Framework Performance Assessment

Transcription

THE LONDON SCHOOL
OF ECONOMICS AND
POLITICAL SCIENCE
Framework Performance Assessment
November 2006
Elias Mossialos, Sara Allin and Joy Ladurner
With: Daniel Hentschel, Kitty Lawrence, Anita Rieder, Caroline Rudisill,
Corinna Sorenson, and Charitini Stavropoulou
Please do not cite without consent of the authors. Suggested citation:
Mossialos, E., Allin, S., Ladurner, J. et al. 2006. Framework Performance Assessment.
Report for the Main Association of Austrian Social Security Institutions.
London: LSE Health and Social Care
Contents
EXECUTIVE SUMMARY
1. OVERVIEW
1.1 Methodology
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2. DISTRIBUTION OF COSTS AND BENEFITS IN THE POPULATION
2.1 Funding health care
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2.1.2 Spending on health care in Austria
2.2 Sources of funding
2.2.1 Sources of funding in Austria
2.3 Defining benefits and beneficiaries
2.3.1 Defining benefits in the Austrian health system (what is covered?)
2.3.2 Defining beneficiaries in the Austrian health system (who is covered?)
2.3.3 The e-card
2.4 Progressivity of financing
2.4.1 Progressivity of financing in the Austrian health system
3. ACCESS TO HEALTH CARE SERVICES
3.1 Analysis of European Community Household Panel
3.2 Analysis of SHARE survey – equity in use of services among over 50 population in Europe
3.3 Access to care and cost sharing
3.4 Access to care and voluntary health insurance
3.5 Access to care for asylum seekers, refugees and illegal immigrants
3.6 Geographical access to care
3.7 Barriers to access health services in Austria
3.7.1 Financial barriers
3.7.2 Geographical barriers
3.7.3 Cultural barriers
3.7.4 Barriers in accessing preventive health services
3.7.5 Inequalities in utilization of health services in Austria
3.7.6 Measures to improve access to care in Austria
3.8 Patient pathways
3.8.1 Patient pathway in Austria
4. REGULATION OF THE HEALTH SYSTEM
4.1 Performance indicators
4.2 Regulating the health system in Austria
4.2.1 Independent monitoring agencies
4.2.2 Extent of decentralization of regulatory functions
4.2.3 Regulating purchasing
4.3.5 Regulating provision
5. ALLOCATIVE EFFICIENCY AND RESOURCE ALLOCATION
5.1 Health technology assessment
5.1.1 HTA in Austria
5.2 Resource allocation in Austria
5.2.1 Decisions about the health care budget
5.2.2 Allocation of budgets
5.2.3 Decisions about capital investments
5.2.4 Hospital planning
5.2.5 Geographical differences in per capita health expenditures
6. TECHNICAL EFFICIENCY
6.1 Administrative costs
6.1.2 Administrative costs in Austria
6.2 Physical and human resources
6.2.1 Hospital capacity in Austria
6.2.2 Substitution policies in Austria
LSE Project Framework Performance Assessment
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6.2.3 Physician career paths in Austria
6.3 Provider payment methods
6.3.1 Provider payment methods in Austria
6.4 Continuity of care
6.4.1 Continuity of care in Austria
7. QUALITY OF CARE
7.1 Appropriateness of care
7.1.1 Quality of care in Austria
7.2 Patient safety and medical errors
7.2.1 Patient safety in Austria
7.2.2 Patient rights in Austria
7.3 Patient choice
7.3.1 Choice in the Austrian health system
7.4 Satisfaction with health care
7.4.1 Patient satisfaction in Austria
7.5 Inter-generational solidarity: caring for older people
8. CONTRIBUTION OF THE HEALTH SYSTEM TO HEALTH IMPROVEMENT
8.1 Trends in life expectancy in Europe
8.2 Avoidable mortality
8.3 Trends in chronic diseases in Europe
8.4 Screening programs
8.4.1 Prevention and screening programs in Austria
8.5 Health inequalities
8.6 Health trends in Austria
8.6.1 Obesity and overweight
8.6.2 Tobacco consumption
8.6.3 Alcohol
8.6.4 Poverty and health
8.6.5 Socio-economic status and health
8.6.6 Evidence on measures of mortality amenable to medical intervention: variation across regions
8.6.7 Factors contributing to changes in health status
8.6.8 Are these factors related to health care, public health, health policy, lifestyle or other aspects
8.7 Health targets in Austria
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8.7.1 National health targets
8.7.2 Regional health care goals
8.7.3 Targets in Social Insurance
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9. SUMMARY AND CONCLUSIONS
9.1 Options for research
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EXECUTIVE SUMMARY
Performance assessment in health care has become a goal of national and international bodies in recent
years. Aggregate measures of performance, such as the WHO World Health Report rankings, fail to identify
strengths and weaknesses of health systems. This report adopts the perspective of health system functions in
order to provide a more comprehensive and policy-relevant evaluation focusing on: financing, distribution
of costs and benefits, access to care, regulatory capacity, resource allocation, technical efficiency and
payment methods, quality and satisfaction, and health improvement.
1. Financing health care: levels, sources, and progressivity of funding
Recent years have witnessed significant increases in health spending, in some countries at a faster rate than
GDP, due to increases in labour costs, technological innovation, rising public expectations, pressures from
providers, and population ageing. At present, average health spending in the EU is 8.6% of GDP, with a
range from 6% in Poland and Slovakia to 11% in Germany. In the European region, public sources of
financing (taxation or social health insurance) comprise the bulk of expenditure, ranging from 51% in
Greece to 90% in Czech Republic. The bulk of private payments stems from out-of-pocket payments;
ranging between 20% in the Netherlands and 40% in France to over 90% of private expenditure in Greece,
Denmark and the Slovak Republic. Financing reform has been seen in some countries, e.g. France – in
1998, social insurance contributions expanded to include total income rather than solely wages; with similar
discussions taking place in Germany.
Calculations of health expenditure in Austria have been the focus of longstanding debate. Until recently
calculations of health spending has followed a system of national accounts – which led to an estimation of
total health spending to be 7.5% of GDP in 2004. However with the new system of health accounts
(OECD), estimates for total spending in 2004 are much higher at 9.6% of GDP. This revised estimate places
Austria above the average spending in the EU. The mean annual growth rate over the past ten years was
lower than the EU average, at 6.3% compared to 6.9%. With regards to the proportion of total spending that
derives from public sources, the level in Austria is lower than the majority of EU countries. Indeed, the
share of private funding is about 30%, which places Austria 3rd highest in the EU 15 and 9th highest among
30 OECD countries. The public sources of funding in Austria consist of statutory social insurance (45% of
total spending), and 25% from general and value-added taxation (which is mainly directed towards hospital
payments). On the other hand, the private sources of funding consist largely of out-of-pocket payments –
both indirect (13.5%) and direct (7.6%) user charges. Private health insurance plays only a minor role in the
financing of health care in Austria, constituting 2.4% of total health expenditure.
Progressivity of financing refers to the extent to which individuals on higher income are contributing
relatively more than those on lower income. Taxation tends to be more progressive than social health
insurance (SHI). However, while direct taxes are progressive, indirect taxes (e.g. VAT) are regressive.
Furthermore, having fewer tax bands and low marginal tax rates makes the system more regressive. Out-ofpocket payments are regressive, however exemption mechanisms can reduce the financial burden on those
least able to pay.
In Austria there have not been any comprehensive studies on the level of progressivity in the financing of
health care; however, some evidence exists. For instance, inequality of wage income in the country appears
to be increasing, however the state plays a role in redistributing from the wealthy to the poor in the form of
social and health care related transfer payments. Analysis of the progressivity of the funding components
suggest that taxes are progressive up to income threshold (maximal tax rate up to 50% for self-employed
and 44% for employed), then regressive. Similarly, SHI contributions are progressive up to the earnings
threshold for chargeable contributions (€ 3,750 per month in 2006), then regressive. It is important to note,
however, that wages and the wage quota are declining, which is resulting in an erosion of the SHI funding
base. Further exacerbating the financial constraint is the observation that SHI spending is increasing at a
faster rate than revenue through SHI contributions. The other large component of financing is user charges,
which are regressive. However, there are extensive exemption mechanisms in place that generally are based
on income level and illness categories, but few specifically for children. The financing system in Austria,
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however, allows many forms of redistribution, thus contributing to fair financing: between generations,
income groups, healthy to sick individuals, and insured single persons to insured with dependants.
2. Access to care: barriers to access and equitable utilization
Almost all European countries provide universal or near-universal coverage to statutory health insurance, a
precondition for access. However, barriers to access exist – e.g. financial, geographical, cultural,
administrative – and are unequally distributed across the population, where lower socioeconomic groups
tend to experience greater barriers to access than their better off comparators. Furthermore, barriers to
access may be especially pronounced for asylum seekers and refugees. There is considerable variation
across Europe in reported barriers to access. For instance, waiting times for elective surgery exist in some
countries (mainly tax-funded) more than others (mainly SHI funded). Furthermore, some countries appear
to have more inequitable access in terms of geographic proximity to health facilities than others.
Results of two comprehensive analyses of survey data (European Community Household Panel Survey
(ECHP); and Survey of Healthy Ageing and Retirement in Europe (SHARE)) are reported, both measuring
the extent to which equity in utilization – i.e. equal use of services for equal need – is achieved. Overall, it
appears there is no evidence of inequity, or in some cases pro-poor inequity in primary care (GP services) in
Europe. On the contrary, there appears to be significant pro-rich inequity in specialist services in almost all
European countries analysed. This means that higher income groups are more likely to access specialist care
than lower income groups, after standardizing for differences in need (health status). Finally, it appears
there is little evidence of inequity, or in some cases pro-rich inequity, in hospital (inpatient care). For
inpatient care, the probability of admission is measured and not the number of separate hospital admissions.
In Austria, like the rest of Europe, statutory health insurance covers almost the entire population (97.8%),
with insurance contributions based on ability to pay and not health risk. However, barriers to access are still
present, e.g. geographical barriers (for instance in rural areas there is limited access to some specialist
services), cultural or language barriers, difficulties faced by people with disabilities in accessing care, and
differences in level of information about entitlements across population groups. Furthermore, regional
variations exist in the utilization of services and health spending per capita, however more research is
needed to better understand reasons for these differences. Analysis of ECHP and SHARE reveal that in
Austria, GP services appear equitable or pro-poor (depending on the survey), while specialist services and,
to a less extent inpatient care, are pro-rich. With the aim at reducing barriers to accessing care and
improving equity in access, a number of initiatives have been introduced. For example, opening hours of
contract physicians have been extended, translation services are offered for migrants, initiatives to raise
awareness of insured population of entitlements have been provided through insurance fund-led facilities.
In addition to the above-mentioned barriers to access, financial barriers in the form of direct and indirect
user charges exist in most European countries. User charges for physician visits are present in Austria,
France, Greece, Italy, Sweden and Switzerland; and for pharmaceuticals in all countries. User charges for
inpatient care are less common. In Austria and Germany, there is a co-payment per day of around €8-9, with
exemptions after 14 days in Germany and 28 days in Austria. Furthermore, where voluntary health
insurance (VHI) offers faster access to public services (supplementary insurance), individuals who can
afford to purchase VHI may be receiving better access than lower income earners.
In Austria, user charges do not seem to be significant barrier because of exemptions for low-income groups
and individuals with diseases incurring high treatment costs. It should however be noted that user charges
are not aligned meaning there is no upper limit which takes all user charges into consideration, e.g. per
person per time period (Moreover, analysis of SHARE show that a low proportion of individuals (<3%)
forego care because of costs (among 50+ population) in comparison to other European countries. However,
there is no blanket exemption for children, except for prescription charges; they are only exempt from user
charges on some specific occasions. Inequalities across employment groups exist because of (slight)
differences in benefits packages across insurance funds, and varying levels of cost sharing across insurance
funds. Furthermore, while waiting times in Austria is not a significant issue for emergency treatment they
do exist for elective care. Data on waiting times are very scarce and usually not available to the public.
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Higher income groups may get faster access to elective treatment through voluntary health insurance
coverage.
3. Regulatory capacity
Regulation involves many functions and takes place at many levels of the health system. There are three
principle models of organizational relationship between purchasers and providers: (1) integrated; (2)
contract; and (3) direct payment to providers. Government may play a regulatory role at national, regional
and district levels; many countries have independent monitoring agencies (e.g. UK). Also regulatory
functions may be the responsibility of independent non-governmental- or arms-length bodies. There is a
general continuum of state authority and supervision that ranges from: command-and-control (e.g. NHS
trusts in the UK; public hospitals in Austria and Germany), to arms-length approaches such as private notfor-profit entities with statutory responsibilities (e.g. sickness funds) and private-for-profit companies with
or without service agreements with public payers (e.g. private hospitals in Italy and Portugal). One specific
regulatory function – health technology assessment (HTA) – is increasingly a part of national prioritysetting; almost all EU countries have established HTA programs; these can be either advisory or regulatory.
In Austria, all three models of service provision can be seen. For example, social insurance funds have
integrated institutions (e.g. rehabilitation clinics), contracts are used for primary and secondary care; and
private payment exists for services outside of the SHI benefits package. One serious challenge in Austria is
the fragmentation of responsibilities for funding and provision of services, especially for secondary care.
Although regulation is strongly based on federal (and some state) legislation (in the SHI system, the
Federation defines rules and insurance funds implement them and purchase services), regulatory functions
are largely decentralized. Thus, Government relies heavily on delegation of regulatory functions and
devolution to federal states, for example in the case of hospital care. As seen in the rest of Europe, HTA is
increasingly being used for decision-making; however, further elaboration of HTA activities should be
encouraged.
4. Allocative efficiency and resource allocation
Allocative efficiency refers to the extent to which the amounts and types of health services are efficient and
maximize health gain. Health expenditure by sector is one indication, although crude, of allocative
efficiency. For instance, while increasing expenditure in some sectors like pharmaceuticals should
correspond to improved health outcomes, it is difficult to measure the extent to which this is the case. High
levels of spending in inpatient care may be seen as inefficient and reflecting deficiencies in lower levels of
the system. Furthermore, spending on primary care and prevention, the most cost effective care, is very low
in most countries (including Austria).
Methods of resource allocation have moved away from historical and retrospective reimbursement towards
fixed fee schedules, budgets, and activity-based payments. Capitation with risk adjustment is increasingly
common in Europe; risk adjustment formulae are developed in order to compensate purchasers (health
plans; sickness funds) with high risk/high cost patients and avoid risk selection in countries with
competition among funds (e.g. Germany, the Netherlands) or reduce geographic inequalities in health care
(e.g. United Kingdom).
In Austria there is considerable fragmentation in sources of funding, especially for hospital care. Further
contributing to inefficiency is the fact that resource allocation remains mostly based on historical patterns.
With the aim at improving efficiency and continuity of care, recently more cooperation between primary
and secondary care has been promoted; but budget insecurity still exist (Reform pool1). Planning resource
allocation is one method of improving allocative efficiency. In Austria while instruments for resource
planning exist, including mandatory quality standards; they are not yet covering all areas of care. Recently
the scheme for risk adjustment between funds was revised to incorporate characteristics of insured
population (e.g. average costs, revenue generated by prescriptions charges, extraordinarily high cost
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Will funds of the recently established reform pool really be available and used?
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patients). While this is a positive change, follow-up activities will be necessary: an evaluation of the actual
impact of this change is needed along with further improvements and refinements to the risk adjustment
formula.
5. Technical efficiency
Technical efficiency means producing the maximum possible sustained output from a given set of inputs.
Many factors influence technical efficiency including: administrative costs, supply and payment of
providers, and continuity of care. On average, administrative costs tend to be lower in tax-funded systems,
and Austria appears to be keeping costs down compared to other SHI systems (3.6% of total health
spending in Austria; 4-6% in Netherlands and Germany). Higher levels of high-cost equipment (e.g. hightech diagnostics) and providers (e.g. doctors versus nurses) may create inefficiencies. Substitution policies
may serve to increase efficiency as well, for example between doctors and nurses, or using generic instead
of brand name prescriptions. Hospital efficiency can be inferred from average length of stay, which has
been declining significantly across Europe in recent years. Ensuring continuity of care may improve quality
of care and efficiency, for example by reducing consultation times, making better clinical decisions.
In Austria, there have been only few studies on productivity using data envelopment analysis for hospital
care, however more research is needed. There is a relatively high level of resources relative to other
countries; a high number of hospital beds per capita, although this has reduced over recent years; and a high
number of high technology diagnostics (CT and MRI scanners) per capita compared to other European
countries. It is unclear to what extent this high capacity is excessive and inefficient. It seems hospital
efficiency appears to be improving since introduction of DRG payment system, as indicated by low average
length of stay and reduction in acute care beds. However the number of inpatient-admissions has gone up
constantly since 1991 whereby the increase has been stronger after the introduction of the performance
related reimbursement system, the socalled LKF system (especially in hospitals not funded by the federal
health funds). This is partially rooted in the increase in day-clinic cases as well as case-splitting. Increases
in costs were contained by capping expenditures.
It is important, however, that monitoring of potential cost-shifting and gaming of the system (“DRG creep”)
is undertaken. Other areas of potential inefficiency in Austria relate to incentive structures such as the lack
of selective contracting of physicians, the fact that generic prescribing is not encouraged, generic
substitution by pharmacists is not permitted and pharmacist payment methods do not encourage the
dispensing of lower cost drugs.
Continuity of care in Austria is quite limited at present. This relative lack of continuity can be attributed to
numerous causes such as: different funding streams and responsibilities for health and social services;
duplication of services in primary and secondary care (although it is encouraging that the acceptance of
laboratory tests done at primary care level by hospital physicians seems to be increasing); variation in
clinical processes in the absence of clinical guidelines, lack of standards (e.g. for care in general or with
regards to checking patients out of hospitals); the only recent development of disease management
programs (which is solely for diabetes at present); and extensive choice of provider. Finally, there may be
excessive referrals between providers taking place in order to remain within certain limits defined by
insurance funds, such as with regards to the number of prescriptions.
With respect to long term care more than 350,000 individuals in Austria are in need of daily care2, and the
number is constantly increasing. There is a considerable demand for qualified nursing staff as well as
standards for long term care. Currently staff needs are partially met by illegal carers from Eastern Europe;
this fact became an important topic during the election campaign of 2006. While as a short term solution the
employment of illegal carers in private households is not being reported, long term solutions are being
discussed.
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Federal Ministry of Social Insurance, Generations and Consumer Protection (2005). Introduction, orientation
guide on the topic of disability, Vienna
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Provider payment methods have significant implications for technical efficiency. Physicians are paid on a
fee-for-service basis in many countries (Austria, Belgium, France and Germany); while this method
encourages increases in productivity, it may lead to unnecessary cost escalation and supplier-induced
demand. Moreover, payment based on activity and without targets for quality or performance may limit the
influence of payers on quality of care. Hospital payment is increasingly based on activity in Europe, with
many countries using DRGs (diagnosis-related groups).
In Austria, physicians are paid mainly on the basis of fee-for-service, which is supplemented by capitation.
In light of the cost-escalating potential of fee-for-service payments, various mechanisms for cost control
have been introduced such as price -volume adjustments after a certain threshold is met. Fee structures of
most insurance funds include quality criteria for service provision though funds have limited scope to
demand and monitor quality of providers and services. Incentives are part of the general contract or fee
structures, although there is still limited use to date, and a relative lack of evaluation of impacts. Hospitals
are paid on the basis of an activity – DRG (LKF) system dating back to 1997 – which covers about half of
hospital payments. This system increases transparency and provides hospitals with the incentive to improve
efficiency, but there is a need to monitor potential upcoding practices.
6. Quality of care
Quality of care is extremely difficult to measure, although some indicators include medical errors, patient
satisfaction, and level of support for patient safety and patient rights. Patient choice, which can be for
insurance, provider, or treatment, is often associated with quality and patient satisfaction. In Europe,
satisfaction with health care varies quite a lot; Austria appears to have among the highest levels of
satisfaction with the health system/health care and perceived quality of care. Choice of provider is perceived
to be very high in Belgium, Switzerland, France, Germany, Denmark, Ireland and Austria - and low in
Iceland, Portugal and Ukraine. With the aim to improve quality, quality assurance and patient safety
initiatives have been introduced in many countries, such as clinical guidelines. Furthermore, efforts to
monitor prescribing patterns and establish national patient safety programs have been seen in many
countries.
Medical errors, another indication of quality, represent a significant cost and health burden in Europe.
Surveys reveal citizens in some countries perceive medical errors to be more of a concern (e.g. in Greece,
Poland, the UK, Slovenia) than others (e.g. Austria and Sweden); and are more confident in their doctors in
some countries (e.g. Austria and France).
Overall in Austria, perceptions of quality of care are quite high. For instance, there appears to be
consistently high satisfaction with health care and public services. Also, choice of provider is very high, but
very limited choice of insurance fund exists, and choice of physician in hospital is mainly restricted to
private hospitals. Efforts are needed to maintain the current level of quality and satisfaction, and there is a
need to develop and monitor quality indicators. Many quality-related activities have been initiated;
however, at present they are only partially implemented.
Although it seems the population is on the whole satisfied in Austria, insurance funds have very limited
possibility of monitoring and improving quality of providers and care. Furthermore, providers are not
subject to re-validation of their skills. The quality of services provided by physicians in their practices is
currently only evaluated by means of self-assessment. Evaluation is organized by the ÖQmed Company
which is owned by the Austrian Medical Association. Regarding patient safety, there is currently no
national body for patient safety to set standards, and, until recently, no legal basis for reporting medical
errors existed. Finally, there is no information on quality of providers reported to public. Austria has issued
a Patient Charter which has been signed by all federal states. Patients can seek advice from patient lawyers,
ombudsmen and other institutions protecting patient rights. In 2006 the Advance Directive Act was issued
enabling patients to set up an advance directive.
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7. Health outcomes
Health gains have been seen in all European countries in terms of life expectancy and infant mortality.
However, all across Europe, the prevalence of obesity is increasing, and while overall smoking levels and
related deaths have declined in most countries, among certain population groups such as youths and women,
this is not the case. In Austria, life expectancy at birth is higher than the EU average and appears to be
increasing. In 1980, female life expectancy was ranked 11th in the EU, which has increased to 7th in 2003;
for men the same trend was seen with a change in ranking from 14th to 9th. These improvements have
largely been attributed to reductions in infant mortality due to better quality care and improved living
conditions.
