisionmakers fulfilled the legal mandate of limiting coverage to "effective, appropriate, and efficient" treatments, and how factors, such as decisionmakers' information, interests and ideology, influenced their use of information in making coverage decisions. The conceptual framework, assembled from the literature on health care rationing, policy implementation, and information use in policymaking, led to the use of a retrospective, multiple case study design and the selection of coverage decisions on four treatments as cases. Data for the historical, legal, economic, and political analysis came from a combination of sources, including confidential documents, informal face-to-face interviews, and informal written surveys. This study finds that the coverage decisionmaking process has not always functioned as mandated by law. It confirms the existence of a pattern of unintended influences on the intended functioning of the process, which sometimes distracts decisionmakers from the ideal of implementing an "evidence-based" coverage decisionmaking process. To the Swiss governments credit, the coverage decisionmaking system devised in the 1994 reforms at least attempts to come to grips with the issue of rationing. It remains to be seen whether the implicit rationing performed by this system will adequately control costs. |
