Vocational rehabilitation: the Swiss model

Introduction [1]

Since the end of the 19

century and in line with its European neighbours, Switzerland has devoted itself to setting up a system of social security. In 1890, the Federal Constitution was completed with an article authorizing the Confederation to pass legislation on sick- ness and accident insurance. Since then, Switzerland’s safety net of social security has deve- loped in a piecemeal way over a long period at the mercy of economic crises and their financial risks, which accounts for the lack of harmony in the benefits of the various insu- rance schemes and makes coordination between the different systems indispensable.

In a statement for the Federal Assembly in 1919, the Federal Council proposed the creation of Federal Disability Insurance (DI), linked to Insurance for Old-Age and Survivors (OASI). Faced by financial difficulties, Switzerland chose to focus its social efforts on Old-Age and Survivors’ Insurance (OASI: came into force in 1948) rather than on Disability Insurance, which was enacted in 1960 [2].

Before the introduction of DI, one section of the active population had already been eligible for Accident Insurance (from 1918), although the armed forces had obtained benefits since 1902 (Federal Military Insurance: FMI), as had some employees in the public or private sector affiliated with a pension fund. Compulsory Accident Insurance for everyone was only introduced in 1984.

Since it came into force in 1960, DI gives priority to the principle of “Rehabilitation before Pension”. Legislators also had to clarify the boundaries between DI and the other branches of social insurance. In principle, DI is not intended to cover the benefits that are normally the responsibility of health, accident and unemployment insurance but should cover the real risk of disability.

The Swiss insurance framework

Accidents and health are governed by two laws: the Accident Insurance Law and the Health Insurance Law.

M.-F. Fournier-Buchs and C. Gobelet

Every Swiss worker is compulsorily insured by his employer against accidents and their consequences. The main Swiss accident insurer is Suva (Swiss National Accident Insurance Fund), which insures all construction workers and manual workers in general.

Numerous private companies as well as mutual insurance companies provide the rest of the Swiss population with accident insurance cover.

Where health insurance is concerned, each inhabitant is insured by around 69 diffe- rent mutual insurance companies or groups.

The armed forces are covered for health and accident insurance by federal military insurance, which is directly dependent on and financed by the Confederation.

The disabling consequences of an accident are paid for by accident insurance whereas disability as the result of a disease is the responsibility of disability insurance (DI), finan- ced by compulsory advance deductions from salaries, as is unemployment insurance.

At present, the various social insurances are in charge of the following benefits:

Disability insurance: vocational rehabilitation measures, technical and assistive devices, disability allowances, daily benefits during rehabilitation, pensions in cases of disability as a consequence of disease. Financing is based on advance direct deductions from the wages of every worker.

Health insurance (compulsory): medical and pharmaceutical expenses, medical care, maternity, hospitalisation, medical prescribed spa, supplementary cover against acci- dents, complementary insurance, optional daily benefits. Health insurance does not cover any benefits for vocational rehabilitation. Financing is by personal contributions whereby employers can participate.

Accident and occupational disease insurance (compulsory): medical, pharmaceutical and hospital costs, medically prescribed health spa stays, technical and assistive devices and daily benefits until possibility to return to work or until the start of a disability pen- sion (but not during rehabilitation measures provided under DI), disability pension fol- lowing an accident or an occupational disease (possibly concurrent with a DI pension but not in excess of a maximal fixed compensation), integrity compensation, disability allowance. It is financed by employers by means of advance deduction from wages or by individual contributions.

Military insurance: medical, pharmaceutical and hospital costs, technical and assistive devices, disability allowance, rehabilitation measures, daily benefits while unable to work and during rehabilitation, disability pension if due to illness or accident sustained during a period of military service, integrity compensation. Financed by the Confederation.

Unemployment insurance: reintegration measures, unemployment benefits. Finance by advance deductions from wages.

The diversity of these intervening parties is coordinated by the Federal Law on the general part of the social security law, which:

– defines the principles, ideas and the institutions of the social security law;

– standardizes procedures and regulates the judiciary organization within the field of social security;

– harmonizes social security benefits, and regulates the right of social security to press

claims against third parties.

Close coordination between the various sectors is essential and cooperation between insurers is imperative, at the risk of being penalized if some insurees are refused benefits to which they are entitled.

The parameters of vocational rehabilitation

Disability insurance is responsible for vocational rehabilitation both in terms of financial aspects and practical implementation by centres for vocational rehabilitation funded by DI.

Epidemiological aspects

The statistics published by Suva [3], which insures 1,8000,000 employees, recorded 446,335 accident cases in 2002, 187,587 of which were occupational accidents and diseases and 245,011 were non-occupational accidents (leisure time, vehicle, domestic) while the total number of unemployed in Switzerland who suffered accidents amounted to 12,023.