As with other European countries, there appears to be a worsening in the case of some important risk
factors. For instance, obesity is on the rise for all age groups, but especially for children and young people.
Tobacco consumption also appears to be increasing among Austrian women, but falling for men. Moreover,
smoking prevalence for teenagers is one of the highest among European countries (age 15: 26% of girls,
20% of boys smoke daily). Finally, alcohol is a serious health problem; death rate due to cirrhosis of the
liver is among the highest in Europe.
It is possible to disentangle overall levels of health between those that are attributed to the health care
system, and those that are not. The concept of avoidable mortality, or deaths that should be avoided in the
presence of timely and effective medical care, sheds some light on the strengths and weaknesses of the
health system in leading to health improvement. Evidence suggests there has been better progress in
treatable than preventable diseases in Austria. This may reflect the curative focus of the health system in
Austria, and only recent prioritization of prevention. However, more research is needed to update the
current evidence base which draws from data in the 1990s, and to generate information on a regional basis
within Austria to determine whether any regional differences exist in the functioning of the health system.
For example, to date, screening programs are limited; they are only opportunistic although a national
mammography screening program will be introduced shortly.
8. Conclusions
By adopting the performance assessment framework that identifies the objectives and functions of the
health system, the Austrian health system appears to have both strengths and limitations. There is a
relatively high degree of trust, confidence, choice, and satisfaction among the Austrian population. Further,
there appear to be several positive developments in recent years, such as to the implementation of a
performance based hospital payment system, the introduction of an electronic health card (e-card), the
development of a diabetes management program, and national mammography screening program. These
developments could all lead to improvements in equity and efficiency. Despite these strengths, there are
some lessons that can be learned from examining the system more closely and drawing comparisons with
other countries.
Continuity of care in Austria could be improved. Disease management programs could be extended to
include other disease areas following an evaluation of the diabetes initiative. Research could be done to
identify high service users and then assigning them to a personal doctor or clinical team. Clinical
information could be better shared across areas and levels of care. Finally, although high levels of patient
choice of provider are valued by the population, one may consider questioning the extent to which this
current level compromises continuity of care.
Public health and prevention activities appear to be gaining in importance in Austria. This is a positive step
towards shifting care from high cost to lower and cost-effective care. Spending on inpatient care in Austria
appears quite high relative to other countries, therefore reflecting possible inefficiencies at lower levels.
Furthermore, the new mammography screening program should be evaluated for effectiveness and costeffectiveness, and extensions to other disease areas should be considered based on this evaluation and
international evidence. The new health check-up program also reflects the increasing importance paid to
prevention; however, this should also be subject to monitoring and evaluation. Furthermore, as the health
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trends indicate emerging and persistent health threats such as alcohol consumption, obesity, and smoking,
particularly among young people, more research is needed to develop national surveys focusing on these
areas, and to initiate public health programs targeting population groups, such as youths, and those most at
risk. Finally, in light of the ageing population, prevention and care programs aimed at elderly people,
particularly those living alone, should be developed.
Quality of care appears to be perceived as quite high by the population, therefore efforts are needed to
maintain this high level. Also, additional quality indicators and standardized measures of waiting times
could be developed and released to the public, in order to increase transparency and empower patients,
which may lead to efficiency improvements. Research into avoidable mortality which provides an
indication of the quality and overall performance of health care should be updated and perhaps conducted
on a regional level, thus highlighting variation in performance within the country. The risk equalization
scheme of social health insurance represents an important step towards ensuring equity in the financing of
the health system. However, this scheme should be evaluated, and possibly elaborated to better reflect need.
Moreover, research investigating regional variations in access to care, costs and health outcomes would be
beneficial. Awareness for gender medicine is only gradually arising in Austria, it will be beneficial to place
more importance on this issue in the future.
The current supply of health services appears in some cases sufficient (for instance regarding hospital beds
and advanced diagnostic equipment) but relatively low in other cases (e.g. regarding the number of nurses,
especially for long term care). Research assessments on the current needs and also projections of future
human resources need should be undertaken. Payment of professionals appears in some cases to incentivise
productivity (e.g. fee-for-service arrangements for physicians and DRG-type system for hospitals) however,
these schemes should be evaluated in terms of impacts on costs and outcomes, and further incentives may
be considered to be elaborated, such as by including quality targets in the payments system and revising
pharmacist payments to remove the link to the cost of prescriptions. A special fund for research could be set
up drawing on funds from federal and state government and insurance funds that is at an arms-length from
government. Further, an institute could commission work to local institutions such as universities and
research centers in order to address key research areas.
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1. OVERVIEW
Modern health systems developed out of concern for social protection and equity. Health insurance systems
arose in many countries in the late nineteenth century, through mutual aid societies or sickness funds that
covered some workers. After the Second World War, there was a major emphasis across the developed
world on expanding health insurance coverage driven in part by advances in medical care such as penicillin
and antibiotics, alongside the election of quasi-socialist governments with the aim to better protect their
citizens.3
The first post-war health reform was in the United Kingdom with the Beveridge Report of 1942, leading to
the National Health Service (NHS) Act and its implementation in 1948. Shortly thereafter the Japanese,
Canadian and French systems were formed (1958-1961), followed by Italy and Germany. At present all
OECD countries offer (near) universal health care coverage of the population with the exception of Turkey
and the United States. The public systems that were set up were relatively generous, with comprehensive
baskets of health services, little cost-sharing, and few controls on health care demand and supply.4
Since the 1970s, spending on health care grew more quickly than governments could easily afford, due to
the limited constraints on spending and growing technical sophistication of medical practice. As a response,
there was a gradual shift away from ensuring the generosity and equality of coverage to cost containment in
large part by introducing tighter regulatory mechanisms5. For instance, in the hospital sector, countries that
relied on global budgets restricted the budgetary limits with some countries introducing activity-based
payments (e.g. in Italy). For physicians, cost containment measures consisted of tightening the fee
schedules and introducing prescription drug budgets (e.g. in Germany).
Despite some success in putting downward pressure on increasing health expenditures in many countries,
these cost-containment policies, alongside the rationed model associated with it, became less popular for
many reasons. In summary, these reforms were associated with: increased difficulties in accessing care,
such as long waiting lists; a lack of incentives to increase efficiency; and only short-term cost savings.6
Therefore, more recently a new wave of health reform emerged focussing on introducing incentives to
improve efficiency largely by: a) increasing cost sharing, b) introducing competition between insurance
funds, c) separating purchasing from provision (e.g. the purchaser-provider split in the United Kingdom),
and d) reforming payment mechanisms; by now almost all European countries operate some form of
diagnostic related group (DRG) funding mechanism. Continuing pressures on health systems worldwide
stem from the conflicts between the goals of efficiency and equity which becomes more complicated as the
cost of health care continues to rise.7
Measuring health care performance
Health care system performance is currently a high priority on international and national policy agendas.
However the concern with measuring the performance of health systems dates back to the 1800s. In fact,
Florence Nightingale in the 1860s initiated the practice of comparing hospital outcomes data with the aim to
better understand and improve performance. Only in the last decade or so has the vision of making use of
large-scale data sources to measure and improve health system performance been realised. Performance
3
D.M. Cutler, "Equality, Efficiency, and Market Fundamentals: The Dynamics of International Medical-Care
Reform," Journal of Economics Literature XL (2002).
4
J.P Newhouse, "Medical Care Costs: How Much Welfare Loss?," Journal of Economics Perspectives 6, no. 3 (1992).
5
Cutler, "Equality, Efficiency, and Market Fundamentals: The Dynamics of International Medical-Care Reform.", E
Mossialos and J Le Grand, eds., Health Care and Cost Containment in the European Union (Ashgate: Aldershot,
1999).
6
Cutler, "Equality, Efficiency, and Market Fundamentals: The Dynamics of International Medical-Care Reform."
7
Ibid.
11
data serve broadly two purposes: to identify what works to achieve the health system objectives; and to
identify specific areas of competence.8
Following the publication of the World Health Report by WHO in 2000 which yielded a ranking of health
systems in 191 countries, most governments have been concerned with the measurement of their own health
system’s performance and comparing strengths and weaknesses with other countries. One of the major
criticisms of any approach to measure performance based on aggregate data is that they provide little or no
indication of what needs to be done to improve the system when faced with evidence of sub-optimal
performance. It is vital that more detailed analyses of the components of health care systems is conducted in
order to disentangle the specific issues that warrant attention.
The World Health Report provides a useful starting point for measuring health system performance. This
report outlines three fundamental dimensions of performance: health attainment as measured by healthy (or
disability-free) life expectancy, responsiveness to the needs of the population, and fairness of financing. The
report further delineates four functions through which countries can achieve these three goals: service
provision, resource generation, financing, and stewardship. On the basis of these components, health care
systems of different countries are ranked: France came out as the best performing health system in the
world; Austria was ranked 9th (5th in the EU) (see Table 1.1).
One of the major contributions of this report was the development of an instrument to assess health
systems’ responsiveness to the population based on seven dimensions: autonomy, confidentiality, dignity,
prompt attention, quality of basic amenities, access to social support networks during care, and choice of
providers. While as a concept this is clearly important to consider when evaluating a country’s health
system, these indicators are incredibly difficult to measure, and even more difficult to compare across
countries. In light of the limited data to measure these concepts, WHO methodology consisted of surveys of
a selection of informants in 35 of the 191 countries, with imputation methods used for the remaining
countries.
Table 1.1 Top 25 countries in WHO rankings by health status and health system performance
Rank
Countries ranked by Countries ranked by health
health status
system performance
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Oman
Malta
Italy
France
San Marino
Spain
Andorra
Jamaica
Japan
Saudi Arabia
Greece
Monaco
Portugal
Singapore
Austria
United Arab Emirates
Morocco
Norway
France
Italy
San Marino
Andorra
Malta
Singapore
Spain
Oman
Austria
Japan
Norway
Portugal
Monaco
Greece
Iceland
Luxembourg
Netherlands
United Kingdom
8
P Smith, ed., Measuring Up: Improving Health System Performance in OECD Countries (Paris: Organization for
Economic Co-operation and Development, 2002).
12
19
20
21
22
23
24
25
Netherlands
Solomon Islands
Sweden
Cyprus
Chile
United Kingdom
Costa Rica
Ireland
Switzerland
Belgium
Colombia
Sweden
Cyprus
Germany
Source: WHO World Health Report 2000
The findings of the World Health Report were highly controversial and led to widespread international
criticism. Critics argued the choice and measurement of specific indicators was flawed, there were doubts
about the reliability of the data used, debates over how the various indicators should be weighted, and
identified other problems related to the methodology.9 Furthermore, a large part of the analysis derived
from expert opinion, and indeed public opinion and satisfaction with the system appear to deviate
significantly from the WHO rankings.10
A Canadian non-profit organization, the Conference Board, recently undertook a benchmark analysis of 24
OECD countries looking at three categories of performance: health status, non-medical factors and health
outcomes, each with their own set of indicators.11 Health status indicators include life expectancy,
disability-free life-expectancy, self-reported health status, infant mortality rates, and low birth weight. Nonmedical factors consist of body weight, tobacco and alcohol consumption, road traffic accidents, sulphur
oxide emissions, and immunizations (DPT and influenza). Finally, health outcomes are comprised of
mortality rates from lung cancer, acute myocardial infarction, stroke, suicide, and potential years of life lost
(PYLL) through suicide (male), lung cancer, and breast cancer. To aid interpretation, they categorise each
country as either gold, silver or bronze based on their relative position. The ranking of performance based
on the three indicators is seen in Table 1.2.
Table 1.2 Ranking of a selection of OECD countries based on Canada’s Conference Board health
system performance indicator system (rank based on weighted average of indicators)
Rank
Country
Gold
Silver
Bronze
1
Switzerland
14
9
1
2
Sweden
14
7
0
3
Spain
12
9
3
4
France
12
9
2
5
Italy
11
11
0
6
Germany
9
15
0
7
Norway
13
6
2
8
Japan
14
3
7
9
Iceland
12
7
2
10
Australia
10
11
3
11
Netherlands
11
9
4
12
Finland
11
7
4
13
Canada
7
13
4
14
Mexico
12
4
4
15
Belgium
9
8
4
9
C Almeida et al., "Methodological Concerns and Recommendations on Policy Consequences of the World Health
Report 2000," Lancet 357, no. 9269 (2001).
10
RJ Blendon, Kim, M, Benson, JM, "The Public Versus the World Health Organization on Health System
Performance," Health Affairs 20, no. 3 (2001).
11
The Conference Board of Canada, "Understanding Health Care Cost Drivers and Escalators," (Ottawa: The
Conference Board of Canada, 2004).
13
16
17
18
19
20
21
22
23
24
New Zealand
Austria
Denmark
Korea
Portugal
United Kingdom
Ireland
United States
Greece
7
6
8
9
8
6
7
5
5
12
13
8
5
7
11
7
9
8
5
3
6
9
5
7
7
10
5
Disaggregating the three indicators provides a suggestion on the relative strengths and weaknesses in those
areas. In terms of health status, Switzerland again ranks first, Austria 14th, and Mexico last. Regarding the
non-medical factors, Sweden ranks first, and Austria 20th with Greece last. Finally, indicators of health
outcomes surprisingly places Mexico first, Austria 11th and the United States the lowest.12
Similarly, the Social and Cultural Planning Office of the Netherlands compared health care in the EU plus
Australia, Canada, New Zealand and the United States.13 They employ a range of indicators and group them
into four indicators: 1) user charges, 2) waiting times, 3) public confidence in the system, and 4) health
status, measured by life expectancy, quality-adjusted life years, infant mortality and self-assessed health.
Through this exercise, the health systems in France, Sweden and Austria rank the highest since they score
well in all four indices.
A different way of measuring the performance of different countries’ health systems is by evaluating
primary health care in terms of health outcomes.14 A study using OECD data found that strong primary care
systems are negatively associated with aggregate and gender-specific mortality rates, overall levels of
premature deaths, and premature deaths from asthma, heart disease, cerebrovascular disease and
pneumonia, even when other determinants of health (e.g. GDP and behavioural factors) were controlled for.
While lower mortality rates are associated with greater supply of primary care physicians, it seems that this
is not the case with specialist physicians.15
Although the quest for a single number or ranking of performance is prioritised on policy makers’ agendas,
it is highly unlikely that a single estimate could possibly capture the multitude of costs and benefits of the
health system. Furthermore, a composite indicator compounds the inaccuracy of its component measures16.
While rankings may be popular among policy makers, rankings based on a single measure may be
misleading and uninformative, whereas rankings based on disaggregated indicators such as infant mortality,
waiting lists or other specific measures are likely more easily related to policies or practices.17
Others have assessed health system performance along four key parameters: Health status, satisfaction and
responsiveness, equity, and efficiency. This assessment was based on available quantitative data for
countries that rely largely on social health insurance for funding.18 Health status is measured by life
12
Ibid.
Social and Cultural Planning Office of the Netherlands, "Public Sector Performance," (The Hague: Social and
Cultural Planning Office of the Netherlands, 2004).
14
J Macinko, B Starfield, and L Shi, "The Contribution of Primary Care Systems to Health Outcomes within
Organization for Economic Cooperation and Development (OECD) Countries, 1970-1998.," Health Systems Research
38, no. 3 (2003).
15
Barbara Starfield et al., "The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence," Health
Affairs Jan-Jun, no. Suppl Web Exclusives (2005).
16
C D Naylor, K Iron, and K Handa, "Measuring Health System Performance: Problems and Opportunities in the Era
of Assessment and Accountability," in Measuring Up: Improving Health System Performance in OECD Countries, ed.
P Smith (Paris: Organization for economic co-operation and development, 2002).
17
D Navarro, "Assessment of the World Health Report 2000," Lancet 356 (2000).
18
J Figueras et al., "Patterns and Performance in Social Health Insurance Systems," in Social Health Insurance
Systems in Western Europe, ed. Richard B. Saltman, Reinhard Busse, and Josep Figueras (Copenhagen: World Health
Organization on behalf of the European Observatory on Health Systems and Policies, 2004).
13
14
expectancy, disability-adjusted life expectancy, and avoidable mortality. Satisfaction and responsiveness are
measured through population, patient, and policy-makers’ surveys, in addition to examining the length of
waiting times and levels of choice available in the health system. Equity of financing is measured through
progressivity and regressivity estimates, as well as fairness of financial contribution estimates by the WHO.
Finally efficiency is examined in four parts: cost and expenditure; relative resource levels and utilization
rates; administration costs; and clinical performance (quality). The authors note that the complexity and
often divergent organizational arrangements within the countries following the social health insurance
model make evaluations incredibly difficult.
It is important not to mistake health status with health care. In other words, we need to be cautious about
drawing conclusions from measures of health system performance that are based, at least in part, on broad
population health indicators. These measures of population health are largely affected by broader
determinants such as social and educational policies, socio-economic and living conditions, inequalities,
nutrition and other lifestyle factors. Moreover, some estimates suggest that health care might account for
less than 20 percent of health improvement observed in the past century.19
1.1 Methodology
This report provides a disaggregated approach to evaluate the performance of the Austrian health system
from an international perspective. We do not attempt to calculate a composite indicator, but construct this
evaluation on the basis of the different objectives and functions of the health system, building upon the
evaluation frameworks developed by the WHO and OECD. The broad objectives can be categorised by the
concepts of equity and efficiency. The various functions of the health system represent the means through
which the objectives can be achieved: financing arrangement, payment methods, methods of resource
allocation, delivery of care, quality of care, access to care, and to the extent that is possible, satisfaction.
Finally, we present evidence on health status, in particular attempting to disentangle the impact of the health
system on the health of the population.
To summarise, the aim of this study was to evaluate the performance of the Austrian health system on the
basis of the following criteria:
-
Distribution of costs and benefits across the population
Access to care
Regulation of the health system
Allocative efficiency and resource allocation
Technical efficiency
Quality of care and patient satisfaction
The contribution of the health system to health improvement
Initially two reports were elaborated, one presenting the international evidence and experience with regards
to performance measurement as well as presenting and analysing material for various countries related to
the above mentioned criteria, the other describing and analysing the Austrian health care system, based on
the above listed dimensions. In August 2006 the amalgamation of both reports was initiated and performed
mostly by research staff at LSE Health and Social Care, The London School of Economics and Political
Science. In addition to the joint report options for further research for Austria were elaborated, depicting
either areas which require further research or showing gaps in data or resources encountered in the course of
the project work.
The methodology employed in the preparation of this report consisted of a combination of literature review,
analysis of survey data, and interviews with Austrian stakeholders.
19
J Bunker, H Frazier, and F Mosteller, "Improving Health: Measuring Effects of Medical Care," Milbank Quarterly
72, no. 2 (1994).
15
Empirical analysis of survey data was also undertaken. Several surveys were analysed:
•
•
•
•
European Community Household Panel Survey
Survey of Healthy Ageing and Retirement in Europe
European Social Survey
Eurobarometer Surveys
The international report was developed by the London School of Economics and Political Science (led by
Elias Mossialos and Sara Allin), and the Austrian report was written by Joy Ladurner. In the course of the
project two co-operations were initiated for the Austrian part, one with Univ.-Prof. Dr. Anita Rieder
(Prevention, measures of mortality amenable to medical intervention, factors contribution to changes in
health status) and another with Mag. Daniel Hentschel MSc (Health expenditures, health indicators, factors
affecting health status and health targets).
Work on the Austrian part was initiated in October 2005. In addition to performing a comprehensive
literature review, using databases such as Medline and Web of Knowledge as well as the internet search
engine Google information (giving priority to national research reports and recent literature 2000-2006)
resources were collected at various national institutions (ministries, social insurance, patient lawyer, etc.).
For the literature review, electronic databases such as MEDLINE, EconLit, and JSTOR were searched. The
Internet search engine Google was also used. Key terms that were used for searches included:
•
•
•
•
•
•
•
•
•
Health care + performance
Health care + financing
Health care + productivity
Health care + efficiency
Health care + access
Health care + equity
User charges
Health care + patient choice
Quality of care
The sources identified in the searches were reviewed for relevance and the most up-to-date sources were
selected. There were no restrictions on study design but preference was given to studies that were
comparative across countries, and case studies reinforced by supporting observed or professionally provided
evidence (from national authorities, purchasers and providers). Priority was given to national research
reports and recent literature 2000-2006.
Statistical data for Austria was compiled mostly based on sources from Statistik Austria, the Main
organization of Austrian social insurance funds and the Austrian Medical Chamber. Furthermore numerous
interviews with Austrian health care experts were conducted, representing the following institutions:
-
Main Organization of the Austrian Social Insurance Funds (Hauptverband der österreichischen
Sozialversicherungsträger)
Social insurance funds
Federal Ministry of Health Care and Women
Patient lawyers (for the federal states of Lower Austria and Burgenland)
Austrian Medical Chamber (Österreichische Ärztekammer), Academy of Doctors
Austrian Federal Institute for Health Care (Österreichisches Bundesinstitut im Gesundheitswesen,
ÖBIG)
Institute of Advanced Studies (Institut für Höhere Studien, IHS)
Universities
A list of the interview partners can be found in Appendix 1.
16
During the course of the project various meetings and presentations took place. A list of these, including
names of participants, can be found in the Appendix 2.
The report was produced both in German and in English. Translation of the Austrian part was done by Joy
Ladurner, editing was undertaken by the London School of Economics and Political Science. Review of
the Austrian section of this report20 for quality assurance was performed by Mag. Herta Marie Rack
(Federal Ministry of Health and Women) and by Dr. Gottfried Endel (Main organization of the Austrian
social insurance institutions).
20
Not including the appendices.
17
2. DISTRIBUTION OF COSTS AND BENEFITS IN THE POPULATION
2.1 Funding health care
Health care expenditure increased rapidly throughout the 1960s and early 1970s in the EU, and then reached
a plateau.21 During the 1970s, a combination of economic recession following the 1974 oil crisis and the
growing burden of unemployment eroded the view that increased welfare spending was sustainable. This
change created a widespread belief that the welfare state was in crisis, yet these fears were not realized; in
fact, welfare state spending has stabilized in many countries. However, health care expenditure has
continued to rise. This situation may intensify the conflict between the demand for and the supply of public
revenue for health care, unless countries pursue deficit financing,22 cut other areas of public expenditure,
shift to private sources of revenue or increase efficiency.23
Despite the many methodological problems with international comparisons of health expenditure data, it
appears that health care expenditure continued to grow throughout the 1980s and 1990s in most European
countries (See Table 2.1). This was also the case with expenditure from public sources, especially in
Ireland, Portugal and the United Kingdom, where public spending on health care has grown faster than total
expenditure particularly since the mid- to late-1990s.
