Author reply to technical comment

Reply to the letter to the editor “Freedom of choice”


Publication Date: 12.03.2012
Swiss Med Wkly. 2012;142:w13528

Isabelle Peytremann-Bridevaux, Christiane Ruffieux, Bernard Burnand

Institute of Social and Preventive Medicine, Lausanne University Hospital, Switzerland


We thank Dr. Gnädinger for raising the issue of freedom of choice, which would certainly be of great interest to debate within the framework of the current Swiss healthcare system. Current chronic care models and concepts (such as patient empowerment, shared decision-making and patient-centred care) place the emphasis on patients’ needs, values and roles. In addition, patients need to be well informed if they are to be appropriately involved in their care. Patients cannot be considered “passive recipients of care but as live actors – replete with hopes, anxieties, desires, …” [1]. Knowing individuals’ opinions, be they current or future patients, is therefore important. This may be particularly true in Switzerland, in view of the opportunities for popular referenda and initiatives, which may prevent policymakers from implementing changes in the healthcare system. We would remind readers here that the point of our article is not to state a position regarding the ongoing discussions on managed care in Switzerland, but rather to describe, objectively, the answers Swiss respondents gave to the question (included in the Swiss Health Survey) “How important is it for you to be able to choose the specialist you would like to consult?”, as well as to determine the factors characterising individuals who deemed the freedom of choice to be very important. Results showed that, in 2007, 45% of respondents found this choice important. They also showed that those more likely to value freedom of choice were women, in middle/senior executive positions, with an ordinary insurance scheme, reporting ≥2 chronic conditions, presenting poorer subjective health or reporting ≥2 outpatient visits. If freedom to choose specialists were restricted in the healthcare system, Swiss respondents would need to be convinced that an appropriate policy decision was taken. This is important since Switzerland has a long tradition of unrestricted access to healthcare providers, of citizens satisfied with their healthcare system despite ongoing high healthcare expenditures, and good healthcare indicators [2, 3]. Switzerland faces the challenge of tackling the rising burden of chronic diseases. Good information, in addition to appropriate incentives, are needed to motivate Swiss citizens to accept and support the development of new care models such as those currently discussed as part of the revision of the Federal Health Law (managed care – integrated care models). Appropriate incentives for individuals to enroll in managed care insurance schemes (to avoid risk selection by health insurance companies) are also key for their wider use. Future Swiss studies must show that these models offer a way not only to limit healthcare costs, but also to improve healthcare quality.

Letter to the Editor:


Correspondence: Isabelle Peytremann-Bridevaux, MD, MPH, DSc


  1 Kravitz RL. Beyond gatekeeping: Enlisting patients as agents for quality and cost-containment. JGIM. 2008;23:1722–3.

  2 Schoen C, Osborn R, Squires D, Doty MM, Pierson R, Applebaum S. How health insurance design affects access to care and costs, by income, in eleven countries. Health Aff (Millwood). 2010;29:2323–34.

  3 Organisation for Economic Co-operation and Development. OECD reviews of health systems: Switzerland. Paris: OECD; 2011.

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