Since 1990, accident prevalence has changed, with non-occupational accidents increasing to the figure mentioned above in 2002. 0.7% of accidents result in disability and 3,061 new disability pensions were allocated by the Suva in 2002. The total benefits paid out to accident victims in 2002 amounted to 3,1492 billion CHF for lost earnings and 1,3145 billion CHF for pensions.

During the last years, an increase of 7% to 9% in the benefits was paid out. Among the prevailing factors in this rise from 7% to 9% was the increase in average age of the insurees, which caused a rise in the cost of healing and a rise in life expectancy. This meant that disability pensions would be paid for a longer period of time.

A marked increase in mental complications is one of the factors that make the course of an accident more serious. Unfortunately, there is no data at national level for the various accident insurance companies and the figures given above only cover 50% of all employees in Switzerland.

Any analysis of the consequences of disease is far more difficult due to the lack of national data on the 69 mutual insurance companies or groups that cover health insu- rance.

The annual statistics for 2001 for disability insurance [4], which is responsible for all the disability pension due to disease show that expenditure amounted to 9,500 billion CHF, of which 5,500 billion CHF were allocated to pensions, 300 million CHF to daily benefits, 200 million CHF to disability allowances and 1,400 billion CHF to individual rehabilitation and training measures.

DI insurance has 7.5 million insurees, of which 4.2 million pay contributions. In 2001

485,000 received benefits (285,000 men and 200,000 women). Thus the probability of

receiving disability benefits in 2001 was 7.4%. This probability is relative to age and

gender and, for men, rises on a graduated scale from 3% for those aged between 20 and 24 to more than 20% for those aged between 60 and 64.

It should also be pointed out that the likelihood of receiving DI benefits has risen from 5.5% to 7.4% during the course of the last decade.

When all the disability pension benefits (after accidents and diseases) paid out in Switzerland by the various authorities are taken into account, they add up to about CHF 13 billions, which roughly corresponds to 1/3 of the health budget.

This gives a better idea of the financial impact that the disability can have on Federal finances and of the need to develop structured rehabilitation measures to enable all those with a disability to return, at least part-time, to an active working life.

Rehabilitation and the law on disability insurance (DI) [2, 6, 7]

Since its enactment in 1960, the law on disability insurance laid down a basic principle:

rehabilitation before pension. A series of measures have been formed around this postu- late, the purpose of which is to allow persons afflicted by diseases or accidents to regain, safeguard or improve their earning capacity.

As with any insurance system, certain conditions should be met first in order to receive benefits.

Article 8 of the law on the general part of the Social Security Law* (which came into force on 01.01.03) [4], article around which all the law on disability insurance revolves, states that inability to earn (or disability) amounts to the permanent or long-term impossi- bility of pursuing gainful employment on the entire job market as a result of health impair- ment or disabilities and after exhausting all rehabilitation attempts and opportunities.

The main point of this idea of disability is the causal link between severity of the disease or the accident and the loss of earning ability. With the term ability to earn, the law on disability insurance means the ability of a person to obtain an income from an activity adapted to his or her state of health that exists in a so-called balanced job market (cf. paragraph below about self-rehabilitation). The confusion between disability and loss of integrity is encountered very frequently; sometimes, patients are heard to say “I’ve paid my contributions, I’m ill, I’m therefore entitled to compensation for the loss of my health”. While this may be true within the framework of the law on accident insurance (loss of integrity compensation), this is not the case with the law on disability insurance.

Evaluation of residual occupational capacity

Disability insurance has set specific structures in place that enable claimants’ state of health and residual occupational capacity to be analysed.

* The Federal Law about the general part of the Social Security Law (ATSG/LPGA) coordinates the law on

social security by defining the principles, ideas and the institutions of the Social Security Law; by standardi-

zing procedures and regulating the judiciary organization within the field of social security; by harmonizing

social security benefits; by regulating the right of social security to press claims against third parties.

State of health is determined by a general practitioner (GP) and, in cases of doubt, claimants are referred by the disability insurance’s office to a medical evaluation centre specifically approved by disability insurance (COMAI: DI’s medical observation centre) or to an acknowledged expert. At the end of the check-up, either COMAI or the expert submits a report to the disability insurance office stating the claimant’s residual occupa- tional capacity.

Vocational evaluation and, if necessary, vocational rehabilitation is carried out in the DI’s occupational observation centres (COPAI) where a claimant’s skills are observed and his/her immediate occupational capacity. The DI can also delegate this task to clinics that are specialised in vocational rehabilitation or to private institutions that operate in the same field. These institutions are similarly approached when handicapped people have to be reintegrated into the working market.

Inability to work and inability to earn

There are other ideas that give rise to confusion, in particular those relating to an inabi- lity to work and to an inability to earn. Both of these are the result of health impairment but, where the former is concerned, a patient is partially or completely no longer fit for work in his/her regular activities or sector while, with the latter, a patient is partially or completely no longer capable of carrying out any gainful activities whatsoever, since there is nothing in the job market that is adapted to his or her state of health. Whereas inability to work is determined by the doctor, inability to earn is a matter for disability insurance.