Table 2.1 Percentage mean annual growth rates of total health expenditure (public health
expenditure in parentheses) in the EU based on national currency units at 2000 GDP prices
1980-1985
1985-1990
1990-1995
1995-2000
2000-2004
(%)
(%)
(%)
(%)
(%)
Austria
-1.4 (0.6)
4.6 (3.9)
9.2 (7.9)
2.3 (2.5)
1.9 (2.2)
Belgium
3.1
3.9
4.2
3.5 (2.8)
Czech Republic
7.3 (5.8)
0.7 (0.6)
5.1 (4.7)
Denmark
0.9 (0.4)
0.8 (0.2)
1.8 (1.7)
3.2 (3.2)
2.9
Finland
5.4 (5.3)
5 (5.6)
-1.8 (-3.1)
2.3 (2.2)
5.5 (6)
France
4.4 (4)
4.3 (3.8)
3.6 (3.6)
2.4 (2.2)
5.2 (6.1)
Germany
2 (1.7)
2.1 (1.8)
8.4 (9.6)
2.3 (1.8)
Greece
6.7 (6)
4.1 (4.3)
4.7 (4.7)
Hungary
3 (-0.4)
8.3 (8.9)
Ireland
0.6 (-0.9)
0.3 (-0.7)
6.9 (6.8)
8.1 (8.6)
8.7 (10.9)
Italy
-0.4 (-2.2)
4.1 (4.5)
2.4 (3.4)
Luxembourg
2.3 (1.5)
8.2 (9.2)
4.8 (4.6)
7.2 (6.4)
11.6 (11.9)
Netherlands
0.7 (1.1)
5.1 (4)
3.1 (4.3)
3.4 (1)
4.6 (4.3)
Poland
4.8 (0.1)
5.4 (4.6)
6.4 (5.8)
Portugal
2.6
6.1 (10.1)
7.5 (6.6)
6.7 (9.9)
2.2 (1.9)
Slovak Republic
Spain
1.6 (1.9)
8.7 (8.1)
4.2 (2.4)
3.4 (3.3)
6.1 (5.8)
Sweden
0.9 (0.5)
1.9 (1.7)
0 (-0.7)
4 (3.6)
4.2 (4.3)
United Kingdom
2.8 (2)
3.8 (3.2)
4.7 (4.8)
4.1 (3.3)
5.8 (7.3)
Source: OECD Health data 2006
During the past decade, health care expenditure as a percentage of GDP appeared to grow more slowly, and
even stabilized in some countries (See Table 2.2). GDP grew faster than health care expenditure between
21
22
H Glennerster, Paying for Welfare: Towards 2000. 3rd Ed. (Englewood Cliffs, NJ: Prentice Hall, 1997).
Deficit financing is not a realistic option for the European Union countries that have joined the Economic and Monetary
Union.
23
E Mossialos and A Dixon, eds., Funding Health Care: Options for Europe (Copenhagen: European
Observatory on Health Systems and Policies, 2002).
18
1995 and 1998 in 8 of the 15 current EU countries, and in Denmark, Greece, Portugal and Spain, health care
expenditure grew only slightly more than GDP.24 Thus, the stabilization of health care expenditure as a
percentage of GDP in some EU countries may not reflect success in controlling growth in health care
expenditure but rather economic growth. For example, the growth in health care expenditure in Ireland in
the 1990s corresponded with economic growth of 8.8 per cent. In Finland and less notably in Sweden,
health care expenditure actually declined. For Sweden, this decline actually reflects a shift in expenditure
from health care budgets to social service budgets. In Finland, severe economic recession resulted in largescale cuts in expenditure, especially public expenditure.
Although health care systems in the European Union are still characterised by a high degree of public
expenditure, in some countries, there has been a decline in levels of public expenditure as a proportion of
total health expenditure. Private expenditure grew substantially as a proportion of total expenditure on
health care in Czech Republic, Portugal and the United Kingdom in the 1980s, and in Poland, Italy, Czech
Republic, Luxembourg and Spain during the 1990s (Table 2.3).
Health care expenditure continues to grow in the EU member states. Some explanations for this growth
include: the ageing population, increases in labour costs, technological innovation, rising public
expectations, and pressures from providers.25 There are also situational factors (e.g. political changes),
structural changes (e.g. economic and demographic structure), changes in the labour market, the stability
and capacity of political structures and institutions, environmental factors (e.g. changes in regulation,
developments in science), and cultural factors (e.g. status of professionals and beliefs in government) that
impact health care expenditure.
Table 2.2 Total health care expenditure as a percentage of GDP in EU countries, 1980-2004
Austria
Belgium
Czech
Republic
Denmark
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Luxembourg
Netherlands
Poland
Portugal
Slovak
Republic
1980
1985
1990
1995
2000
2001
2002
2003 2004
7.5
6.5
7
9.7
9.4
9.5
9.5
9.6
9.6
6.3
7
7.2
8.2
8.6
8.7
8.9 10.1
4.7
7
6.7
7
7.2
7.5
7.3
8.9
6.3
7
8.7
6.6
8.5
7.1
7.9
9
8.3
7.5
5.2
7.2
5.2
7.1
5.6
6
8.3
7.8
8.4
8.5
7.4
6.1
7.7
5.4
7.7
4.9
6.2
8.1
7.4
9.4
10.3
9.6
7.4
6.7
7.1
5.6
8.1
5.6
8.2
8.3
6.7
9.2
10.4
9.9
7.1
6.3
7.9
5.8
7.9
5.7
9.4
5.5
8.6
6.9
9.3
10.6
10.4
7.3
6.8
8
6.4
8.3
6
9.3
5.5
8.8
7.2
10
10.8
10.3
7.7
7.2
8.2
6.8
8.9
6.6
9.5
5.6
8.9
7.4
10.4
10.9
10.5
8.3
7.2
8.2
7.7
9.1
6.5
9.8
5.9
8.9
7.5
10.5
10
8.3
7.1
8.4
8
9.2
6.5
10
24
The relationship between national income growth and health expenditure growth can be expressed as an expenditure elasticity.
This is calculated as the change in total health care expenditure as a proportion of the change in GDP. Values greater than 1 indicate
that growth in health care expenditure exceeds economic growth.
25
S. Altman and R. Blendon, eds., Medical Technology: The Culprit Behind Health Care Costs? (Washington,
DC: Government Printing Office, 1979), M.L. Barer, Evans, R.G., Hertzman, C., and Lomas, J., "Aging and
Health Care Utilization: New Evidence on Old Fallacies," Social Science and Medicine 24 (1987), W. Baumol,
"Health Care, Education and the Cost Disease: A Looming Crisis for Public Choice," Public Choice 77 (1993), K
McGrail et al., "Age, Costs of Acute and Long-Term Care and Proximity to Death: Evidence for 1987-88 and
1994-95 in British Columbia," Age and Ageing 29 (2000), A.A. Scitovsky, " 'the High Cost of Dying': What Do
the Data Show?," Milbank Memorial Fund Quarterly 62, no. 4 (1984).
19
Spain
Sweden
United
Kingdom
5.3
9
5.6
5.4
8.6
5.9
6.5
8.3
6
7.4
8.1
7
7.2
8.4
7.3
7.2
8.7
7.5
7.3
9.1
7.7
7.9
9.3
7.9
8.1
9.1
8.3
Table 2.4 disaggregates the two predominant private sources of funding – out-of-pocket payments and
private insurance to observe trends over time. In general it appears that out-of-pocket payments has
increased as a proportion of private health expenditure in many countries.
On average, health systems financed largely through taxation spend more on health care than those relying
on a model of social health insurance26. However, while the level of spending is higher in these countries,
the recent growth rate has been equal (on a per capita basis) or lower than the countries with tax-funded
systems. Also, the proportion of health spending that is public in the social health insurance countries tends
to be lower than those funded through taxation ; and the overall public role in social health insurance
funding decreased further in many countries in the 1990s (e.g. in the Netherlands).
Table 2.3 Public and private expenditure as a percentage (%) of total health expenditure, 1980-2004
Austria
Public
Private
Belgium
Public
Private
Czech Rep. Public
Private
Denmark
Public
Private
Finland
Public
Private
France
Public
Private
Germany
Public
Private
Greece
Public
Private
Hungary
Public
Private
Ireland
Public
Private
Italy
Public
Private
Luxembourg Public
Private
Netherlands Public
Private
Poland
Public
Private
Portugal
Public
Private
26
1980
68.8
31.2
1985
76.1
23.9
1990
73.5
26.5
96.8
3.2
87.8
12.2
79
21
80.1
19.9
78.7
21.3
55.6
44.4
92.2
7.8
85.6
14.4
78.6
21.4
78.5
21.5
77.4
22.6
97.4
2.6
82.7
17.3
80.9
19.1
76.6
23.4
76.2
23.8
53.7
46.3
81.6
18.4
75.7
24.3
92.8
7.2
69.4
30.7
89.2
10.8
70.8
29.2
64.3
35.7
54.6
45.4
71.9
28.1
79.1
20.9
93.1
6.9
67.1
32.9
91.7
8.3
65.5
34.5
1995
69.3
30.7
78.5
21.5
90.9
9.1
82.5
17.5
75.6
24.4
76.3
23.7
80.5
19.5
52
48
84
16
71.6
28.4
71.9
28.1
92.4
7.6
71
29
72.9
27.1
62.6
37.4
2000
69.9
30.1
75.8
24.2
90.5
9.5
82.4
17.6
75.1
24.9
75.8
24.2
78.6
21.4
52.6
47.4
70.7
29.3
73.3
26.7
73.5
26.5
89.3
10.7
63.1
36.9
70
30
72.5
27.5
2001
69.5
30.5
76.4
23.6
89.9
10.1
82.7
17.3
75.9
24.1
75.9
24.1
78.4
21.6
55.5
44.5
69
31
75.6
24.4
75.8
24.2
87.9
10
62.8
37.2
71.9
28.1
71.5
28.5
2002
70.5
29.5
75
25
89.7
10.3
82.9
17.1
76.1
23.9
78.1
21.9
78.6
21.4
54.1
45.9
70.2
29.8
75.2
24.8
75.4
24.6
90.3
9.7
62.5
37.5
71.2
28.8
72.2
27.8
2003
70.3
29.7
71.1
28.2
89.8
10.2
2004
70.7
29.3
76.2
23.8
78.3
21.7
78.2
21.8
53.6
46.4
72.4
27.6
78
22
75.1
24.9
90.6
9.4
63
36.9
69.9
30.1
72.6
27.4
76.6
23.4
78.4
21.6
89.2
10.8
52.8
47.2
72.5
27.5
79.5
20.5
76.4
23.6
90.4
9.6
62.3
37.6
68.6
31.4
71.9
28.1
Figueras et al., "Patterns and Performance in Social Health Insurance Systems."
20
Slovak Rep. Public
Private
Spain
Public
79.9
Private
20.1
Sweden
Public
92.5
Private
7.5
UK
Public
89.4
Private
10.6
81.1
18.9
90.4
9.6
85.8
14.2
78.7
21.3
89.9
10.1
83.6
16.4
72.2
27.8
86.6
13.4
83.9
16.1
89.4
10.6
71.6
28.4
84.9
15.1
80.9
19.1
89.3
10.7
71.2
28.8
84.9
15.1
83
17
89.1
10.9
71.3
28.7
85.1
14.9
83.4
16.6
88.3
11.7
70.4
29.6
85.4
14.6
85.4
14.6
70.9
29.1
84.9
15.1
85.5
14.5
Table 2.4 Out-of-pocket payments and voluntary health insurance as a proportion of private health
expenditure, 1980-2003
1980
Austria
Belgium
Czech Rep.
OOP
VHI
OOP
VHI
OOP
VHI
24.4
1985
41
1990
1995
2000
2001
2002
34
49.7
30.7
55.3
28.8
51.5
28.4
50.9
29.8
100
100
100
100
92
8
81.8
10.3
43.3
52.5
49.7
38.6
95.2
4.8
89.3
1
48.8
26
83.9
3.7
64.7
9.3
23.4
43.6
100
Denmark
OOP
93.1
94.6
92.6
93.3
91
VHI
6.9
5.4
7.4
6.7
9
Finland
OOP
87.7
85.8
81.4
83.9
82
VHI
6.5
8.4
11.2
10
10.6
France
OOP
64
66.9
48.7
45.5
43.4
VHI
28.5
27.5
46.9
50.3
52.2
Germany
OOP
48.5
49.6
46.8
51.2
49.6
VHI
27.5
28.7
30.4
39.2
38.7
Greece
OOP
94.7
VHI
5.3
Hungary
OOP
100
89.8
VHI
0.6
Ireland
OOP
59.5
58.7
54.7
50.5
VHI
32.5
31.9
28.4
Italy
OOP
68.2
73.8
87.9
86.2
VHI
3
3.5
3.4
Luxembourg OOP
100
85.5
79.5
81.9
65.2
VHI
10
Netherlands
OOP
24.3
VHI
43
Poland
OOP
100
100
100
VHI
Portugal
OOP
80.8
VHI
0.5
2.3
3.5
11.1
Slovak Rep.
OOP
100
VHI 0
0
Spain
OOP
84.6
83.1
VHI
15.9
19.3
17.4
12.1
13.7
UK
OOP
80.8
64.5
67.6
VHI
12.3
17.6
19.9
19.8
Note: OOP is out-of-pocket payments; VHI is voluntary health insurance
Source: OECD 2006
81.3
11.3
100
2004
50.1
29.8
94.5
2.2
50.6
29.7
83.5
12
97.7
2.3
92.8
7.2
81.8
10.1
35.8
56.1
48.2
39.9
94.3
4.9
88.2
1.3
53
21.6
83.1
3.7
70.6
8.7
21.4
45.6
88.2
1.8
80.5
13.2
100
81.4
10.1
35.6
56.5
47.9
40.2
94.3
4.5
88.9
2.1
60.7
29
83.3
3.8
71.1
18.2
21.3
48.4
87.8
1.9
77.1
16.7
100
80.9
10
34.9
57.3
81.2
16
81
16.2
0
83.1
13.9
2003
95.5
2.1
95.7
4.3
88
3.2
65.9
32.7
83
4
69.9
17.6
20.8
50.7
89.5
1.9
76.8
17.4
0
82.6
14.3
21
2.1.2 Spending on health care in Austria
Table 2.5 shows the change in total, public and private health care expenditure in Austria from 2000 to
2004. Nominal health care expenditure amounted to just over 22.8 billion Euros, 4.4% more than in 2003.
Real growth (based on prices underlying the GDP in 2000) represented 2.9%. Public health care
expenditure, situated at 16.1 billion Euros, amounted to 70.7% of total health care expenditure and
increased by 5% from the previous year. Correspondingly, the level of private health care expenditure,
which was 6.7 billion Euros in 2004, increased at a lower rate.
Table 2.5 Spending on health care in Austria 2000 - 2004
2000
2001
2002
2003
2004
215.900
220.700
227.000
237.000
2,61%
2,22%
2,85%
4,41%
212.300
214.100
216.800
223.000
% increase from previous year
0,90%
0,85%
1,26%
2,86%
Health care expenditure, nominal, 19.786
million €
Health care expenditure, GDP 19.786
prices 2000, m. €
20.559
21.057
21.802
22.770
3,91%
20.215
2,42%
20.424
3,54%
20.823
4,44%
21.417
2,17%
1,03%
1,95%
2,85%
Public health care expenditure, 13.822
nominal, m. €
Private health care expenditure, 5.963
nominal, m. €
14.287
14.853
15.330
16.091
3,36%
6.271
3,96%
6.204
3,21%
6.472
4,96%
6.679
5,17%
-1,07%
4,32%
3,20%
Total health care expenditure, as a 9,40%
percentage of GDP
9,52%
9,54%
9,60%
9,61%
Public expenditure, as a percentage 69,86%
of total health expenditure
69,49%
70,54%
70,31%
70,67%
as
a 30,14%
health
30,50%
29,46%
29,69%
29,33%
210.400
GDP, nominal, million €
GDP, GDP-prices 2000, million €
Private
expenditure,
percentage
of
total
expenditure
210.400
Note: Calculation method: OECD System of Health Accounts
Source: Hofmarcher and Rack 2006
The above overview of expenditure on health care is based on the “System of Health Accounts” of the
OECD, which was calculated for the first time in 2005 by Statistics Austria and published in February 2006.
Past expenditure for 1995-2004 was assessed according to the same principles. The System of Health
Accounts (SHA) calculates health care costs based on costing units, health care providers and types of
benefits, thereby ensuring that all relevant expenditures are taken into consideration and facilitating
22
comparisons with data from other countries. In February 2002 14 OECD countries27 (out of these 7 EU
countries) calculated their health care expenditure based on this calculation method28)
Since the publication of a study by the Institute for Industrial Research (IWI)29 in 2002 (E. Pichler and E.
Walter) on the funding of the Austrian health care system, the real level of Austrian health care expenditure
has been subject to intense discussion. At the root of the debate is the definition of public health care
expenditure, especially the expenditure on public hospitals. Further points of criticism are the classification
of institutions for long-term care, rehabilitation and health promotion (health care resorts) as well as the
consideration of financial long-term care benefits.
Until 2004 health care expenditure was calculated according to the OECD/ ESA 95 (system of national
accounts) which is compulsory in the EU. Based on this system of national accounts, which records
expenditures in terms of consumption (who consumes how much?), public hospitals, whose expenses are
covered to more than 50% by revenue, are classified as private producers in the market. This leads to a
significant underestimation of actual health care expenditures, especially of public health care expenditure.
Health care expenditure based on ESVG 95 amounts to 7.5% of the GDP whilst health care expenditure
calculated according to the OECD System of Health Accounts reaches 9.6%. For details about the
calculation of health care expenditure according to the OECD system of health accounts please see the
webpage of Statistics Austria at http://www.statistik.at/fachbereich_03/gesundheit_ausgaben.shtml. Figure
2.1 displays total health care expenditure as a percentage of GDP in the different EU Member States.
Austria now spends 9.6% of GDP on health care, according to the new SHA calculations, which places it
above the EU 25 average of 8.6%. Within the EU, only Germany (10.9%) and France (9.7%) depict a
higher health care quota. Figure 2.2 displays the share of public expenditure of total health care expenditure.
When taking the EU 15 members as a basis, Austria, with a share of 70.7%, is situated in the lower third,
with only Greece, Portugal and the Netherlands spending less from public sources.
Figure 2.1Total health care expenditure as percentage of gross domestic product (GDP), last available
year
6,5
EU10 since May
EU (2003)
EU15 before May
Germany (2003)
France (2003)
Austria (2003)
Greece (2003)
Portugal (2003)
Malta (2004)
Sweden (2002)
Belgium (2003)
Netherlands (2003)
Denmark (2003)
Slovenia (2004)
Italy (2003)
Hungary (2002)
United Kingdom
Spain (2003)
Ireland (2002)
Finland (2003)
Czech Republic
Cyprus (2003)
Luxembourg
Poland (2002)
Lithunia (2004)
Slovakia (2003)
Estonia (2004)
Latvia (2003)
6,2
6,1
6,0
5,9
5,5
5,1
0,0
2,0
4,0
6,0
8,6
9,0
7,8
7,7
7,6
7,3
7,3
7,1
7,0
8,0
9,7
9,6
9,5
9,3
9,2
9,2
9,1
8,8
8,8
8,6
8,5
10,0
10,9
12,0
Source: Hofmarcher and Rack (2006); WHO Health for All Database. (updated: January 2006, accessed 10/05/2006)
27
OECD countries: Switzerland, Turkey, Japan, Canada, Korea, Mexiko. OECD and EU countries: Denmark,
Germany, Netherlands, Poland, Spain, Hungary, Austria
28
Institute of Advanced Studies (Institut für Höhere Studien, IHS). “New calculation of health care expenditure lets
Austria appear in the correct light.″ Press information. 21 February 2006. Vienna.
29
Institute for Industrial Research (Industriewissenschaftliches Institut, IWI)
23
Figure 2.2 Public health care expenditure as a percentage of total health expenditure, last available
year
Czech Republic (2004)
Slovakia (2003)
Luxembourg (2002)
Sweden (2002)
United Kingdom (2002)
Denmark (2003)
Slovenia (2004)
Germany (2003)
Italy (2004)
Estonia (2003)
France (2003)
Finland (2003)
Ireland (2002)
Lithunia (2004)
Poland (2002)
Malta (2004)
Spain (2003)
Belgium (2003)
Austria (2003)
Portugal (2003)
Hungary (2002)
Netherlands (2003)
Latvia (2004)
Greece (2003)
Cyprus (2003)
91.2
89.4
85.4
85.3
83.4
83.0
79.0
78.5
76.4
76.3
76.0
75.7
75.2
72.6
72.4
71.8
71.3
71.2
70.7
70.5
70.2
65.6
64.1
52.9
41.3
0.0
20.0
40.0
60.0
80.0
100.0
Sources: Hofmarcher and Rack 2006; WHO Health for All Database (updated: January 2006, accessed 10/05/2006)
2.2 Sources of funding
European health care systems rely on a mix of funding sources with the majority providing universal (or
near universal) statutory health coverage. Most funding is public expenditure from taxation (as in Denmark,
Finland, Italy, Portugal, Spain, Sweden and the United Kingdom), social health insurance (as in Austria,
France, Germany, Luxembourg, and the Netherlands), or a combination of both (as seen in Belgium and
Greece).
Taxation
Taxation has different sources (direct or indirect), different levels (national or local) and different types
(general or hypothecated), each with varying implications for equity and efficiency. Direct taxes, which
predominantly fund health care in the UK, are taxes levied on individuals, households or firms. Direct taxes
have the potential to redistribute income between rich and poor people. For example, personal income
taxes, a form of direct tax, are progressive if tax rates are higher for those with higher incomes. However,
horizontal inequities occur in situations where income tax rates vary geographically, some forms of income
are exempt from income tax, or some forms of expenditure are tax-deductible.30 Indirect taxes, taxes on
30
E Van Doorslaer et al., "The Redistributive Effect of Health Care Finance in Twelve OECD Countries," Journal of
Health Economics 18, no. 3 (1999).
24
transactions and commodities, are more regressive than direct taxes as they relate to consumption and not
income.31
Taxes may be collected locally, as in Denmark, Finland, Norway, Sweden and Italy, or nationally, as in
Greece, Portugal, Spain and the UK. There are several arguments in favour of local versus national taxation.
First, there is increased transparency since there is a closer link between the amount generated and the
amount spent on health care. Second, there is more accountability because local politicians are closer to the
electorate and allocation decisions are more apparent. Third, there is more responsiveness to local
performance. Fourth, health is separated from competing national priorities. However, there are some
disadvantages associated with local taxation. For instance, inequities can arise if tax rates vary across
regions, or if the same tax rate yields differing revenue according to the wealth of different regions.
On the other hand, national taxation has several potential advantages. First, this method has the potential to
redistribute across the whole of the income distribution within a country. Second, it allows trade-offs to be
made between health and other sectors. Third, collecting taxes nationally benefits from administrative
economies of scale.32 However, there are trade-offs with other spending or transfer programs, tax or debt
reduction.
Taxation may be general, as in Italy, or hypothecated (earmarked for health care), as in France. General
taxation draws on a broad revenue base and allows trade-offs between health care and other sectors,
however allocation to health care is subject to public spending negotiations which may or may not be
favourable. On the other hand, hypothecated taxes may reduce resistance to taxation because it is more
visible33, it increases transparency and responsiveness34 and they may be less susceptible to political
manipulation. However, hypothecated taxation may cause increased rigidity in the budgetary process, and
prevent integrated public health policies.35
Social health insurance
Social health insurance provides the organizing principle and much of the funding in seven Western
European countries: Austria, Belgium, France, Germany, Luxembourg, the Netherlands, and Switzerland.36
Social health insurance is essentially an earmarked payroll tax that usually relies on contributions that are
shared between the employer and the employee. The advantages of the social health insurance model are
common to those associated with hypothecated taxation. For instance, it is more transparent than taxation
hence more acceptable to the public in general. Also, social health insurance revenue may be better
protected from political interference than revenue from taxation since an independent system of revenue
collection is at an arm’s length from government.37 However there are some disadvantages associated with
this method of financing. For example, since employers are often required to pay large contributions, labour
costs may rise, resulting in negative economic implications. Also, if eligibility to health insurance is
dependent on income or employment, there may be limited access to health care for the not employed
population.
31
J Hills, "Taxation for the Enabling State," in CASE Discussion Paper No. 41 (London: Centre for Analysis of Social
Exclusion, London School of Economics and Political Science, 2000).
32
Mossialos and Dixon, eds., Funding Health Care: Options for Europe.
33
Commission on Taxation and Citizenship, "Paying for Progress: A New Politics of Tax for Public Spending,"
(London: Fabian Society, 2000).
34
A Jones and A Duncan, Hypothecated Taxation: An Evaluation of Recent Proposals (London: Office of Health
Economics, 1995).
35
E Mossialos, A Dixon, and M McKee, "Paying for the NHS," BMJ 320 (2000).
36
R.B Saltman, "Social Health Insurance in Perspective: The Challenge of Sustaining Stability," in Social Health
Insurance Systems in Western Europe, ed. R.B Saltman, R Busse, and J Figueras (Copenhagen: World Health
37
25
The types of collection agents vary: France has devolved independent funds, Belgium, Germany and the
Netherlands have individual health insurance funds with open enrolment, Greece has individual health
insurance funds organized by occupational groups, and Luxembourg has an association of insurance funds.
The different organizational arrangements have their advantages and disadvantages. For instance, multiple
funds may compete which may, in turn, improve efficiency, however a single fund may have lower
administrative costs because of the monopsony purchaser and a universal risk pool, which is more desirable
from an equity perspective.
Voluntary health insurance
The majority of health care spending derives from public sources in the EU, however, the last twenty years
have seen a shift from public to private expenditure. The main sources of private funding for health care
include voluntary health insurance (VHI) and out-of-pocket payments. The agents collecting VHI premiums
can be independent, private-for-profit insurance companies (in countries that have a VHI market) or private
not-for-profit insurance companies and funds (in Belgium, Denmark, Finland, France, Germany, Ireland,
Italy, Luxembourg, Netherlands, Spain and the UK).38
VHI can be classified as substitutive, supplementary or complementary.39 Substitutive insurance substitutes
cover otherwise available from the state. Substitutive insurance is available in Germany and the Netherlands
for individuals with high incomes who wish to opt out of (or, as in the case of the Netherlands, are excluded
from) statutory insurance scheme. Portugal and Italy’s proposals to permit people to opt out of the public
system were withdrawn in response to considerable resistance. Supplementary insurance provides cover for
faster access and increased consumer choice. Because supplementary insurance allows individuals
additional or higher quality services than what is offered through the public system, differential access
between those with and without this insurance may result. Complementary insurance provides cover for
services excluded or not fully covered by the state, including cover for co-payments for public services.
Tax incentives to purchase VHI exist in most European countries, although recently there have been some
efforts to reduce or remove tax incentives in some countries as they are argued to be expensive, regressive
(i.e. benefits higher income earners disproportionately), and largely unsuccessful in stimulating demand40.
There are no tax incentives for individuals to purchase any kind of VHI in Denmark, Finland, Spain or the
United Kingdom, and there are no tax benefits for employers purchasing VHI for their employees in
Finland, France, Germany, Greece, Italy, Luxembourg, the Netherlands, Sweden or the United Kingdom. In
Austria, Ireland and Portugal, private health insurance is partly subsidised by the state using tax credits or
tax relief.
In Austria, there are tax incentives for individuals as well as firms, although they have been reduced
significantly in recent years. Single people can deduct 25% of VHI premiums from taxable income, up to a
limit of €2,907, provided their gross income does not exceed €36,336.41 Firms can deduct all premiums paid
for their employers from tax.
Spending on VHI as a proportion of private expenditure is relatively low, accounting for less than 5 per cent
in Greece, Italy and Portugal and around 25 per cent in Austria, Spain and the United Kingdom. Spending
on VHI constitutes a much higher proportion of private expenditure in Germany (29.9 per cent), where
higher income groups are able to opt out of the statutory system, and the Netherlands (70 per cent), in the
form of substitutive insurance, where individuals over an income threshold are required to leave the
statutory system, and France (51.7 per cent), where there is extensive coverage of co-payments.42
38
Ibid.
(Mossialos and Thomson 2004)
40
E Mossialos and S Thomson, Voluntary Health Insurance in the European Union (Copenhagen: World Health
41
Ibid.
42
Ibid.
39
26
In Austria, about one third of the population subscribed to VHI in 1998 with 18.8% holding complementary
VHI and 12.9% supplementary.43 But the share of total health spending from VHI is low. The proportion is
quite high because of Austrians’ propensity to purchase complementary VHI to cover hospital per diem
charges. Supplementary VHI in Austria covers physician costs, supplementary hospital costs, and offers
faster access and increased choice. Subscribers to VHI in Austria tend to be mostly high income earners.
About half of those with VHI are self-employed, and about 40% are civil servants or salaried employees.
There are different levels of uptake across the country, with individuals residing in Carinthia most likely to
purchase VHI.
Cost sharing
Out-of-pocket payments comprise a substantial proportion of private health care expenditure in many
European countries, especially in Austria, Finland, Greece, Italy, Portugal and Spain and the Netherlands44
(as shown in Table 2.4). The highest proportion of financing through out-of-pocket payments is in Greece,
which resultantly has a highly regressive system of financing. Among European governments user charges
are generally preferred to promoting and subsidising VHI.
Advocates of user charges argue that they discourage excess utilization of health services by creating price
signals which deter individuals from consuming unnecessary care45. Hence, cost sharing is argued to
improve efficiency at a micro level while containing costs at macro level. In countries where public budgets
are under pressure, cost sharing has been argued to be one mechanism for generating revenue.
However, many argue against user charges stating that information asymmetries in health care present a
major obstacle to achieving any gains in efficiency, since individuals are not always able to differentiate
necessary from unnecessary services. Furthermore, health care spending is primarily driven by supply side
factors therefore cost containment in the long-term is unlikely to result from a cost sharing arrangement.
Finally, it is widely agreed that user charges have undesirable effects on equity in two ways: by shifting the
financial burden onto the individual; and introducing barriers to access for individuals on low income.
Out-of-pocket payments can come in broadly three forms: direct payments (‘pure private’ payments), cost
sharing (individuals who are covered pay part of the costs of care received) and informal payments
(unofficial payments for services that should be fully funded by the public system). Cost sharing exists to
some extent in all European health systems. The three forms of direct cost sharing consist of: co-payment,
where the user pays a fixed (flat) fee per item or service; co-insurance, which refers to the user paying a
fixed proportion of the total cost; and deductible, wherein the user bears a fixed quantity of the costs.
Among the original 15 EU Member States, cost-sharing is applied to pharmaceuticals and dental care in all
countries. For GP, specialist and hospital care, however, only Austria46, Belgium, Finland, France, Ireland
(Category II patients47), Luxembourg and Sweden impose cost-sharing. In Germany and Portugal, physician
services are free at the point of use but cost sharing is applied to inpatient care.48
43
Ibid.
In 1999 85 per cent of the French population was covered by complementary VHI to cover the cost of statutory copayments, while 28.9 per cent of the Dutch population is excluded from statutory coverage of primary care and acute
inpatient care.
45
B. Abel-Smith, An Introduction to Health: Policy, Planning and Financing (London: Longman, 1994), M Chalkley
and R Robinson, Theory and Evidence on Cost Sharing in Health Care: An Economic Perspective (London: Office of
Health Economics, 1997), J. Kutzin, "The Appropriate Role for Patient Cost Sharing. Critical Challenges for Health
Care Reform in Europe," ed. R.B Saltman, J Figueras, and C Sakellarides (Buckingham: Open University Press, 1998).
46
Some sickness funds
44
47
48
Category II patients in Ireland are those with higher incomes.
S Thomson, E Mossialos, and N Jemiai, "Cost Sharing for Health Services in the European Union," (Brussels:
European Commission DG Employment and Social Affairs, 2003).
27
GP and ambulatory specialist cost sharing tends to be in the form of co-payments or co-insurance. For
inpatient care, cost sharing tends to be in the form of a co-payment per day ranging from about €5-10 in
Austria49, France, Germany and Luxembourg, to €26-65 in Finland, Ireland (Category II patients) and
Belgium. Prescription drugs may have cost sharing in the form of a fixed co-payment as in Austria (€4.25)
and the United Kingdom (€8.80) whereas a fixed deductible is combined with co-insurance in the remaining
countries. However in Sweden individuals must pay the full cost of prescription drugs up to an out-ofpocket maximum.
Protection mechanisms are in place in all countries in order to protect lower income earners from the
financial burden of cost sharing arrangements. Protection mechanisms for inpatient care user charges tend
to be annual out-of-pocket maximums ranging from about €100 in Sweden to about €600 in Finland.50
Exemptions can also be granted for very long hospital stays, for example inpatient stays longer than 14 days
in Germany or 28 days in Austria.
For pharmaceuticals, significant population groups are exempt from cost sharing in many countries. For
instance, individuals with low incomes are exempt in Austria, Belgium, Germany, Ireland and United
Kingdom, and older people in Greece. In addition, exemptions may be targeted towards individuals with a
clinical condition, e.g. diabetes in Sweden, pregnancy in the United Kingdom, or certain age groups such as
children in Germany and the United Kingdom, and older people in Belgium, Ireland, Spain and the United
Kingdom51. Certain types of drugs may be exempt from cost sharing, e.g. for chronic illnesses in Portugal,
for life-threatening illnesses in Belgium, both types of drugs in Germany, and effective drugs in France.
Also, out-of-pocket maximums for pharmaceutical costs exist in Belgium, Denmark, Finland, Germany,
Ireland, Italy and Sweden.
Funding reforms
Systems of financing are not static; rather the contributions to total health spending of the different sources
of funding have changed over time in some countries.
In France, for instance, in 1998, “general social contributions” (CSG) were introduced such that social
insurance contributions were based on total income rather than salary alone. Since then, employees’
contributions have fallen from 6.8 to 0.75% of gross earnings. This change thus represented a shift from a
social insurance model based on wage to a more tax-financed model based on total income.
Debates about reforming the financing system in Germany are ongoing. Similar to France, it has been
argued that the payroll taxes should draw from a wider tax base than solely gross salary. Despite the
extensive discussions taking place and repeated calls to shift funding towards taxation, the German
Government is still yet to decide whether to make any reforms to the financing system.
2.2.1 Sources of funding in Austria
Table 2.6 shows the corresponding shares from the different sources of funding out of total health care
expenditure. About 45% of Austrian expenditure on health care is funded by social insurance.
Contributions, which are income-dependent (on average between 7.1% and 9.1% of the contribution base)
are collected by the sickness funds and are mainly used for reimbursement of benefits in the primary and
tertiary sector (excluding long-term care).52
49
User charges for inpatient care are based on regional hospital law and on social insurance law (may be both)
N Jemiai, S Thomson, and E Mossialos, "An Overview of Cost Sharing for Health Services in the European
Union," Euro Observer 2004.
51
Thomson, Mossialos, and Jemiai, "Cost Sharing for Health Services in the European Union."
52
Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria. Copenhagen, World Health
Organization on behalf of the European Observatory on Health Systems and Policies.
50
28
Table 2.6 Share of total health expenditure from different sources (in % of total expenditure)
Sources of funding, in % of
1997 1998 1999 2000 2001 2002 2003 2004
health expenditure
Public
67.8
67.6
67.8
67.8
69.1
70.1
70.0
70.4
Taxes
22.5
23.3
22.4
22.3
23.8
24.3
24.7
25.1
- for long-term care
8.7
8.4
8.4
8.3
8.2
8.1
8.0
7.7
Social health insurance
45.3
44.4
45.4
45.6
45.3
45.8
45.3
45.3
Private
26.3
26.8
26.4
26.8
25.9
25.4
25.4
25.0
Private health insurance
3.3
3.9
3.7
3.9
2.82
2.3
2.3
2.4
b
Indirect user charges
14.7
14.5
14.1
14.1
13.8
13.7
13.6
13.5
Direct user chargesc
6.8
6.9
7.1
7.3
7.7
7.7
7.9
7.6
Private non-profit
1.4
1.3
1.3
1.4
1.4
1.4
1.4
1.4
organizationsd
Employerse
0.1
0.1
0.1
0.2
0.2
0.2
0.2
0.2
f
Investments
5.9
5.5
5.7
5.3
5.0
4.6
4.6
4.6
a
Total health expenditure
100
100
100
100
100
100
100
100
a) OECD System of Health Accounts
b) Defined as user charges of households not covered by social insurance by private households, including services of
private insurance in the inpatient sector
c) Defined as user charges of private households to services provided by social health insurance
d) Expenditure of private, non-profit hospitals, emergency ambulance services as well as expenditures for others,
services provided by private non-profit organizations
e) Services provided by company physicians
f) Including public and private investments (private investments also include the investments of the hospital
associations)
Source: Hofmarcher and Rack (2006)
About 20% of health care expenditure is funded by taxes, primarily by general taxes and value added tax,
and is in the first instance used to pay for inpatient care in hospitals but also for public health services
(Öffentlicher Gesundheitsdienst). The federal states (Länder) are the owners of public hospitals, therefore
they are responsible for covering the investment- and maintenance costs, as well as running costs.53 The
share of health care expenditure funded by taxes has increased since 1997.54
The legal representatives of university hospitals receive a lump sum from central government to cover
“additional clinical expenses55” for training and research. Financial means for construction work and
investments are also negotiated between central government and the legal representatives of the hospitals.
Funds generated by tobacco tax are partially shifted to the Healthy Austria Fund (Fonds Gesundes
Österreich), which is engaged in health prevention matters, and also to the equalization fund of the Austrian
statutory sickness funds.
Private households contribute about 29% of total health care expenditure in terms of direct and indirect user
charges and private insurance. In 2004 Austria had the 3rd highest proportion of private funding in the EU15
countries and the 9th highest among 30 OECD countries56. Between 1995 and 2002 private health care
expenditure increased by 45%57, but as a percentage of total health spending, it declined between 1997 and
2005 (Table 2.6).
53
running costs
Hofmarcher, M., Rack, H.M. (2006). Health Care Systems in Transition. Austria. Copenhagen, World Health
55
additional clinical expenses (klinischer Mehraufwand)
56
OECD health data, accessed 01/09/2006
57
Hofmarcher, M., Riedel, M., Röhrling, G. (2004), ″Focus: Health remains precious to us–so what?.″ Health System
Watch I:2004, supplement of the journal of Social insurance in Austria, Soziale Sicherheit.
54
29
Table 2.7 shows the composition of private health care expenditure. In the year 2004, 57.6% of private
expenditure consisted of indirect user charges (cost sharing) for benefits/services or products not included
in the reimbursement scheme of the sickness funds. Examples of services with cost sharing arrangements
include inpatient care (52.8%58), dental services (29.8%) and pharmaceutical products (12.4% of total
indirect user charges). 32.3% of private health care expenditure are direct co-payments, being either fixed
charges or other co- payments (e.g. prescription charge). Furthermore costs arise due to the partial
reimbursement of benefits when using non-contract doctors. The remaining 10.1% of total private health
expenditure derive from private health insurance.
Table 2.7 Composition of private health care expenditure
Indirect
Direct
user charges
user charges
Private health
insurance
59.1%
57.2%
56.6%
55.7%
56.8%
57.8%
57.0%
57.6%
13.4%
15.5%
15.0%
15.3%
11.5%
9.8%
9.7%
10.1%
1997
1998
1999
2000
2001
2002
2003
2004
27.4%
27.3%
28.5%
28.9%
31.7%
32.4%
33.3%
32.3%
Source: Adapted from Hofmarcher and Rack 2006.
The share of voluntary private health insurance amounts to 2.4%59 (see Table 2.6) of total health care
expenditures. The reason it is such a small proportion could be the comprehensive coverage provided by
statutory social health insurance. Private health insurance in Austria is mainly used to pay for better
accommodation in the private ward of hospitals, treatment by a certain doctor60 and reductions in waiting
time. However, private health insurance accounts for 7%61 of the public hospital revenue.
2.3 Defining benefits and beneficiaries
In recent decades there has been a trend towards extending coverage to health services. Indeed, Table 2.8
shows that all OECD countries cover 100% or almost 100% of the population to statutory health insurance.
At the same time there has been an increase in user charges in some countries in recent years, which has
eroded coverage to some extent. The only countries that have not achieved universal coverage of the
population are Germany and the Netherlands (which offers or compels individuals over a certain income
threshold to take up private insurance instead of the statutory insurance) and the United States.
58
Hospitals, spas, nursing homes
60
The doctor is either employed in the hospital (and receives a share of the payment from the private health insurance
company) or the doctor is a private and has an arrangement with the private hospital to come and operate using their
facilities.
61
ibid
59
30
Table 2.8 Proportion of the population covered by statutory health insurance
1970
1980
1990
2000
2004
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Japan
Netherlands
New Zealand
Norway
Portugal
Spain
Sweden
Switzerland
United Kingdom
United States
85
91
97.8
100
100
100
100
95.6
89.2
55
100
85
93
100
100
100
40
61
100
89
100
100
99
99
100
100
100
100
99.1
92.3
88
100
100
100
100
100
74.6
100
100
100
83
100
96.5
100
100
99
97.3
100
100
100
100
99.4
88.8
100
100
100
100
100
100
73.9
100
100
100
98.1
100
99.5
100
24.5
100
99
99
100
100
100
100
99.9
90.9
100
100
100
100
100
100
77.6
100
100
100
98.9
100
100
100
24.7
100
98
99
100
100
100
100
99.9
89.8
100
100
100
100
100
76.3
100
100
100
100
100
100
In many European countries, there is a legal basis for entitlement to health care services. Among the
countries with social health insurance systems, Germany legislates that all insured citizens are entitled to
receive all ‘reasonable and effective’ health services necessary for the treatment of diseases. Services and
technologies should be ‘medically necessary, effective and cost-effective.62 Most other countries indicate
the importance of medical necessity and effectiveness, however not all countries consider economic aspects
as important. Table 2.9 provides a brief description of the basis for defining the benefits package in some
social health insurance systems. Benefits packages are an essential part of social health insurance systems;
they not only clarify the entitlements to health care for citizens, but also facilitate reimbursement for
providers and control the diffusion of new technologies.
However several factors in recent years have been putting pressure on decision-makers to place limits on
the broad frame of social health insurance systems. Among others, these factors include rising demand by
patients coupled with supplier-induced demand, the ‘medicalization’ of society, and rising health care
costs63. While there is growing discussion about the possibility of restricting the benefits packages in social
health insurance countries to only the core basic, medically necessary services, so far no country has been
able to do so. Countries have responded by making use of two types of regulations that may be implicit,
such as negative lists, or explicit, such as positive lists to define benefits packages.
62
B Gibis, P.W. Koch-Wulkan, and J. Bultman, "Shifting Criteria for Benefit Decisions in Social Health Insurance
Systems," in Social Health Insurance Systems in Western Europe, ed. R.B Saltman, R Busse, and J Figueras
(Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies,
2004).
63
Ibid.
31
Most countries rely on a combination of positive lists (e.g. benefits catalogues) and negative lists for the
different sectors. For instance, in ambulatory care, of the seven countries listed in Table 2.9, all make use of
explicit regulation, i.e. a benefits catalogue or positive list (in the case of Austria, the list is not closed,
rather additional benefits are possible on an individual basis) with the exception of the Netherlands (which
uses a negative list for specialist care) and Switzerland (no regulation). For inpatient care, Austria, Belgium
and Luxembourg rely on explicit regulation of the benefits package, in Netherlands they also use negative
list, and there is no regulation in France, Germany and Switzerland64. All countries explicitly regulate
medical devices, and all but Germany (implicit) do so for pharmaceuticals.
Decisions regarding benefit catalogues can only formally be challenged in some countries, such as for
pharmaceuticals in Austria and Switzerland, and for other services in ‘social courts’ in Austria and
Germany, or civil courts in Belgium and the Netherlands.65
Unlike social health insurance and private health insurance systems, coverage through many national health
service-type systems is not based on a defined list of benefits. For instance, in the UK, under the National
Health Service Act 1977, the Secretary of State for Health has a duty to provide a health service ‘to such an
extent as he considers necessary to meet all reasonable requirements’.