Example

Following an accident, a paraplegic who was previously employed as an office worker will not receive any disability pension if the former job can be resumed once his/her health has been stabilized with full-day presence and a 90% workload. Since the former activity is considered suitable, the loss of ability to earn is 10%, in other words, disability of 10%

does not entitle a claimant either to a disability pension or to retraining via the interme- diary of DI. On the other hand, this person will receive a one-off cash benefit from acci- dent insurance as integrity compensation and a 10% pension in accordance with the law on accident insurance.

Residual capacity in a modified occupational activity

Once an impaired state of health has been clearly established at medical level, the ques-

tion now arises of residual capacity in a modified occupational activity. In order to deter-

mine this, the DI office, in line with legislation, consults the general practitioner or the

specialists or even the occupational or the company physician who is in charge of the

patient.

In this case, the DI office asks them to point out what the functional limitations are as a result of the deficiencies or impairments.

If the DI office considers the information provided by the GP or other referred phy- sicians to be insufficient, it can request an analysis by its own medical service or practi- cal observation in specialized institutions or even an expert medical opinion. Pursuing the principle of rehabilitation before pension, the DI office will then investigate whether rehabilitation measures (medical, vocational, technical and assistive devices, etc.) will safeguard a person’s ability to earn or even improve it.

Self-rehabilitation, prerequisites with the aim of vocational rehabilitation

No insuree has a right to vocational rehabilitation for no matter what condition. The insurance system not only involves rights but also obligations. Thus, having impaired health and having to change one’s job is not sufficient for an automatic right to vocatio- nal rehabilitation provided by DI.

Insurees are obliged to cooperate and to do everything possible to reduce the damage sustained. Where jobs are concerned, this means that they must do their utmost to return to occupational activity, without training, to ensure that any loss of earnings is kept to a minimum thereby avoiding the need for the payment of a pension: as a result, the term self-rehabilitation is used. If it is impossible to find a job that safeguards a person’s ability to earn in a so-called balanced job market (abstract idea that postulates a job market where there is a balance between supply and demand for work and where the range of possible jobs is sufficiently extensive), the DI office will look into the possibility of initial training for insurees who have never had any gainful employment or reclassification for insurees who have had gainful employment.

In order to qualify for reclassification measures, the loss of earnings must be a mini- mum of 20% between what the insuree’s wage was without health impairment and what he/she could obtain without any training and taking into account the functional limita- tions following health impairment.

Example

An unskilled construction worker suffers chronic low back pain following an operation for a discal herniation. According to his physician, he has long-term 100% inability to work in his normal job (bricklaying) but 0% inability in a suitable job that does not involve carrying heavy loads, that saves him having to work in positions that are painful for his back and allows him to alternate between sitting and standing.

Prior to his operation, this insuree’s annual wage was 57,000 CHF. If occupations

suitable for his residual capabilities are considered and which are open to him on the job

market (assembly work in the field of small-scale industrial production, quality control

for various goods, surveillance jobs, small goods delivery, etc.), an annual wage of around

52,000 CHF can be earned, this income being calculated on the basis of statistical surveys

that establish the average wages for unqualified employees on the current Swiss job mar- ket. The drop in annual wage of 5,000 CHF corresponds to an inability to earn of 9%, thus not entitling him to either a pension (a minimum of 40% loss of earnings is requi- red for entitlement to a quarter of the DI pension) or to retraining (a minimum of 20%

loss of earnings is required for entitlement).

Vocational measures can be requested right away from DI from the point in time when it becomes evident in medical terms that a change of occupational activity is essential due to permanent or long-term health impairment. In fact, it is unnecessary to wait for a full year of partial or total inability to work (qualifying period) as is the case when applying for a pension. It is important for the general practitioner to be familiar with this so that the reha- bilitation measures offered by DI can be activated as quickly as possible so that they have the greatest effect.

Example

A qualified baker develops asthma because of an allergy to flour. Once all the tests have been conducted, a diagnosis made and even the decision taken on inability due to occu- pational disease, the family doctor should urge his patient to submit a request for occu- pational rehabilitation to DI as quickly as possible. There is no reason to sit out a whole year of inability to work, which is the minimum legal period for entitlement to disability pension benefits other than vocational rehabilitation.

What distinguishes the baker from the unskilled manual worker mentioned above is their levels of vocational training. In contrast to the manual worker, the baker has a Federal Certificate of Proficiency (FCP). In a case like this, even if the DI office concludes that the baker is less than 20% disabled (theoretical payability), he can be considered for vocational retraining based on the fact that, in contrast to the unskilled manual worker whose income has peaked, the baker has both career and salary prospects and his loss of income is therefore potentially more important (= principal of so-called equivalence).