A detailed discussion on health technology assessment, a tool used to determine which medical
technologies or pharmaceuticals will be reimbursed, is provided in section 5.1.
Table 2.9 Legal framework for accepting services and technologies to the benefit package
Country
Terms
Legal base
Austria
Medically necessary, sufficient, General Social Insurance Act (ASVG)
appropriate
§133(2)
Belgium
Medical necessity, activity, cost- Published by Royal Decree
effectiveness, safety
France
Inscription of new medical and Decree to be published soon
surgical procedures after advice of
ANAES on efficacy and safety
Germany
Medically necessary, effective, cost- Social Code Book (SGB) V, §135(1)
effective
Luxembourg
1. Sufficient, appropriate
1. Code des assurances socials, art.
2. Medically necessary, effective,
17.1
efficient
2. Code des assurances socials, art.
23.1
The Netherlands
Medically necessary
Sickness Fund Act (ZFW), preamble
Switzerland
Effective, appropriate, cost-efficient Swiss Insurance Law (KVG), §32
Source: Gibis, Koch-Wulkan et al 2004
2.3.1 Defining benefits in the Austrian health system (what is covered?)66
Service coverage of the legal health insurance is legislated in the social insurance laws (ASVG, B-KUVG,
GSVG, BSVG and FSVG67). Health insurance funds retain only limited scope. Services can be classified in
respect of their legal nature (compulsory services, voluntary services or compulsory duties) or by the way in
64
Ibid.
Ibid.
66
Section 5.1.1 provides more detailed description of the health technology assessment process in Austria.
67
ASVG=Allgemeines Sozialversicherungsgesetz (General Social Insurance Law), B-KUVG=Beamten Kranken- und
Unfallversicherungsgesetz (Civil Servants’ Health- and Accident Insurance Law), GSVG=Gewerbliches
Sozialversicherungsgesetz (Commercial Social Inusrance Law, for self employed), BSVG=Bauern
Sozialversicherungsgesetz (Farmers’ Social Insurance Law), FSVG= Bundesgesetz über die Sozialversicherung
freiberuflich selbständig Erwerbstätiger (Federal law regarding social insurance for freelance, self employed persons)
65
32
which they are provided (allowance in kind or cash benefits).68 The insured person (on submission of an
insurance case as well as fulfilment of certain criteria69) has an enforceable right to compulsory benefits
(e.g. treatment of illness). With the compulsory services, differentiation must be made between the
minimum legal service requirements (type, scope, and conditions are governed by law) and the statutory
additional services (health insurance funds are permitted to define more comprehensive services in their
statutes (according to grounds, level, or duration), as long as these remain within the scope of the model
statutes set out by the Hauptverband). The insured person has no enforceable legal claim to preventive
services (measures to improve health, e.g. stays in convalescent homes or services related to health
promotion), these are granted at the discretion of the health insurance fund. The insured person has no
individual legal claim to compulsory duties (e.g. medical rehabilitation or health promotion), these are to be
provided at the dutiful discretion of the insurance fund.
Differences in the package of services provided by different insurance funds can occur due to various
reasons:
-
Variations in legal regulations, e.g. when utilising inpatient care in the private ward, special
services are available for B-KUVG (civil servants) insured and GSVG insured70 (self-employed).
-
Variations in contractual rules.71 (Insurance funds have varying contractual arrangements with
providers of health care services. These variations can not be entirely explained by the individual
sickness fund but are also dependent on the contract partner, i.e. the representative association)
-
The financial situation of the sickness fund, for instance the regional fund in Vienna does not
reimburse Spa treatment
-
Variations in the levels of co-payments set by the sickness funds
-
Variations between branches of sickness funds, e.g. in health insurance (sufficient and appropriate,
not exceeding the necessary amount) and in accident insurance (with all appropriate means) and
also depend on the insured event (illness vs. occupational illness).
Services are provided either as allowance in kind (in form of tangible assets or provision of service) or as
cash benefits. The first can be called upon by contractual partners (contractual facilities, contract doctors) or
the insurance funds’ own facilities. The latter may be claimed once or repeatedly (ongoing). The health
insurance primarily provides benefits in kind72, cash benefits predominate in accident and pension
insurance.73 There are variations in the terms for persons entitled to cash benefit insured by the Austrian
Social Insurance Authority for Business (Sozialversicherungsanstalt der gewerblichen Wirtschaft, SVA).
Cash-benefits provided in health insurance are partially calculated based on the income of the insured. This
applies to benefits such as sickness allowance (Krankengeld) which is supposed to be a substitute for
income during a spell of sickness, daily allowance (Taggeld) according to the GSVG, maternity benefit
(Wochengeld) or business allowance/maternity benefit (Betriebshilfe/Wochengeld) according to the
GSVG/BSVG. Cash benefits which are independent of the income of the insured include child care
benefit74, the additional subsidy to the child care benefit75 or other allowances in the context of
rehabilitation, e.g. for adaptation of an apartment or a car.
68
§ 121 ASVG
Seidl, W. (2002), Social Insurance Law. Skriptum, Graz, Neuer Wissenschaftlicher Verlag.
Reiter, G. (2002). ″Compulsory insurance versus the obligation to take out insurance – more than a play of words?″
WISO 3, pp. 79-90.
70
Those consuming benefits in cash; they have an option whereby they can opt to pay higher contributions for hospital
care meaning that they are treated in the private ward instead of general ward.
71
Schrammel, W. (2002). Report of the chair of the expert commission „Compulsory insurance – the obligation to
take out insurance“, accessible at
http://www.auva.at/mediaDB/63990.PDF#search=%22Schramml%20Expertenkommission%20Pflichtversicherun
g%22.
72
Federal Ministry of Social Insurance, Generations and Consumer Protection, BMSGK (2003). Social protection
in Austria, an overview, Vienna.
Kind, M. (2005). My rights as a patient. Vienna, Verlag des Österreichischen Gewerkschaftsbundes GmbH.
73
74
a yearly threshold for additional earnings of € 14,600 exists
75
In certain cases income-dependent
69
33
The service commitment or scope is based, in part, on the recommendations of the supreme sanitary council
(definition of what is the medical standard?) and diverse internal expert committees of the insurance funds.
The final decision lies with the political decision makers76. The definition of disease treatment in
accordance with § 133 ASVG para.1 has a considerable influence on the scope of services provided by the
health insurance, according to which disease treatment should be “adequate and appropriate, it must
however not exceed the level of what is necessary”. Treatment is dependent on the curative understanding
of the definition of illness (§ 120 ASVG para. 1 1.), which is defined as “an irregular state of body or mind
making treatment necessary”. Regarding the definition of “illness” it is important to note that different
understandings exist, as the current definition stated in the law gives room to subjective perceptions and
thus different methods of interpretation. Due to this reason the case may occur in which a sickness fund is
obliged to reimburse a certain benefit even if it is not part of the benefits package. Decisions regarding these
issues are taken by the senior physician of the fund or, in case the insured addresses court, by the respective
institution.
2.3.2 Defining beneficiaries in the Austrian health system (who is covered?)
In Austria social insurance is governed by law77 and is based on the principle of compulsory insurance. It
encompasses the branches of health insurance, accident insurance and pension insurance as well as,
unemployment insurance.78 In 2005 97.8% of the population (about 8.2 million) were covered by social
health insurance79. Individuals become insured after starting a job, by fulfilling other compulsory insurance
criteria (compulsory insurance) or by way of a derivative insurance cover (e.g. joint-insured dependants).
For those without compulsory insurance there is the possibility of voluntary insurance.
Affiliation to a social insurance fund cannot, apart from a few exceptions, be freely chosen by the insured
person (see Section 7.3.1 on “Patient choice in Austria”). Health insurance funds are classified by
occupational groups and, in the case of general employed persons, also by region. With salaried employees
(ASVG) the health insurance fund is notified by the employer, self-employed (SVA, SVB) and voluntarily
insured individuals register themselves, pensioners are registered through the respective pension insurance
fund and the unemployed via the Public Employment Service Austria (AMS). As already mentioned, the
dependants of gainfully employed individuals e.g. husband/wife, children (mostly free of charge) may be
joint-insured as long as they are residing within the country80 and do not have their own health insurance. In
2005 this group of people constituted around 26% of all insured persons.81
Protection of insured with low or no income
Low wage employees, so called “minimum wage” employees82, are upon commencement of employment,
solely covered by accident insurance, they may however, voluntarily obtain health and pension insurance
for a comparatively low monthly fee (€47.0183) (§ 19a ASVG). On the 1st July 2004, 42,024 persons took
advantage of this option.84 Foreign nationals working in Austria are covered by the legal health insurance
through their employer or possibly as relatives, unemployed or pensioners. Should they not fit into one of
76
77
General Social Insurance Law (ASVG), Special Laws (Sondergesetze): GSVG (Gewerbliches
Sozialversicherungsgesetz), B-KUVG (Kranken- und Unfallversicherungsgesetz der Beamten), BSVG (Bauern
Sozialversicherungsgesetz), FSVG (Sozialversicherungsgesetz der Freiberuflich Selbständigen Erwerbstätigen) as well
as relevant amendments
78
Unemployment insurance is organised by the Public Employment Service Austria (Arbeitsmarktservice, AMS) and
is independent
79
Hauptverband der österreichischen Sozialversicherungsträger, incl. individuals insured with health care institutions
(Krankenfürsorgeanstalten)
80
Exception: stay abroad for study purposes
81
Hauptverband der österreichischen Sozialversicherungsträger (HVB), insured persons with health insurance
82
Monthly charge no more than € 333.16 (§ 5 Abs. 2 ASVG)
83
Hauptverband der österreichischen Sozialversicherungsträger, HVB (2006). Social security data (contributions) in
the Austrian Social Insurance 2006. cut-off-date 1 January 2006, Version 13.02.2006
84
Haydn, R. (2005), ″Multiple insurance in Austrian Social insurance, individual-related statistics 2004.″ Soziale
Sicherheit 2, pp. 74-82.
34
these groups then the procedure is similar to that for tourists, whose access to services is basically
unrestricted, but the share of costs to be paid is on the one hand linked with the existence of a bilateral
agreement with Austria and on the other hand the type of service called upon. In the case of, for example,
EU citizens, as well as citizens of the European Economic Area and Switzerland the claim is documented
by means of the European Health Insurance Card (formerly E111 certificate) for care and medical services
received during the temporary stay in Austria, which must be presented when visiting a doctor.
Asylum seekers under federal supervision as well as sick and needy asylum seekers are covered by social
health insurance as long as their place of residence is in Austria and they do not perform any activity which
would reason compulsory insurance (see also Section 3.5 “Access to care for asylum seekers”).
Entitlement to use services
Access to services is dependent on whether a valid entitlement to services is in existence at the time of
claiming for benefits. The scope of services, as well as any preconditions for claiming benefits, is regulated
by various social insurance laws.
Should an insured person not have their e-card with them then this does not prevent them from calling upon
services (see Section 2.3.3 “e-Card”). The fact that some doctors demand a deposit fee when a card is not
presented could be seen as a barrier. To some extent, this approach was already practiced when a health
insurance voucher was not presented under the previous system.
Not insured persons
In 2003 the Ministry of Health and Women carried out a study to determine and record those persons not
insured that drew the following conclusions:85
“At the end of June 2003 up to 205,000 people from the age of 15 years (3.1% of the resident population
from age 15 years) are not covered by national health insurance. Of these up to 160,000 people from the age
of 15 years (up to 2.4% of the resident population from the age of 15 years) are without any (registered)
entitlement to services in case of illness (they also have no obligatory health insurance under private law, no
(registered) entitlement to medical help, no health care through judiciary institutions).86
•
Compared with the respective proportion of the population, in both groups there are very few men
and the number of people aged 15-29 years disproportionately high.
•
Based on secondary analysis of a representative WHO study there are sufficient grounds to
presume that, amongst those not health insured, a large proportion of people do not have Austrian
nationality and have a low level of education compared with their respective proportion of the
general population.
•
The total number of (registered) persons entitled to medical help (excluding self-insured) was about
19,000 in December 2002.
•
Compared to their respective portion of the general population men, people in the age groups 40–
49 and 50–59 years as well as foreign nationals are disproportionately highly represented.
•
The total expenditure for medical help (excl. self-insurance contributions) was around €50 million
in 2002 (based on available data).
•
In addition there were around 4000 self-insured persons in December 2002, for whom the social
security funds paid the contributions.
•
Compared to the respective portion of the general population, here women, the over 50s (esp. over
70 years) as well as (to a limited extent) Austrians are disproportionately represented.
•
The sum of the health insurance contributions paid by the social security funds was around €10
million in 2002 (based on available data).”
85
Federal Ministry of Health and Women (2003). Quantitative and qualitative assessment and analysis of individuals
not covered by health insurance in Austria, Final report.
86
Maximum values
35
The report also presents reasons for temporary as well as permanent lack of insurance coverage. Models for
the extension of access to health insurance are discussed.
Self employed professionals/members of a pertaining to a Chamber (doctors, pharmacists, dentists, notaries,
patent lawyers, solicitors, civil technicians, tax consultants, vets) who have opted for a private insurance
scheme as well as their dependants are not covered by social insurance (17,000 persons in 2003).
Insured who do not benefit from services
Only a relatively low proportion of insured persons make no claim on services. In Austria at the end of
2004, 7,470,454 people were entitled to benefits covered by insurance funds according to LIVE.87 When
those people entitled to benefits, but who died in 2004, are added to this number the total reaches 7,540,000
(plausible approximated value). Of these, 95% used at least one service from one of the areas of medical
help or equivalent, medication or dental treatment, dental prosthesis.88 This means around 360,000 people
have not used any type of health service.89 In their study published in 2004, Wurzer et al. reported that 84%
of persons insured with the Carinthian sickness fund received one or more services in 2002.90 Compared to
the overall percentage this is lower although in this study all service areas were taken into account.
The motivation not to access services of the national health insurance may be divided into two categories:
a) The insured person does not need or want them:
-
The insured person is healthy and does not require any medical services
The services that the insured person would like to use, are not covered by the scope of services
offered by health insurance (e.g. oral hygiene at the dentist, in part alternative therapies, cosmetic
surgery) and are therefore paid privately (with or without the cover of a private health insurance)
The insured person treats him/herself and uses non-prescription medicines (OTC medicines)
The insured person seeks medical advice or assistance from family or friends who work in the field
of health care and do not charge for their services
b) The insured person cannot access them:
-
The insured person does not fulfil the requirements for entitlement (e.g. for access to medical
rehabilitation measures91)
The insured person cannot or does not wish to use services on financial grounds
The insured person cannot or does not want to use services via social insurance due to long waiting
times and accesses a private provider (without subsequently submitting the bill to the health
insurance for reimbursement of costs)
The insured person does not use a service because they do not know that it is offered/ covered by
the health insurance (lack of information).
The insured person cannot or does not access services due to cultural reasons
Access to a particular service is not possible for the insured person on geographical grounds
o The resources are not reachable within a reasonable amount of time92
87
LIVE = Service information for insured persons (Leistungs-Informationen für Versicherte) , 7,704,292 records with
a social insurance number (not including entitled persons insured by the Insurance of the Austrian Railway Industry
and health care establishments as well as persons eligible for benefits without services). Multiple-insured persons were
consolidated.
88
90% at least one service in the field of medical attendance, 73% in the field of medication and 47% in the field of
dental treatment & dental prosthesis
89
Hauptverband der österreichischen Sozialversicherungsträger (HVB), basic data for the LIVE – analysis 2004.
received 18/04/2006
90
Wurzer, A., Robinig, R., Rodler, J. (2004). User charges, a review for orientation. Klagenfurt, Regional sickness
fund of Carinthia.
91
When claiming to need rehabilitation the diagnosis of the patient has to be such that treatment in a rehabilitation
clinic will either maintain the effect of the treatment the patient received before (e.g. in a hospital) or will alleviate any
consequences of the illness. The aim is to restore the patients’ health to such an extent that they won’t need continuous
care. Legal requirements see § 154a ASVG
36
The treatment is not available in Austria in the form required and it is not possible to travel
abroad. This situation is not common.
o The insured travels abroad and utilizes health care services which he however, upon return,
does not bill his health insurance fund (a refund is not requested)
The insured does not realise they require medical services (e.g. because of mental illness) or,
because of their illness, refuses any form of medical assistance.93
o
-
Non- insured persons who benefit from services
In principal all providers of health care services in Austria are, independent of the insurance status of the
patient, obliged to provide assistance in case of emergency. There are only a few national health insurance
services which may potentially be utilized without the need for compulsory insurance or joint insurance.
Within this category of services is preventive health or health examination. For non-insured persons their
costs are covered by the health insurance funds who receive reimbursement from the federation at a later
date, or “Mother-Child-Pass” examinations, which, for non-insured persons, are paid in full by the “Fund
for Balancing Family Burden” (FLAF).94 For human genetic precautionary measures, especially genetic
family consultation, prenatal diagnosis and cyto-genetic examinations the costs for non-insured persons are
carried by the federation95. Furthermore cash reimbursements for the non-insured exist for FSME
vaccinations (for tick-borne encephalitis ).96
State-run hospitals are, in accordance with § 22 Abs. 2 KAKuG, obliged to admit sick people. People
without health insurance coverage are attended as private payers and must pay the general care charges. If
this is not possible the social support of the federal states steps in, which, depending on the provisions of the
legal requirements in the federal state concerned, recovers the payment from the patient or relatives.97
In certain circumstances child benefit is also granted to non-insured persons, or people who have never
worked, such as, housewives/house husbands, students or those receiving minimum wage. Entitlement and
level of child benefit is linked with attendance at the “mother-child-pass” examinations. People drawing
child benefit are part insured by the national health insurance. Child benefit is financed by the “Fund for
Balancing Family Burden”.
Individuals who are not covered
Usually citizens in Austria do not have the option of deciding if they would like to join social insurance or
not. Either they meet the prerequisites for statutory insurance (full- or partial insurance) and are thus
automatically insured or they meet the requirements to be insured as dependants or they do not fulfil either
of the conditions stated above.
The principle of subsidiarity is applied; anybody not covered by compulsory insurance or by insurance as a
dependant does not meet the legal requirements to be protected by social insurance. However in all
92
Geographical availability of treatment in case of an emergency is available according to international standards.
Other services (e.g. specialists) may exhibit varying local access but are in principle available for insured without
significant restrictions. Commuting time of about 1.5 hours may occasionally be necessary but is judged to be
acceptable. (Hauptverband der österreichischen Sozialversicherungsträger, HVB. Dr. Endel, 9 August 2006,
telephone)
93
An examination of the characteristics of those insured persons who do not call upon services available through the
health insurance could have been conducted by analyzing data from the health insurance funds (probably from FOKO
- Folgekostenrechnung, analysis of follow-up costs), but it was not initiated within the framework of this study due to
time and resource constraints.
94
Financed by contributions from employers, contributions from land and forestry businesses, federal budget, social
services of the federal states and repaid services (www.bmsg.gv.at)
95
Federal Ministry of Social Insurance, Generations and Consumer Protection (2003). Report describing the
situation of disabled persons in Austria. Vienna. Accessed at:
http://www.bmsg.gv.at/cms/site/attachments/4/7/1/CH0007/CMS1058781346290/behindertenbericht.pdf, on
07/04/2006
96
Regional sickness fund of Vorarlberg, accessed at www.vgkk.at on 07/04/06
97
Dr. Felix, (Hauptverband der österreichischen Sozialversicherungsträger, HVB). 10 April 2006 (via email)
37
branches of social insurance (health, accident and pension insurance) the option of voluntary insurance is
available. Factors excluding individuals from social insurance coverage are for example:
•
Their employment has only secondary significance– in the ASVG (earnings below a certain
threshold (€333.16 per month, €25.59 per day)98
•
Their income is below a certain threshold (GSVG): €6453.36 or €3997.92 respectively,
depending on if the individual exercises only the self-employed occupation (first threshold) or
if another occupation is held or alternatively any of the following financial benefits are
consumed: pension according to the B-KUVG (Ruhe- oder Versorgungsgenßs), child care
benefit or any other financial benefit resulting from statutory health- or unemployment
insurance (second threshold) 99
•
The professional organization of the insured has chosen to opt out of social insurance
according to § 5 GSVG (amongst others physicians, veterinary doctors)
•
Individuals who are only insured in one or two branches of social insurance (partial insurance),
for instance recipients of a pension, persons serving military service
•
Members of orders and congregations of the catholic church as well as of institutions belonging
to the evangelic deaconry
•
Individuals whose main residence is abroad (exemptions include studies, professional training
as a dependant, deployment, employees of an embassy, foreign companies, employees in the
field of transportation, development workers)
•
The insured is already insured under another law (covered as a dependant)
•
A dependent child older than 27 years100
Individuals who are not covered by compulsory social insurance may take out voluntary insurance (with a
private insurance company or with a social insurance fund). Social insurance can only verify the occupation
of self-employed after these have registered with the tax authorities. They are obliged to register with the
Austrian Social Insurance Authority for Business within 4 weeks after fulfilment of the criteria for
compulsory insurance (§ 18 GSVG). If they do not do so financial penalties can come into effect.
2.3.3 The e-card
With the 56th amendment of the ASVG the Main Association of Austrian Social Insurance Institutions
(Hauptverband der österreichischen Sozialversicherungsträger, HVB) was assigned the responsibility of
creating an e-card for social insurance which should be the basis of an electronic administration system
(elektronisches Verwaltungssystem, ELSY). Administrative processes ought to, to the extent possible, be
performed without paper documents (§ 31 a (1) ASVG). In the first expansion stage the chip card should
replace all types of health insurance voucher. The card is to be presented by the insured whenever using the
services of a contract partner of social insurance (§ 31 c (1) ASVG).101
From the 1st January 2003 contract doctors (based on the 59th amendment of the ASVG) and from 1st
January 2004 other contract partners (based on § 349a ASVG) were obliged to bill provided services
98
Austrian Social Insurance, accessed at www.sozialversicherung.at
low-income-earners (below € 333.16 per month) are only insured with accident insurance
99
Austrian Social Insurance Authority for Business (SVA), accessed at: www.sva.at
100
Children older than 18 years can be insured as dependants if they are predominantly occupied by educational or
professional training (e.g. university). This is possible until they are 27 years old. After that they may only be insured
as dependants in case they are unemployed (limited to 2 years) or unfit to work (limited to duration of inability to
work).
101
e-card website, accessed at: www.chipkarte.at on 03/03/2006
General Social Insurance Act, ASVG
Schober, I. (2005). ″Plan for the introduction of the e-card and preparations within social insurance.″ Soziale
Sicherheit 1, pp. 19-22
38
electronically with their insurance fund. Fulfilling this legal requirement is facilitated by the fact that the
data from the e-card system can be transferred to the software of the physician. Further legal basis are the
SVÄG and the E-GovG.
Distribution of e-cards to the insured102
Issuing of the e-card is regulated by law, amongst other in § 31b para.3 ASVG. The e-card is sent to the
insured automatically (without application) by mail. Only those individuals (insured and their entitled
dependants) for which an entitlement in health insurance, according to one of the social insurance laws
(ASVG, B-KUVG, BSVG, GSVG, FSVG), was verified at a certain point in time or those covered by one
of the health care establishments103 (Krankenfürsorgeanstalten, KFA: KFA of the employees of the city of
Vienna, KFA of the civil servants of the provincial capital Graz, KFA of the civil servants of the city of
Villach, KFA of the magistrate’s civil servants of the provincial capital Salzburg) received an e-card. The
insured has to reside within the boarders of the country. In case he didn’t have any entitlement at the above
mentioned point in time he receives the card by mail as soon as entitlement exists. Having an e-card does
not automatically mean that a person is insured. Entitlement status can be verified by using the card to
access the system (e.g. when consulting a physician). The nationwide rollout in Austria (about 8.1 million
cards104) took place between May and November 2005, in weekly stages for different regions. Nationwide
use was ensured by January 2006
Cost
Social insurance finances the e-card from its own funds. According to § 135, para.3 ASVG a yearly service
charge of €10.00 is levied (for each insured). The employer levies the service charge which is due by
November 15 and pays it to the respective sickness fund, independently of the employee actually having an
e-card or not (it is assumed that most of the employed persons have one). The service charge is to be paid,
regardless of amount/number of services actually consumed by the insured which results in a relief for
critically ill persons or those suffering from a chronic illness. Individuals paying a co-payment (selfemployed, civil servants) are not obliged to pay the service charge. The service charge is only accrued for
employed persons who are insured based on the ASVG and who so far had to pay the charge for a health
insurance voucher when visiting a physician. Individuals receiving child care benefits, sickness- or
maternity benefits receive the bill for the service charge from their respective sickness fund.
Multiple insured persons initially pay for each insurance entitlement, they may however ask for a refund of
the excess payment at their concerned sickness fund when presenting the payment documents. This
procedure is conducted by means of an informal claim. Children or pensioners with multiple insurance do
not pay any service charge.
All revenue generated by the service charge is invested in health insurance benefits.
The service charge includes the usage of the e-card as a citizen card105 (Bürgerkarte). A gadget to read the
card costs the insured €20.00, the software is provided free of charge.
Areas of application
In the first stage of expansion the e-card only replaces the paper-health insurance voucher and verifies the
patient’s entitlement towards the sickness fund and the contract physician in Austria with respect to utilising
102
Ms.Schober (Hauptverband der österreichischen Sozialversicherungsträger, HVB) interview 11 November 2005
e-card website, accessed at: www. chipkarte.at on 03/03/2006
103
Insurance funds for employees of cities and municipalities not insured according to B-KUVG.
104
No author (2005), ″The dispatching of the e-card has been finished″, Soziale Sicherheit 12, pp. 504-506
105
The citizen card offers individuals more convenience, more security and more speed. Using it enables the
identification of persons and authentication via electronic signature. With the card amongst many other services
administrative processes (communication with authorities and companies) can be handled from at home, for instance
secure access of forms, registrations (e.g. at www. finanz.at), ciphering and securing documents. For further
information, refer to www.buergerkarte.at
39
services of contract physicians in real time.106 In addition the e-card infrastructure is used to handle the prior
authorization for pharmaceuticals (Arzneimittelbewilligungsservice, ABS). In the future further functions
should be made possible through which the card will become the central key of access for services provided
by social insurance and within the health care system. It is planned to include and electronically link all
providers. The administration of the prior authorisation of medication takes place using the e-card
infrastructure. Further services (e.g. e-prescription) are planned and are described at a later point.
Currently only personal data of the card owner such as name, title and social insurance number have been
saved on the card. On the front side the card is provided with a card sequence number, the telephone
number of the service line, the web address of social insurance and a chip which contains information about
sex and date of birth. The card is valid for an unlimited amount of time which does however not imply that
a person is constantly insured.
The back of the e-card serves as European health insurance card (EHIC) and is not electronic. It replaces the
treatment voucher (before E 111 form) to utilize physician services during temporary stays in the EU
member states, EEA-states and Switzerland and is valid for up to 10 years.
The card itself does not carry application data but acts as a key card (it has various signature functions) to
grant access to applications, services or data for the card owner himself or entitled third parties (e.g.
physicians). When the card is read, the physician has access to the following data (which is saved in the
operation centre (Betriebszentrale) of the e-card system: name, insurance status (insured/not insured),
insurance category (e.g. pensioner), type of entitlement (in cash or in kind), exemption of charges
(prescription charges, exemption of co-payments), consultation of a physician of the same specialty in the
same quarter. To be able to read the data actually two cards, namely the e-card of the insured as well as the
o-card (practice card of the physician – secured by PIN) of the physician have to interact logically. This is
supposed to prevent fraud.
Assignments and referrals performed by the first contact health practitioner (Erstbehandler) have to still be
taken along in paper form. In this situation the e-card is like a verification of entitlement and is to be
presented together with the referral note.107 The E 112 form (travelling only in order to utilize a certain type
of treatment in one of the formerly mentioned countries) still has to be issued regularly.
The infrastructure of the e-card makes an electronic linking of all physicians (contract partners) possible.
The extension of the system in order to include other providers such as hospitals and outpatient departments
is planned; the inclusion of all providers is the overall vision. The secure transfer of data which has to be
protected is facilitated by various signature functions.
Types of signature functions108
Simple signature (SV signature) without PIN input allows the exchange data between practice and central
system. Administration signature according to § 25 E-Government law (PIN signature) i.e. citizen card
signature: for this a certificate is necessary – the application can be directed at the Hauptverband or any
other appropriate provider of certificate services (area of application: E-Government, activities within
administration) and is free of charge. The signature is a secure signature towards the outside (area of
application: private services, signing of contracts) – an application associated with some costs.
It is planned that the following functions will be added to the e-card :109
106
Krüger-Brand, H. (2004). ″The e-card starts in Austria.″ Deutsches Ärzteblatt 101:49, pp. 3318-3319
e-card Website, accessed at: www. chipkarte.at on 03/03/2006
108
Ms.Schober (Hauptverband der österreichischen Sozialversicherungsträger, HVB). Interview 11 November 2005
e-card website, accessed at: www. chipkarte.at on 03/03/2006
Otter, H. (2004). ″The e-card as citizen card in e-government.″ Soziale Sicherheit 12, pp. 499-501
109
Medical Chamber of Vienna (Eds.) (2005). E-card administrative, accessed at http://www.aekwien.or.at/media/ecard_administrativ.pdf on 12/09/2006
107
40
•
•
•
•
•
•
•
•
•
Integrating hospitals and other contract partners into the system
Electronic prescription (e-prescription)
Extending the area of application of the e-card to a recognised health-chipcard in the EU
Handling of registration in social insurance
Using the e-card for transferring sensitive health data (e.g. transmission of medical records)
Substituting the paper-referral note by an electronic referral note (2006 or 2007)
Storing emergency data (on the card or accessible via a server)
Using the e-card for e-government and eSV
According to the law biometric data are to be upgraded via a chip beginning in 2010
Information relevant for the e-card which can be accessed in the electronic data processing centre
(Rechenzentrum) can be extended arbitrarily as long as they are in accordance with the legal provisions
(Health Care Telematics Act). The legal basis for the storage of emergency data was created by the 59th
amendment of the ASVG. The storage is technically feasible. Before actually executing this step a whole
range of questions still have to be clarified.
Improvements through the e-card
The e-card is an infrastructure project because it provides a basis for telecommunication in the health care
system and consequently also for a range of forward-looking follow-up projects. By means of the e-card all
contract partners (doctors, institutes, etc.) are linked electronically through a secure health care information
network (Gesundheitsinformationsnetz, GIN). The project is not only advantageous for social insurance but
for the entire economy, the present network makes it possible to transfer diagnostic findings. Involved
stakeholders benefit from the introduction of the e-card in different ways. Results of two public opinion
surveys performed in September and November 2005 show that the Austrian population are supportive of
the e-card and that physicians increasingly accept it.110
The employer no longer has to issue health insurance vouchers but only has to levy the service charge once
a year. The card saves time and money with respect to administration (no filling out or repeated requesting
of health insurance vouchers). Equally the issuing of health insurance vouchers for holidays ceases to exist.
Social insurance was however allocated the responsibility for all sorts of administrative duties related to the
e-card such as the issuing or posting of the card.
Patients only need their personal e-card (and if need be a referral note) when consulting a doctor. Seeing the
employer or the public employment service (Arbeitsmarktservice, AMS) is no longer necessary. The
patient’s privacy is better protected (it is not required to inform the employer every time before consulting a
physician). Because of the convenient format the patient can always carry the card with him and will most
likely not forget it as often as the health insurance voucher.
In the case of multiple insurance, as yet, the patient has the right to choose the sickness fund through which
he accesses the service. The e-card does not interfere with this existing regulation.
The card has sufficient storage space for future applications and may be used as a citizen card
(Bürgerkarte).111 The citizen card offers individuals more convenience, more security and more speed. With
the card amongst many other services administrative processes can be handled from at home, for instance
secure access of forms, registrations (e.g. at www. finanz.at), ciphering and securing documents.
Otter, H. (2004). ″ The e-card as citizen card in e-government.″ Soziale Sicherheit 12, pp. 499-501
Bugner, W.M. (2004). ″The infrastructural project of the e-card system of Austrian Social insurance in practice.″
Soziale Sicherheit 12, pp. 488-492
110
Anonymous (2005), ″ The dispatching of the e-card has been finished ″, Soziale Sicherheit 12, pp. 504-506
111
For more information on the Austrian Citizen Card, view http://www.buergerkarte.at/index_en.html
41
Using the administrative signature of the citizen card makes it furthermore possible to request personal data
from the social insurance web portal (progression of insurance (Versicherungsverlauf), status of insurance).
This facilitates communication between the insured and the insurance fund.
By using the e-card the physician can immediately tell if a patient has insurance coverage or not. Data is
updated regularly. Because patients will probably not forget the e-card as often as the health insurance
voucher the doctor will not be required to fill out substitute insurance vouchers. Physicians who possess the
e-card infrastructure have not automatically signed a contract with social insurance.
In addition to reducing administration costs by means of the above mentioned mechanisms the process of
billing is facilitated for the doctor because he is now able to transfer data from the e-card server to his
billing software. Furthermore the physician is, within the context of the e-card, granted a range of additional
services such as secure Internet-access or banking-access or use of email.112
Overall, transparency of services is increased by the e-card system. Moreover, security of data is ensured by
means of up-to-date technology.
Forgetting / losing the e-card or theft
In case the insured forgot or lost their e-card, health care services may still be consumed. The patient is at
any disadvantage, provided that they know their insurance number (i.e. a query system for social insurance
numbers is part of the e-card system). The insured has to communicate the number to the doctor who then
introduces it into the system and signs the consultation with his practice card (Ordinationskarte). The card
must be brought along at the next visit. The physician is allowed to charge the patients a deposit fee (as
previously for forgotten insurance vouchers). Patients are obliged to confirm their entitlement with a
signature. Newly born are special cases as their e-cards are not automatically issued with their birth. As
soon as the birth of the child is communicated to a civil registry office this is automatically passed on to the
insurance carrier which initiates the issuing of an insurance number and e-card.
Depending on the insurance fund a certain amount of consultations may be billed without an e-card (as
before, when the contract partner was entitled to only issue a definite amount of substitute insurance
vouchers). Further consultations can be saved, with regard to billing the physician has to contact his
insurance fund though. It is of the physician’s own interest to keep this number as low as possible;
otherwise he takes a risk in the situation of billing the services provided. In the course of a follow-up
consultation or also without consultation the “without-card-limit” is corrected automatically.113
In case the insured would like to utilize benefits abroad he has to fill out an entitlement form at his
respective insurance fund.
Lacking entitlement to social health insurance benefits
The following population groups do not have an e-card114:
•
•
Low income earners (below €333.16 per month or €25.59 per day (2006))
Recipients of social welfare benefits; however, the requirements according to federal law for social
benefits recipients to obtain an e-card were recently created.
112
Ferchner, S. (2005). ″E-card: looking into the future.″, Ärztemagazin 12, accessed at http://www.medizinmedien.info/dynasite.cfm?dssid=4169&dsmid=62700&dspaid=473300 on 12/09/2006
Bugner, W.M. (2004). ″ The infrastructural project of the e-card system of Austrian Social insurance in practice.″
Ms. Resch (Hauptverband der österreichischen Sozialversicherungsträger, HVB). Interview 29 June 2006
114
42
•
•
•
•
Those who opt out from the statutory scheme (persons who can, according to § 5 GSVG, choose
between statutory social health insurance and private health insurance) – they are not interested in
participating
Cross-border commuters (complicated cases with foreign insurance carriers, etc.)
Asylum seekers; however it is planned that the doctor receives the insurance number and can then
check entitlement as well as bill services.
Health care establishments115 (Krankenfürsorgeanstalten): So far only a couple of health care
establishments (Krankenfürsorgeanstalten) are part of the e-card project and even these in varying
intensity. Some have fully adopted the card, others only use the EKVK the European Health
Insurance Card. The reason for this is that this group of insured did not have the system of health
insurance vouchers (exception: for travelling abroad – E111 form) but was billed directly by the
health care provider, being reimbursed at a later stage by their insurer. The inclusion of the
remaining health care establishments will most likely take place in stages.116
2.4 Progressivity of financing
Payments are progressive if the higher income groups pay disproportionately more than those on lower
income. The distribution of financial burden and the degree of progressivity and regressivity differs across
funding sources. Health care payments are progressive if the share of health care payments in gross income
increases with gross income, and they are regressive if payments decrease with income117.
Furthermore, the extent to which a funding system will redistribute income from the higher to the lower
income groups depends on both the progressivity of revenue collection and the incidence of public
spending. It is important to consider these two factors, as failure to do so may reveal an inaccurate picture
of fairness. For example, in order to achieve the same redistributive effect as a progressive system, a
proportional system must unequally distribute benefits.118 It could be argued that a less progressive system
in which public spending benefits the lower income groups disproportionately may create a better situation
for low-income people than in a more progressive system but with less public spending for the poor. Public
spending on health care may be difficult to separate from overall public spending that may also be
redistributing revenue.
A longitudinal perspective is needed to understand the redistributive effect of a health care system in order
to account for redistribution between periods of wealth and periods of poverty over a lifetime. While most
redistribution studies focus on one point in time, the few longitudinal studies generally show a
redistribution from ‘lifetime richest’ to ‘lifetime poorest’, but the redistribution is relatively flat.119
Among the different types of taxation, there are different degrees of progressivity. Wagstaff et al. studied
the progressivity of health care financing in OECD countries.120 This study found that direct taxes were
progressive in all countries, while indirect taxes were regressive in all countries except Spain in 1980
(which may result from higher value-added taxes on luxury goods). Also, among the EU member states,
direct taxes are progressively distributed while indirect taxes are regressive according to Kakwani
indices.121 Indirect taxes constitute a larger proportion of income of poor people than wealthier people. For
example, in the UK, lower income households pay a greater proportion of their income on indirect taxes (32
115
Health insurance fund of individuals employed by a municipality or a city under public law.
ORF Oberösterreich (2006) Electronic health insurance voucher, no e-card for civil servants of the federal states,
accessed at:: http://ooe.orf.at/stories/86505/ on 31/01/2006
117
D De Graeve and T Van Ourti, The Distributional Impact of Health Financing in Europe: A Review (Oxford:
Blackwell Publishing Ltd, 2003).
118
R Ervik, The Redistributive Aim of Social Policy: A Comparative Analysis of Taxes, Tax Expenditure Transfers and
Direct Transfers in Eight Countries (New York: Syracuse University, 1998).
119
120
A Wagstaff, E van Doorslaer, and van der Burg H, eds., Equity in the Finance and Delivery of Health Care: An
International Perspective (Oxford: Oxford University Press, 1999).
121
Ibid.
116
43
per cent) than higher income households (11 per cent).122 In examining the tax system as a whole, in 19981999, the UK tax system was slightly regressive due to indirect taxes, with the lowest income quintile
paying 40 per cent of income in taxes, while the highest income quintile paid 36 per cent of their income on
taxes.123
The extent of progressivity of income taxation depends on the number and rates of marginal tax bands,
where fewer tax bands and low marginal tax rates will create a regressive system. Income tax in France,
Germany, the Netherlands, Sweden and the UK appears to be progressive, with income being transferred
from the highest income quintile to the rest of the population124. Figure 2.3 shows the relationship between
progressivity (measured by the Kakwani index) and the proportion of funding through taxation; tax-funded
systems are more progressive than countries relying more on social and private insurance like the
Netherlands, Germany, Switzerland and the United States.
Figure 2.3 Estimates of progressivity (Kakwani Progressivity Index) of total health spending based on
% financed by tax in the 1980s and 1990s, selected European countries
Note: DK, Denmark (1981,1987); FI, Finland (1990, 1996); F, France (1984, 1989) D, Germany (1989); I, Italy
(1991); NE, Netherlands (1987, 1992); P, Portugal (1990); E, Spain (1980, 1990); SW, Sweden (1980, 1990); CH,
Switzerland (1982, 1992); UK (1993); US (1987).
Source: Wagstaff et al 1999
National taxation has been found to be a more progressive system of financing than local taxation. Wagstaff
et al. put forth evidence showing that national taxation in Denmark, Finland and Sweden is more
progressive than in countries with decentralised tax collection.125 Also in Finland, an increase in the average
rate of local income taxes led to a decline in progressivity in the early 1990s.126
122
Glennerster, Paying for Welfare: Towards 2000. 3rd Ed.
Commission on Taxation and Citizenship, "Paying for Progress: A New Politics of Tax for Public Spending."
124
S Zandvakili, "Income Distribution and Redistribution through Taxation: An International Comparison," Empirical
Economics 19 (1994).
125
Wagstaff, van Doorslaer, and H, eds., Equity in the Finance and Delivery of Health Care: An International
Perspective.
126
J Klavus and U Hakkinen, "Micro-Level Analysis of Distributional Changes in Health Care Financing in
Finland," Journal of Health Services Research and Policy 3, no. 1 (1998).
123
44
In terms of the redistributive effect of tax and benefit systems, there is considerable variance across
countries. Comparing eight countries in the 1990s, Sweden redistributed the most, reducing income
inequality by 50 per cent, followed by Denmark and Germany, reducing inequalities by more than 40% and
the UK redistributed the least, with a 35% reduction in inequalities. It is likely that the observed
redistribution resulted more from social transfers than taxation.127
Within social health insurance systems, the degree of fairness, or equity, depends on whether or not the
contributions are mandatory. It also depends on the existence of ceilings for contribution rates; payments
are progressive up to a ceiling, and then regressive. In cases where individuals are either not allowed, as in
the Netherlands, or are not obliged, as in Germany, to stay in the public system, the payments become
regressive.128 In the Netherlands, about 31% of the population is required to opt out, which leads to a high
concentration of people on lower incomes and higher risk in the statutory health insurance schemes.129 In
Germany, about 21% of the population can choose to opt out, however, only 7% choose to be fully covered
with private insurance. The social health insurance systems in Germany and the Netherlands have been
found to be regressive.130 Kakwani indices also demonstrate that German and Dutch financing systems are
regressive.131Conversely, in France, with the recently introduced compulsory statutory health insurance
scheme (in 1999) which offers insurance for user charges and expanded the contribution basis to include
total income of employees, there is a higher degree of risk pooling which increases equity.
The redistributive effect of social insurance funding has been studied in Germany. Three types of
interpersonal redistribution are seen in Germany: (1) due to varying health risks, there is considerable
horizontal and vertical redistribution with the renunciation of experience rating; (2) dependents are insured,
suggesting redistribution from single people and couples to people in large families, in addition all insured
people are equally entitled to health care services, independent of previous contributions; (3)
intergenerational redistribution between employed and retired people.132 However, it is argued that
redistribution is more effective in a tax-funded system due to limited income equalization through social
health insurance and negative economic effects of linking insurance contributions to earnings.133
Private funding creates inequity because it shifts the funding burden away from population-based riskpooling arrangements, in which people contribute through taxation or social health insurance on the basis of
their ability to pay, towards out-of-pocket payments by individuals and households, with a pro-rich
distributive impact.134 Furthermore, international comparisons of progressivity in health care funding reveal
that health care systems that are largely privately funded are more regressive than those in which funding is
predominantly public.135
127
Ervik, The Redistributive Aim of Social Policy: A Comparative Analysis of Taxes, Tax Expenditure Transfers
and Direct Transfers in Eight Countries.
128
De Graeve and Van Ourti, The Distributional Impact of Health Financing in Europe: A Review.
129
130
Perspective.
131
De Graeve and Van Ourti, The Distributional Impact of Health Financing in Europe: A Review.
132
K Hinrichs, "Social Insurances and the Culture of Solidarity: The Moral Infrastructure of Interpersonal
Redistributions - with Special Reference to the German Health Care System.," (Bremen:: Centre for Social Policy
Research, University of Bremen, 1997).
133
P.F. Lutz and U. Schneider, "Der Soziale Ausgleich in Der Gesetzlichen Krankenversicherung [Income
Redistribution under Germany's Statutory Health Insurance Scheme]," Jahrbücher für Nationalökonomie und Statistik
217, no. 6 (1998).
134
A Creese, "User Fees: They Don't Reduce Costs and They Increase Inequity [Editorial]." British Medical Journal
315, no. 7102 (1997), R.G Evans and M.L Barer, "User Fees for Health Care: Why a Bad Idea Keeps Coming Back
(or, What's Health Got to Do with It?)," Canadian Journal on Aging . 14, no. 2 (1995).
135
In a regressive funding system the poor spend a greater proportion of their income on health care than the rich; in a
proportionate funding system everybody spends the same proportion; in a progressive funding system the rich spend a
greater proportion than the poor.