Legal constraints and vocational training

With regard to the choice of retraining within the framework of vocational rehabilita- tion, several fundamental principles indicate the route to be taken:

To reduce the claim, the law on disability insurance provides for simple and appro- priate measures, the aim being to safeguard a person’s ability to earn. Such measures are not necessarily the best possible ones, particularly from the standpoint of the insuree and his doctor.

In connection with the choice of a new occupational area, the idea of equivalence plays a central role. DI will permit an insuree to obtain new occupational qualifications to the level of his own prior to health impairment (FCP/FCP) but not, in principle, to a higher level (vocational college if previously FCP) unless this is the only way to safeguard his ability to earn.

The principle of the sustainability and success of the measure, the point of which is for

the vocational rehabilitation measures taken to have an effect over a certain length of

time with a minimum of success at the level of gainful activity. For example, DI will not consider a 3-year training scheme for an insuree who is five years away from his old-age pension.

The principle of proportionality: this aims at a reasonable balance between the expenses incurred by the measures and the foreseeable result of the latter. This principle is closely linked to the foregoing one.

In this way, the qualified baker who has an FCP can go in for training at the expense of DI, the aim being to obtain a new FCP in any field whatsoever that avoids contact with the allergen and dependent on his skills and interests.

Job placement assistance

What route is left to disabled patients who fail to cross the threshold that gives them the right to vocational rehabilitation?

For unskilled insurees whose loss of income does not amount to 20%, the DI’s job pla- cement service can be consulted to obtain help from DI experts at the DI office in finding a suitable job: the preparation of job applications, help in finding work and in editing advertisements, the preparation of job interviews, setting up work experience placements or periods for learning basics. Like all the benefits offered by the DI, this right is subject to restrictions. According to a recent court ruling, an insuree who is, in principle, fit to work 100% in a suitable activity does not have the right to assistance from the DI office in finding work unless hampered in looking for a job by his health impairment (blind- ness, deafness, mobility disorders, behavioural difficulties, etc.). If this is not the case, the unemployment insurance advisors will accompany him in this process.

In cases where the insuree’s ability to work in a suitable activity is greater than 80%

and less than 100%, he can receive assistance from the DI office’s job placement service.

However, the DI office is not obliged to place suitable work at the disposal of the insuree.

Example

The construction worker who was operated on for a slipped disc will not benefit from the DI office’s job placement assistance service if his ability to work in a suitable activity is 100% (loss of earnings of 9% in the example quoted above). On the other hand, if the need to take frequent breaks (more frequently than what is generally provided for, i.e.

2 quarter-hour breaks per day) reduces his ability to work to 80% in comparison with a normal employee, he could be assisted in his job-finding process by a rehabilitation advi- sor. In this connection, it is not the rate of disability that is the determining factor but the rate of ability to work in the suitable job.

Some data

In 2001, 375,000 individual measures were granted by the DI [4] for 301,000 beneficia-

ries. Preliminary investigation measures at specialist offices external to DI (COMAI,

experts) affected 166,000 people at a cost of CHF 85 millions (measures intended to verify the right to a DI pension).

One hundred and three thousand people benefited from medical rehabilitation mea- sures at a cost of CHF 492 millions (average of CHF 4,769 per case). Vocational rehabi- litation and training measures (the most expensive on a per-case basis) affected 13,000 people at an average cost of 21,298 CHF per case.

Concerning the results of vocational rehabilitation measures between 70,2% and 71,9% of the measures carried out between 1997 and 2000 were still effective two years later. In 1997, the number of vocational measures was 4,577.

Conclusion

During the period of inability to work, the chances of work resumption and long-term reintegration are considerably increased if insurance institutions intercede at an early stage in the form of vocational rehabilitation measures. For this to take place and given the complexity of the Swiss insurance system, inter-institutional cooperation (disability insurance, unemployment insurance and social assistance) is absolutely vital since, if these rehabilitation measures fail and for all that the inability to earn is greater than 40%, disability insurance will be obliged to pay out disability pensions pro rata based on the degree of disability.

References

1. Viscomi A (2003) L’assurance invalidité, cours 2

cycle AEAS, January/February 2. Federal law on disability insurance (LAI) of 09 June 1959

3. Suva statistics 2002 Swiss National Accident Insurance Fund. CP. 6002 Lucerne 4. 2002 social security statistics. Federal Social Insurance Office, Berne

5. Federal law on the general part of the social security law (ATSG/LPGA) of 6 October 2000 6. Circular concerning occupational rehabilitation measures (CMRP), valid from 1st January

2004

7. Fournier Buchs M-F, Rivier G (2003) De la prise en charge médicale à la réadaptation profes-

sionnelle. Revue médicale de la Suisse romande 123: 617-20