45
Substitutive insurance, as in Germany and the Netherlands, is regressive because those who remain in the
statutory health insurance scheme have lower incomes and will have to pay higher premiums to compensate
for the higher risk and lower average income of subscribers.
Also, while private health insurance has been found to be regressive in France, Ireland and Spain,
contributions appear to be proportional to income in Finland and even progressive in Denmark, Germany,
Italy, the Netherlands, Portugal and the UK.136 Some argue that by encouraging (or forcing) high income
individuals to purchase private health insurance, this will make the financing system more progressive,
since the rich will pay proportionately more than the poor. However, private health insurance may skew the
provision of services to favour the higher income groups.
The WHO World Health Report 2000 devised a measure of fairness of health care financing; however data
on Austria were unfortunately not available. This formula is based on the goal that health care payments
should not be linked to consumption and that a proportional relationship should exist between ability to pay
and health care payments. Thus, a fair system of financing would be one where the ratio of total health
contribution to total non-food spending is identical for all households, independent of income, health status
and utilization; the index would take a value of 1. Table 2.10 shows that according to this formula, all 15
countries have around the same, high, degree of fairness (including the US). This apparent insensitivity is
one of many critiques of this method, along with the use of estimation by the WHO, rather than explicit
calculation of the values for each country.137
Table 2.10 Fairness of financial contribution to health systems: estimates for 1997
Country
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Netherlands
Portugal
Spain
Sweden
Switzerland
United Kingdom
US
Index
0.979
0.979
0.977
0.971
0.978
0.963
0.978
0.961
0.973
0.951
0.971
0.976
0.964
0.977
0.954
Uncertainty Interval
0.964-0.991
0.964-0.991
0.961-0.990
0.956-0.983
0.964-0.989
0.946-0.978
0.965-0.989
0.935-0.981
0.959-0.985
0.932-0.968
0.956-0.984
0.959-0.990
0.948-0.979
0.963-0.988
0.929-0.974
Source: WHO World Health Report 2000
136
Perspective.
137
De Graeve and Van Ourti, The Distributional Impact of Health Financing in Europe: A Review, P Musgrove,
"Judging Health Systems: Reflections on Who's Methods," The Lancet 361 (2003), A Wagstaff, "Reflections on and
Alternatives to Who's Fairness of Financial Contribution Index," Health Economics 11 (2002).
46
2.4.1 Progressivity of financing in the Austrian health system
Proportion of national income represented by total earnings from employment (wage quota)
The income generated by wages constitutes around 70% of national income and is thereby the most
important income source.138 During the 1970s the wage quota increased, but fell during the 1980s and 1990s
(see Figure 2.4). The adjusted wage quota dropped from 71% (1981) to 58.5% (2003). The quota of benefits
increased from 29% to 41.5% of GDP. Income on assets has gained in importance, though taxation of this
type of income has not been adjusted.139 The implication of a reduction in the wage quota for social
insurance is a reduction in social insurance contributions i.e. an erosion of the contributions. GDP increased
by 31.4% between 1993 and 2000 and the sum of wages and income by 23.8%. Revenue generated by
social insurance contributions in the branch of health insurance rose by 26% whilst the expenditures in this
area increased by 32.3%.140 Wages depicted a smaller increase than GDP, expenditures of social health
insurance went up more than the GDP. This is a very crucial situation for social insurance because revenue
rises at a lower rate than expenditures. In such a situation it is important for social insurance to create new
options for acquiring funds, such as including income generated through assets in the contribution base.
Figure 2.4 Development of wage quota
Source: Statistik Austria, WIFO (Juni 2005), AK OÖ; not standardized wage quota as a share of the income of
dependent employees (sum of gross wage and income plus social insurance contributions of the employer) of the
income of the population in steps of four years, yearly from 2002 onwards, incl. prognosis for 2005 and 2006
138
Guger, A., Marterbauer, M.. (2004). ″The long term development of income distribution in Austria.″
Österreichisches Wirtschaftsforschungsinstitut, pp. 254-276, accessed at
http://www.bmsg.gv.at/cms/site/attachments/9/2/3/CH0338/CMS1064227005975/12_einkommen.pdf, on 15/06/2006
139
Guger, A., Marterbauer, M. (2004). ″The long term development of income distribution in Austria.″
Österreichisches Institut für Wirtschaftsforschung, pp. 1-47
140
Hauptverband der österreichischen Sozialversicherungsträger (2001). Working paper to create a sufficient funding
base for social health insurance and to ensure a high level of care in the Austrian health care system in the future in
Zechmeister, I., Meichenitsch, J., Hagleitner, J. (2004). ″Analysis and recommendations for the future funding of the
health care system″, Study commissioned by the ARGE „Öllinger“/Grüner Klub im Nationalrat, p. 27.
47
The lack of an integrated data base poses a considerable problem when evaluating distribution trends.
Therefore, Guger and Marterbauer evaluated the changes in income distribution over time by means of
approximation, including various data sources. Among others they used the social insurance contributions
statistics of the Main Association of Austrian Insurance funds to analyse the development of income subject
to social insurance contributions. This source of data excludes low wage earners and does not differentiate
income generated by employees above a defined maximum earnings limit for chargeable contributions.141
Statistics show that the inequality in wage income has increased during the past three decades. Whilst the
share of employees in the lowest quintile has remained fairly stable between 1970 and 2002 the share of
employees in the top quintile has gone up by around 3 percent. The Gini coefficient demonstrates the
increment in inequality (rise in the coefficient).142
Table 2.11 Development of the distribution of wage income subject to social insurance contributions
(Employees excluding irredeemable civil servants (pragmatisierte Beamte))
Source: Hauptverband der österreichischen Sozialversicherungsträger, HVB
Federal Ministry of Social Insurance, Generations and Consumer Protection, BMSGK (2003).Report on the social
situation, Vienna
Quintile = quntiles, Ginikoeffizient = gini coefficient, Insgesamt = Total, Arbeiter = worker, Angestellter = salaried
employee
1) Change to yearly recording including supplementary grants (Sonderzahlungen)
2) Change in the breadth of the wage level in connection with the adoption of the Euro
3) An increase in the Gini coefficient stands for a rise in income inequality
4) A quintile includes a fifth of the wage recipients
5) Since the introduction of the general assessment of employees (Arbeitnehmerveranlagung) the wage tax statistics
display a comprehensive analysis and includes thereafter around 400.000 more employees as the social insurance
statistics; before that the wage tax statistic registered a couple of hunderedthousand employees less than the social
insurance statistics.
6) In a detailed analysis of social insurance data Gusenleitner, Winter-Ebner and Zweimüller (1996) date the reversal
of distribution trends to the year 1977.
Earnings subject to wage tax
To demonstrate the development of earnings which are subject to wage tax Guger and Marterbauer used the
wage tax statistics which include low wage earners and also accounts for the income above the earnings
limit for chargeable contributions. Since the 1970s income inequality Streuung) has been increasing, and
during the second half of the 1990s a further increase in inequality took place. Between 1995 and 2002 the
141
Guger, A., Marterbauer, M.. (2004). ″ The long term development of income distribution in Austria.″
Österreichisches Wirtschaftsforschungsinstitut, pp. 254-276, accessed at
http://www.bmsg.gv.at/cms/site/attachments/9/2/3/CH0338/CMS1064227005975/12_einkommen.pdf, on 15/06/2006
142
Guger, A., Marterbauer, M. (2004). ″The long term development of income distribution in Austria.″
Österreichisches Institut für Wirtschaftsforschung, pp. 1-47
48
share of wages in the first quartile has dropped and the share in the top quartile has been on the increase.
During the time period under observation the Gini coefficient has risen, which implies that income
inequality has increased.143
Table 2.12 Development of the distribution of the income of employees subject to wage tax
(Employees including irredeemable civil servants (pragmatisierte Beamte))
Quintile = quinitiles, Qunitl = quntile, Ginikoeffizient = Gini coefficient, Arbeitnehmer/innen insgesamt = employees
total
1) Reading assistance: In the year 1976 40.2% and in the year 2002 45.9% of all income subject to wage tax was
attributed to the top 20% of income subject to wage tax.
2) An increase in the Gini coefficient stands for a rise in income inequality
Source: Guger, Marterbauer
Wage differences
Wage differences between sectors have grown since the beginning of the 1980s, which is among other
factors based in the rise in part time employment and irregular working hours. With respect to gender
specific differences in income, considering the average over all economic sectors, the women’s median
income is situated at 67.2% of the of men’s median income. Regarding the wage difference between sexes
Austria has, based on the EURSTAT data, occupied the second rank after Great Britain among the EU
15.144
Table 2.13 Women’s median income as a percentage of men’s median income
(With and without adjustment for working hours)
Notes: Erwerbsttätige, nicht arbeitszeitbereinigt = gainful worker2), not adjusted for working hours
Arbbeiterin = women workers; Angestellte = women employees; Erwerbsttätige, arbeitszeitbereinigt = gainful
workers2) , adjusted for working hours
143
See also Biffl, G. (2003), Distribution of household income in Austria, WIFO Working Papers 214, pp. 1-42
Kalliauer, J., Moser, J., (2005). Data on the current distribution of income in Austria and Upper Austria, Press
conference 15 September 2005
144
49
1) 50% earn more and 50% earn less than...
2) wage and salary recipients
3) adjusted for average of invested working hours
Guger and Materbauer list, among others, the following factors influencing the development of the
distribution of income (wages):
•
•
•
•
Shift in the structure in work demand towards qualified work
Differences in the development of employment according to the qualification of the labour force
Deregulation and flexibility of labour markets
Inflow of foreign workers.
The steady increase in the unequal distribution of household income can be explained by reduced household
size, trends towards single households and the change in labour market participation of the household
members. Weighted net per capita income (taking household size and composition into consideration)
displays a considerably lower inequality in the distribution i.e. proving the influence of the above
mentioned factors but also demonstrating that transfer payments such as family benefits are of considerable
relevance in achieving a reduction in income inequalities.
Table 2.14 Development of disposable net household income
(Relative interquartile ranges1) in %)
First block: Netto - Haushaltseinkommen = net-household income, Second block: Gewichtete Nettoeinkommen pro
Kopf (Äquivalenzeinkommen) = weighted net household income per capita (equivalence income): for
Arbeiter/in = Workers
Angestellte = Employees
Öffentlich Bedienstete = Civil servants
Unselständige gesamt = All employees
1) The interquartile range measures by how much % the upper limit of the 3rd quartile (75% earn less and 25% earn
more than...) surpasses the upper limit of the 1st quartile (25% earn less and 75% earn more than…)
Progressivity of the components of funding
Taxes
Tax revenue in Austria in the year 2002 constituted 44% of total government revenue and is converging
towards the slightly lower EU average of 40.6%. Social insurance contributions (33.4% in 2002) and
indirect taxes (consumption taxes) are high in comparison to taxes on assets (vermögensbezogene Steuern)
(1.3% in 2002). Especially social insurance contributions145 are far above the EU-average of 28.1%. Income
145
Share of social insurance contributions of total tax revenue
50
taxation is progressive (maximal tax rates up to 50% for self employed and 44% for employed persons) and
amounted to 22.8% of the taxation revenue (Gesamtsteuer- und Abgabenaufkommen) in 2002.146
Consumption taxes (e.g. VAT), representing the largest share of tax income, have a regressive effect
because they affect low-income people relatively more than people with a high income. Especially non
employed parts of the population such as pensioners are included in the funding system in a stronger way.
Concerning consumption taxes a higher burden is placed on the consumers of services than on those not
using the services.
The share of taxes exercising a progressive effect (income tax, revenue tax, tax on assets) is relatively low.
When calculating income tax an increasing tax rate is applied to higher income. However, as already
mentioned before, a defined maximum tax rate constitutes the upper limit of taxation. Tax payments of
citizens situated above this tax limit are regressive because people with a higher income pay a smaller
relative share of their income for taxes than people with an income situated below or at the tax limit.
In Austria the population paying taxes and the population subject to social insurance contributions is more
or less the same because the system of statutory insurance includes all employees.
Social insurance contributions
Social insurance contributions are calculated based on the economic ability of the insured. The burden of
insurance contributions of income increases linear i.e. proportionally until a defined earnings limit for
chargeable contributions (every insured of a certain insurance fund pays the same contribution rate) is
reached. The earnings ceiling for chargeable contributions according to the General Social Insurance Act
(ASVG) was situated at 3,750 Euros per month in 2006.147 The insurance contributions of social insurance
funds vary due to historical developments and differing benefits packages of sickness funds.
Contribution rates for insured with an income above the earnings limit for chargeable contributions are
regressive, i.e. insured with a higher contribution base spend a smaller share of their total income on social
insurance contributions than insured whose contribution base is situated below or at the earnings limit for
chargeable contributions. Hence people with a higher income are less affected economically than those with
a lower income.
It is possible to deduct social insurance contributions from the base for income tax. Voluntary health
insurance payments may be set off tax liability as special expenses (up to a ceiling of 2,290.00 Euros per
year).148
User charges
Relative burden of different insured categories due to user charges is difficult to measure because of
heterogeneous regulations in the different laws related to social insurance. Furthermore varying exemption
criteria, benefits packages and reimbursement catalogues exacerbate objective comparison.
User charges have a regressive effect. They primarily affect the persons utilising health care services. A
study performed by the regional sickness fund in Carinthia shows that insured of the lower income
categories have higher average user charges than those in upper income categories.149 Moreover, women of
146
Mayrhuber, C. (2005). Aspects of tax burdens and tax equity in Austria. presentation at the opening event for the
ATTAC campaign "Fair Taxes – More for all" May 19
2005, accessed at:
http://www.beigewum.at/_TCgi_Images/beigewum/20050705084435_Text_fair-steuern-19_05_05_fin.pdf,
on
18/06/2006
147
Hauptverband der österreichischen Sozialversicherungsträger (2006). Social security data (contributions) in the
Austrian Social Insurance 2006, cut-off-date 1. January 2006, Version 13.02.2006
The limit was the same for the social insurance fund of the civil servants, of the railwaymen and miners and of the
self-employed. The sickness fund of the farmers has at limit of 4,375 €.
148
Information provided by the HFP Tax advisor Plc. 19 June 2006
149
fund of Carinthia.
51
each income category pay significantly higher user charges than men because they utilize medical services
more often. When looking at the relative share of their income (median gross income) spent on user
charges, women with the lowest level of education display about the double amount of women with the
highest level of education. For men this difference is roughly a fifth.150
In Austria there is a wide range of exemptions for user charges; these partially vary among the different
sickness funds. The directive of the Hauptverband which bases exemption from user charges on the need of
social protection is applicable to all insured.151 Equally the exemption by law is for persons suffering from
notifiable communicable diseases.
Redistribution: social insurance model and transfer payments
Austrian social insurance is funded by a pay-as-you-go system. Social insurance contributions of the
insured are not used to cover their personal demand for health care services but are immediately used for the
funding of insurance benefits of the insured population. No capital is accumulated apart from a certain
reserve. Insurance contributions are calculated based on the ability to pay of the insured person, not on his
personal risk or usage of services (vertical equity). This individual risk is distributed over the whole insured
population.
Within Social insurance redistribution is not only performed between generations152 (mainly in pension
insurance), between healthy and ill (primarily in health- and accident insurance) but also between insured
with high income and insured with low income. Especially benefits in kind are strongly redistributed in
favour of the poor insured.153 Insured receive benefits in kind independently of the height of their insurance
contributions (horizontal equity154) meaning that insured paying higher contributions pay relatively more for
services. Cash benefits are calculated on the basis of income because they are supposed to have an incomesubstitution effect in case of illness of the insured. Cash benefits are also limited to the earnings limit of
chargeable contributions.155 Further statistics on tax payments and income inequality are provided in
Appendix 3.
The Austrian Institute for Economic Research reported that redistribution in Austria is primarily achieved
by state expenditures (Staatsausgaben).156 State activities cause a considerable redistribution from the
higher income levels to the lower income levels. In the early 1990s taxes and public transfers reduced the
extent of inequality by 30%.157
In a study published in 2003 Biffl analysed among other topics the distribution of transfer payments.158 She
states that the distribution of transfer payments has shifted in favour of the low wage earners. Between 1983
and 1999 the share of social transfers supporting the lowest third of all income groups increased from
150
Hofmarcher, M., Röhrling, G. (2003). ″What are the effects of new user charges in Austria?.″ MIMEO, pp. 1-10
Individuals receiving income support (net income for single persons<690,00 €, for married or cohabitating couples
< 1.055,99 €), Recipients of income support in addition to a pension from pension insurance, recipients of a
supplementary allowance ( Ergänzungszulage), Persons who can provide evidence for above-average expenditures
related to disease or ailment and whose monthly net income does not surpass € 793,50 (singles) or € 1,214.39 for
married or cohabitating couples. For each child liable for support these sums are increased by € 72.32.
152
The so called generation contract
153
Tomandl, T. (2005). What you always wanted to know about Social Insurance. Vienna, Manz.
154
155
Brodil, W., Windisch-Graetz, M. (2005). Main features of Social Law. Vienna, WUV Universitätsverlag.
156
Guger et al. (1996). ″Distribution effect of public households.″, WIFO in Mayrhuber, C. (2005). Aspects of tax
burdens and tax equity in Austria. presentation at the opening event for the ATTAC campaign "Fair Taxes – More for
all" May 19 2005
157
Guger 1996 in Guger, A., Marterbauer, M. (2004). ″ The long term development of income distribution in Austria.″
WIFO,
pp.
254-276,
accessed
at
http://www.bmsg.gv.at/cms/site/attachments/9/2/3/CH0338/CMS1064227005975/12_einkommen.pdf, on 15.06.06, p.
274
158
Biffl G. (2004). Health and Employment Status. The Case of Austria. WIFO Working Papers 219, pp. 1-25
151
52
24.5% to 30.6%. The share of transfer payments benefiting the middle income groups has remained fairly
stable; the share for the higher income groups has experienced a significant decrease. In 1999 on average
about 33% of the household income of the total population resulted from transfer benefits.
Table 2.15 Development of income in Austria
Redistribution by the state (1991)
Lower
Gross income
Taxes & contributions
State expenditure
Health care
Eduction
12
9
29
28
16
Middle
Upper
third of income
(dependent households)
28
60
27
64
31
40
34
38
37
47
Sources: Marterbauer, M., Development of incomes in Austria, presentation given at the enquete „Income and sex:
strategies for more income equality in Austria, 11 July 2005, Renner Institute, Vienna, documentation of the enquete
accessible at: http://www.renner-institut.at/download/texte/einkommen_geschlecht.pdf, accessed 18/0672006
According to Marterbauer there is no recent data available on the redistributive function of the public
sector; the data is unsatisfactory. Table 2.15 displays the income and contributions of employed households
of the lower, middle and upper thirds of income. While individuals in the lower third of income contribute
12% to total national income, they pay only 9% of total income taxes. On the other hand, individuals in the
highest income group contribute 60% of national income and 64% of total income taxes. Thus, in general
every person pays proportionally to their income and wage tax and income tax are largely progressive.
The state does not redistribute by means of the state income but of the state expenditure. The lower third
pays 9% of all state income but receives 29% of all state expenditure. Redistribution is primarily achieved
by transfer payments of the state (social spending in health care). Income distribution in Austria depicts a
trend towards inequality. Redistribution towards lower levels should be pursued due to motives of equality,
for macroeconomic reasons and to encourage private consumption.159
159
Marterbauer, M., Einkommensentwicklung in Österreich, Vortrag im Rahmen der Enquete „Einkommen und
Geschlecht: Strategien für mehr Einkommensgerechtigkeit in Österreich, 11. Juli 2005, Renner Institut, Wien,
Dokumentation der Enquete abrufbar unter: http://www.renner-institut.at/download/texte/einkommen_geschlecht.pdf,
Zugriff am 18.06.06
53
3. ACCESS TO HEALTH CARE SERVICES
European governments are concerned with pursuing the efficient delivery of high quality health services to
the population and also ensuring these services are equitably distributed. Equitable access to health care, or
access based on need and not willingness or ability to pay, is an often stated goal of publicly-funded health
systems. The precondition of access to care is coverage by health insurance. Indeed, universal, or near
universal, coverage of the population by the statutory for a comprehensive basket of health services has
been achieved in all European countries. However, even when near universal coverage is achieved, there
still may be barriers to access that deter or prevent individuals from seeking care.
Access to care is also contingent upon financial factors, such as the degree of cost sharing in the system. In
much of Europe, many health care services are free at the point of use, and in those countries that do rely on
cost sharing arrangements, extensive protection mechanisms are in place in order to reduce or remove the
financial burden from those not, or less, able to pay.
Organizational factors such as waiting times, and geographical factors including the distribution of services
and individuals’ mobility also impact accessibility of health care. It is important also to recognize the role
of personal factors that influence an individuals’ propensity to seek health care. Among the personal factors
that may facilitate or hinder access to care include educational attainment, awareness of available services,
knowledge of and ability to articulate one’s symptoms, and cultural influences.
Knowledge limitations can affect some population groups where eligibility to receive health care requires
participation in an administrative procedure or some other form of conditionality. In Austria for example,
unemployed people may be unaware that coverage by the public system relates directly to their appearance
at a job centre, and failure to appear will lead also to a failure to be eligible to receive care. These types of
problem appear to be limited to health systems funded mainly by social health insurance, and in particular
to those where entitlement may be automatic but eligibility to receive care depends upon fulfilling certain
administrative requirements.
In light of the objective to ensure equity in access to health care, international organizations, national
governments and researchers have made efforts to measure the extent to which this is achieved. On the one
hand, research has focused on analysing the existence of barriers to access, in particular to identify whether
these barriers differ across population groups (geographical, ethnic, or, most commonly, socio-economic
groups), and on the other hand, researchers have attempted to measure the degree to which utilization of
health care services is based on need for health care. Regarding the latter, the extent to which equal
utilization for equal need is an appropriate definition of equity is debatable , however, it can be argued that
evidence of a disproportionate distribution of utilization favouring certain population groups, such as higher
income earners, indicates that the goal equity may be violated.
Using as a yardstick of equity the degree of inequality in utilization after standardizing for need differences,
studies have revealed that even among countries with universal coverage and largely publicly funded health
system, inequity exists. Specifically, while there is little evidence of inequity in GP visits in most countries,
or the distribution of GP visits is pro-poor, there is evidence of significant pro-rich inequity in use of
specialist care in most countries.160
160
C Masseria, X Koolman, and E van Doorslaer, "Income-Related Inequality in the Probability of a Hospital
Admission in Europe," (Ecuity Project 3: Working Paper No. 13, 2004), E van Doorslaer, X Koolman, and A
Jones, "Explaining Income-Related Inequalities in Doctor Utilization in Europe," Health Economics 13, no. 7
(2004), E van Doorslaer and C Masseria, "Income-Related Inequality in the Use of Medical Care in 21 OECD
Countries," (Paris: OECD, 2004).
54
3.1 Analysis of European Community Household Panel
This section will present results from an international comparison of horizontal equity: the degree of
inequality in use is measured by income, after standardising for (measurable) need differences. Inequity is
measured using concentration indices of need-standardized distributions for total doctor visits and
separately for general practitioner and medical specialist visits, inpatient care and dentist visits in 21 OECD
countries: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Hungary,
Ireland, Italy, Mexico, the Netherlands, Norway, Portugal, Sweden, Spain, Switzerland, the UK and the
USA.
Physician visits
There are important differences between countries in rates of doctor visits. On average, more than 70% of
the adult population visited a doctor in the last year; this proportion is lower in Greece (63%), the US
(68%), and especially in Mexico (21% only). The proportion visiting a GP is fairly stable at around 7080%, except in Greece and Switzerland, while there is much more variation in specialist visits. The
percentage of people visiting a specialist ranges from 20% in Ireland or 30% in Denmark and Norway to
60% in Austria and France. In high-use countries like Germany, Hungary, France, Belgium and Austria the
frequency of visits is around 7-8 doctors’ visits per year, which is twice the rate in low-use countries like
Finland, Switzerland, or Denmark. These cross-country differences in utilization rates are not correlated
with doctor/population ratios. However, differences in remuneration types and cultural differences in
seeking medical advice might partly contribute to these differences.
When considering within-country variations in use by income, in virtually every OECD country, lowincome groups are more intensive users of doctor services than higher income groups. The differences vary
by country but, on average, the bottom income quintiles report about 50% more doctor visits per year than
the top income quintiles.
However, the probability of doctor visits is higher among richer groups after standardizing for population
need (as indicated by positive HI161 index for most countries). The HI indices are significantly different
from zero (indicating inequality) in Finland, Italy, Netherlands, Norway, Portugal, and Sweden. No
violation of the horizontal equity principle (i.e. the HI is not significantly different from zero) is found in
Austria, Belgium, Denmark, France, Germany, Greece, Hungary, Ireland, Spain, and the UK. This means
that in about half of the countries studied, given the same need, the rich are more likely to see a doctor than
the poor. The level of income-related inequity in total number of doctor visits seems to be less pro-rich than
when the probability of a doctor visit is measured (Figure 3.1). Pro-rich inequity was found to be
statistically significant only in Finland, Portugal, Sweden and Austria, while the reverse is seen in Belgium
and Ireland (pro-poor).
The probability of contacting a GP is fairly equitably distributed by income, with a few pro-rich exceptions
(Finland, and Portugal). Pro-poor inequalities occur in countries where the access to a medical specialist is
direct (i.e. Greece, Spain and Germany where there is no gate-keeping systems). But, on the whole, the
likelihood of seeing a GP appears distributed according to need, and is not influenced by income.
The need-standardized distributions of total GP visits (Figure 3.1) are significantly pro-poor in ten
countries. In only one country, Finland there is pro-rich inequity (see further discussion of this result
below). Therefore, given that the probability of seeking GP care is equitably distributed, most of the propoor distributional pattern in mean visits must be due to the pro-poor conditional use. In almost every
OECD country, the probability of seeing a GP is fairly equally distributed across income, but once people
go, the poor are more likely to consult more often.
161
HI is defined as the difference between the degree of income-related inequality in actual health care use and the incomerelated inequality in need-expected use. Horizontal inequity is pro-rich and favours the better-off when the horizontal inequity
index, HI, is positive and pro-poor when negative.
55
The pattern is very different for specialist visits; in all countries, the better-off have a significant higher
probability of visiting a specialist. Although there are important differences between countries in the degree
to which this occurs, access to specialist services seems not equally distributed across income groups. In all
countries, controlling for need, the rich are more likely to seek specialist care than the poor, and especially,
but not only, in countries that offer options to seek private care like Finland, Portugal, Ireland, Italy and
Spain. Indeed, pro-rich inequity in specialist visits was observed also in countries without such private
options, and with GP gatekeepers, like Denmark, Norway, Sweden, and to a less extent also in the
Netherlands and the UK.
Figure 3.1 Horizontal inequity indices for annual probability of a doctor visit, 21 OECD countries
Horizontal Inequity indices
for annual probability of a visit
0.14
0.12
0.10
0.08
0.06
0.04
0.02
0.00
-0.02
doc vis
GP vis
U
S
It
al
y
N
or
w
ay
Ca
na
d
Sw a
ed
en
Po
rt
ug
al
Fi
nl
an
d
M
ex
ic
o
U
Au K
st
ra
lia
Sp
ai
n
G
re
ec
e
H
un
ga
ry
Au
st
ria
Fr
an
ce
G
er
m
N
a
et
he ny
rla
nd
s
Ir
el
an
d
D
en
m
ar
Be k
l
Sw giu
itz m
er
la
nd
-0.04
spec vis
Notes: Countries ranked by HI for doctor visits. HI indices are estimated concentration indices for need-standardized
use. Positive (negative) index indicates pro-rich (pro-poor) distribution.
Source: Van Doorslaer, Masseria, and Koolman 2005.
The level of pro-rich inequity is even higher when the total number of specialist visits is measured.
Therefore, in this case, the conditional use reinforces the pro-rich patterns induced by the inequitable
probability distribution. In virtually all countries, distributions are significantly in favour of the higher
income groups. The only exceptions are Norway, the Netherlands and the UK, where the HI indices are
positive but not significantly different from zero.
56
Figure 3.2 Horizontal inequity indices for annual mean number of visits, 19 OECD countries
H or iz onta l Ine quity indic es
f or annua l number o f v is its
0 .2 5
0 .2 0
0 .1 5
0 .1 0
0 .0 5
0 .0 0
-0 .0 5
do c vis
GP vis
U
Po S
rt
ug
al
Fin
la
nd
an
ce
Au
st
r ia
Sw
ed
en
Fr
It
a
D e ly
nm
ar
k
Ca
na
da
Gr
ee
ce
N
or
w
ay
Ge
rm
an
y
Sp
a
itz in
er
la
nd
H
un
ga
ry
Sw
Ne
th
er
la
nd
s
nd
gi
um
Be
l
U
Ir
el
a
K
-0 .1 0
sp ec vis
Notes: Countries ranked by HI index for doctor visits. HI indices are estimated concentration indices for needstandardized use. Positive (negative) index indicates pro-rich (pro-poor) distribution. German GP and specialist indices
for ECHP 1996.
Inpatient care
The probability of being admitted to hospital varies across OECD countries and in Europe it ranges from
5% in Greece to 14% in Austria (Van Doorslaer et al. 2004). Distributional patterns are different for the
number of nights spent in hospitals; among the European countries those with the lowest average numbers
of nights spent in hospitals are Portugal (0.63) and Greece (0.66), while those with the largest are Hungary
(2.5) and Austria (2.01).
People at the bottom end of the income distribution are more likely to be admitted to hospitals in almost all
OECD countries and to spend more nights in hospitals. Unfortunately data on the number of separate
admissions are not included in this survey.
The picture is more heterogeneous after standardizing for population’s needs (i.e. inequity) (Figure 3.3). For
the majority of countries it was impossible to detect any inequity both in the probability and the total
number of nights spent in hospitals. This might be due to the very skewed distributions of hospitals care
(i.e. many people did not go to hospitals) and the difficulty of explaining length of stay with the information
available in these surveys. Significant inequality was found only for the countries with large sample sizes.
Individuals with higher income were more likely to be admitted to hospitals in Mexico and Portugal. On the
contrary, pro-poor inequity was found in Australia, Canada, Switzerland and the USA.
Different results have been found by Masseria, van Doorslaer and Koolman (2004) by pooling several
waves of the European Community Household panel Survey (from 1994 to 1998) for 12 European
countries: Austria, Belgium, Denmark, Italy, France, Germany, Greece, Ireland, the Netherlands, Portugal,
57
Spain, and the UK.162 In almost all these countries, the index of horizontal inequity for the probability of
hospital admission is positive, indicating income-related inequity in favour of the better-off. The level of
inequity is particularly large in Portugal, Greece, Italy, Austria, and Ireland. All these countries, except
Austria, offer hospital physicians some way to practise privately alongside the public sector. Belgium is the
only country with a negative and statistically significant index, indicating horizontal inequity favouring the
poor. This analysis does not separate elective from emergency surgery, which may have different levels of
inequity.
Figure 3.3 Horizontal inequity index for the probability of hospital admission in 12 European
countries (1994-1998)
0.12
0.10
0.08
0.06
0.04
0.02
0.00
-0.02
BE
NL
UK
DK
ES
FR
DE
IE
IT
AT
EL
PT
-0.04
-0.06
Source: European Community Household Panel
Understanding the sources of inequity
Education is an important socioeconomic factor that is related to both income and health. Indeed,
differences in medical care use by level of education often reflect the utilization patterns by income. The
higher educated, ceteris paribus, are more inclined to visit specialists almost everywhere and particularly so
in Hungary where the contribution163 of education to the pro-rich inequity in specialist visits is larger than
the contribution of income (Figure 3.4). The picture is less clear-cut with respect to GP visits, total doctor
visits and hospital care use; contributions are smaller, and most often negative. This means that education
appears to be a more important cause of inequality in specialist care than in other health care services.
162
Finland was excluded because data were available only for two years; for Austria data were available only from the second
year (1995); for Germany and the UK comparable data were available only for the first three years
163
The contribution of each variable to total inequality in specialist visits depends on three factors: (1) the importance of this
variable (as indicated by its mean), (2) the extent to which it is distributed across income (as indicated by its concentration index
value), and (3) the (marginal) effect of this variable on the number of specialist visits (as indicated by the regression coefficient). A
positive (negative) contribution increases (decreases) the overall level of inequity. For example, in Hungary the contribution of
education is 0.03, and this means that the inequality in specialist use is 0.03 higher than it would have been if education did not
have an effect on use.
58
Figure 3.4 Contribution of socio-economic factors to the overall level of inequity in specialist visits in
Europe
US
UK
Switzerland
Sweden
Spain
Portugal
Norway
Netherlands
Income
Education
Activity status
Region
Insurance
CMU/mcard
urban
Mexico
Italy
Ireland
Hungary
Greece
Germany
France
Finland
Denmark
Canada
Belgium
Austria
Australia
-0.03
0.00
0.03
0.06
0.09
0.12
contribution to inequity
Differences in employment status might also affect access to medical care, for example by impacting the
time costs of using the health system. Ceteris paribus, not being in paid employment seems to influence the
degree to which utilization patterns vary by income, and its contribution is generally negative. Individuals
receiving a retirement or a disability pension, holding everything else constant (e.g. self-reported health and
age), have lower incomes and are less healthy than their working counterparts. Activity status might,
therefore, operate as (imperfect) need proxies. However, the difference between needed use and actual use
distributions might be driven by the different time costs that people out of work face in comparison with
their counterparts.
The impact of activity status on inequalities varies across countries. In Denmark and Hungary, the pro-poor
contribution to inequity of employment status is driven by the retired; the (early) retired in these countries
are worse off than those in the same age category who continue working, and also seek more medical care.
In Finland, the pro-rich inequity in GP care is caused by the higher utilization rates of employed versus nonemployed; and this is partly due to the inclusion of occupation-based health visits164, among general
primary health care. To understand and interpret the contributions of education and activity status across the
countries, a thorough understanding of health care policies, and also labour markets and social policies in
each of the countries is necessary.
The results of the decomposition analysis for Austria are the following. For GP visits, the only positive
contribution to the level of inequity is from income, whereas the remaining factors (age, health status,
education and employment) contribute negatively, thus lowering the level of pro-rich inequity. The main
contributors to the pro-rich inequity in specialist care are income and education, with health status and age
164
A more meaningful disaggregation of doctor visits in Finland by sector reveals a high degree of pro-rich inequity for
occupational care and private visits, a very low degree of pro-rich inequity in outpatient care visits and a pro-poor
distribution of health centre contacts (Unto Häkkinen, personal communication).
59
contributing negatively, and no significant contribution from activity status. Finally for hospital care, the
only positive contribution to inequity is income, the remainder exerting a negative influence on equity.
3.2 Analysis of SHARE survey – equity in use of services among over 50 population in Europe
Using a new survey – Survey on Healthy Ageing and Retirement in Europe – perceived barriers to access,
waiting times, and income-related inequality in use of physician and hospital services was investigated
among the over 50 population in ten European countries, including Austria.
Measurement of annual physician and inpatient utilization was based on the following questions:
•
•
•
•
Have you visited or talked to a ‘medical doctor’ about your health in the past 12 months?
How many of these contacts were with a general practitioner or with a doctor at your health care
center?
During the last twelve months, have you consulted any of the specialists mentioned on card 12165?
During the last twelve months, have you been in a hospital overnight? Please consider stays in
medical, surgical, psychiatric or in any other specialized wards.
Table 3.1 outlines the frequency of health care use among the populations studied. On average the vast
majority of the population in each country had reported a visit to a physician, ranging from 78% in Sweden
to over 90% in France and Germany; a broader range is seen with just GP visits, from 65-66% in Greece
and Sweden to about 89% in France. Regarding specialist visits, the probability of a visit ranged from 20%
in Denmark to 57% in Germany. Therefore, it appears individuals are making relatively more use of
physician services in France and Germany with lower rates in Sweden and Greece.
The proportion of the population reporting an inpatient stay of at least one night is considerably lower,
ranging from about 9% of the population in Greece and the Netherlands, to 20% in Austria.
If the overall use of health care –medical visits and inpatient admission – is taken into consideration, it
appears that some countries such as the Netherlands and Greece use proportionally less health care than
others whereas France and Germany have the highest users of health services.
Table 3.1 Sample sizes and proportion of the population reporting health care visits
Country
% reporting % reporting % reporting
% reporting
any medical GP visit
specialist visit inpatient stay
visit
(at least one
night)
Austria
85.74
81.27
39.40
19.99
France
93.58
89.02
49.16
15.07
Denmark
81.48
78.41
20.65
12.62
Germany
92.59
85.94
57.06
15.98
Greece
79.66
65.01
36.99
8.76
Italy
83.77
78.23
43.59
12.46
Netherlands 81.26
75.43
40.91
9.11
Spain
88.87
83.78
45.08
11.22
Sweden
77.58
65.70
36.01
11.81
Switzerland
84.53
76.63
35.89
11.79
Source: Survey of Healthy Ageing and Retirement in Europe
165
Card 12 includes the following specialists: specialist for heart disease, pulmonary, gastroenterology, diabetes or
endocrine diseases; dermatologist; neurologist; opthalmologist; ear, nose and throat specialist; rheumatologist or
physiatrist; orthopaedist; surgeon; psychiatrist; gynaecologist; urologist; oncologist; and geriatrician.
60
Small barriers to access health care for older people are evident everywhere. More than 3% of the survey
respondents declared to forgo health care either because of costs or because services were unavailable
(Table 3.2). The proportion of individuals declaring to forgo care is more than 6% in Italy, France,
Germany and Sweden and reaches over 10% in Greece. Although it was impossible to identify an age
pattern, in almost all countries people with worse health status were more likely to forgo health care (Figure
3.5).
Table 3.2 Percentage of people who declared to forgo health care
Country
Forgo
Forgo
Total
because of
because care
percentage
costs
unavailable
declared to
forgo
Austria
2.89
0.74
3.63
Denmark
1.44
1.88
3.32
France
6.18
2.28
8.46
Germany
5.42
1.47
6.89
Greece
5.64
4.87
10.51
Italy
5.10
3.48
8.58
Netherlands
2.01
0.53
2.54
Spain
3.02
1.86
4.88
Sweden
2.83
3.33
6.16
Switzerland
3.68
0.74
4.42
Cost-sharing may be a major barrier for accessing health care. Figure 3.6 depicts the proportion of people
who declared they had to pay part of the inpatient costs, and if they had to pay more than 100 Euros. In
Sweden, almost all citizens had to pay partly of inpatient costs (98.5%), although only 25% had to pay more
than 100 euros. Cost-sharing is also widely used for rationing health care use in Switzerland, Germany,
Austria and Greece (and in Greece informal payments represent the highest proportion of personal costs).
Figure 3.5 Proportion of people who declared to forgo health care by self- assessed health
30
25
very good
good
fair
very poor
poor
20
15
10
5
i tz
er
la
nd
Sw
Sp
ai
n
ed
en
Sw
N
et
he
rl a
nd
s
Ita
ly
re
ec
e
G
an
y
er
m
G
en
m
ar
k
D
Fr
an
ce
Au
st
ria
0
61
Figure 3.6 Proportion of people who paid part of the costs of inpatient care
120
cost-sharing
yes > 100 euros
100
80
60
40
20
nd
n
er
la
it z
Sw
ai
n
Sp
ed
e
Sw
N
et
he
r
la
nd
s
It a
ly
ce
G
re
e
m
an
y
G
er
D
en
m
ar
k
e
nc
Fr
a
Au
st
ri a
0
Are higher income individuals more likely to have had contact with a physician or hospital than lower
income individuals, once need (as measured by multiple health status indicators) is standardized for?166
It appears that the there is significantly pro-rich income-related inequity in the probability of doctor visit in
Italy, Germany, Austria, the Netherlands, Sweden and Switzerland (See Figure 3.7). When examining GP
and specialist visits separately, some important differences are revealed. The analysis of GP visits reveals
little evidence of inequity; after standardizing for differences in need, there is evidence of pro-rich incomerelated inequity in Netherlands, Italy, Sweden and Switzerland but no significant inequity in the remaining
countries (See Figure 3.8).
The results are quite different when looking at specialist visits. In all countries but the Netherlands we
found statistically significant pro-rich inequity in the likelihood of contacting a specialist (See Figure 3.9).
Regarding inpatient care, in almost all countries, the index of horizontal inequity, defined as the difference
between the distributions of use and need, shows little violation of equity (see Figure 3.10). However, the
distribution of inpatient visit probability is significantly pro-rich in Greece and Switzerland. Unfortunately
data on the number of separate hospital admissions is not available.
166
For any physician visit, GP, specialist, and inpatient care, we modeled the probability of a visit using multivariate logistic
regression on the full set of explanatory variables. In order to achieve horizontal equity in inpatient care, resources ought to be
allocated according to needs, irrespective of personal characteristics unrelated to needs, such as income, wealth, and education (Van
Doorslaer, Wagstaff and Rutten, 1993).The level of horizontal inequity in the access to health care was calculated according to
methodology developed by Wagstaff and van Doorslaer and the focus is mainly on income-related inequity although the results of
the other two indexes are also described. The horizontal inequity index is defined as the difference between the degree of incomerelated inequality in actual health care use and the income-related inequality in need-expected use. The latter is obtained as the
predicted admission probabilities from a regression on need indicators. A zero inequity index implies that, after controlling for
differences in need across income groups, all individuals have equal probability of using health services, regardless of income.
After adjusting for need, when service use is more concentrated among the better-off, the horizontal inequity index is positive, and a
negative index indicates pro-poor inequity. The former implies that individuals on higher income are more like to visit a physician
than one would expect on the basis of their reported need.
62
Figure 3.7 Income-related inequity in probability of any physician visit in the over 50 population
0.05
0.04
0.03
0.02
0.01
nd
n
Sw
it z
Sw
er
la
ed
e
s
N
Au
et
he
rla
nd
st
ri a
an
y
G
er
m
It a
ly
e
ec
en
m
G
re
ar
k
e
nc
D
-0.01
Fr
a
Sp
ai
n
0
-0.02
Figure 3.8 Income-related inequity in probability of GP visit in the over 50 population
0.04
0.03
0.02
0.01
nd
n
er
la
it z
Sw
It a
ly
ed
e
Sw
N
et
he
r
la
nd
s
st
ri a
Au
m
an
y
G
er
D
en
m
ar
k
nc
e
Fr
a
Sp
-0.01
ai
n
0
-0.02
-0.03
63
Figure 3.9 Income-related inequity in probability of a specialist visit in the over 50 population
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
Sw
k
D
en
m
ar
nd
it z
er
la
It a
ly
e
nc
Fr
a
m
an
y
G
er
n
ed
e
Sw
st
ri a
Au
N
et
he
r
Sp
la
nd
s
-0.02
ai
n
0
Figure 3.10 Income-related inequity in probability of an inpatient stay in the over 50 population
0.25
0.2
0.15
0.1
0.05
itz
G
re
ec
e
er
la
nd
k
ar
en
m
D
ed
en
Sw
Sp
ai
n
an
y
Ita
ly
a
Au
st
ri
G
er
m
Sw
-0.1
N
et
he
rla
nd
s
Fr
a
-0.05
nc
e
0
In summary, there is evidence of pro-rich inequity in the probability of visiting a GP in the Netherlands,
Italy, Sweden and Switzerland; for specialist visit in all countries but the Netherlands and for inpatient care
in Greece and Switzerland. While some of the inequity may be explained by differences in waiting times,
cost sharing arrangements and accessibility of voluntary health insurance, it is important to further
investigate the potential contributors of inequality in health care use among older people in Europe.
Comparing the results of equity analyses using two different surveys and different age groups reveal broad
similarities. In Austria, the probability of visiting any doctor, and specifically a specialist is pro-rich in both
studies, whereas there is no inequity for GP visits. The difference is seen in hospital visits, where the
probability of admission appears to be pro-rich using pooled European Community Household Survey data,
while there is no inequity found using the Survey of Healthy Ageing and Retirement in Europe. This
difference could be a result of the significantly smaller sample size in SHARE. Both surveys did reveal high
64
utilization rates for hospital care, with both studies showing Austria with the highest proportion of the
sample reporting at least one night in hospital.
3.3 Access to care and cost sharing
One possible explanation for the presence of inequity in some countries could be the cost sharing
arrangements. The income-related inequity that is seen in physician care could arise from either user
charges for physician visits, or even from cost sharing with pharmaceuticals. User charges for physician
visits are present in Austria, France, Greece, Italy, Sweden and Switzerland. In Sweden, the median user
charge for physician visit is around 100 SEK, with an out-of-pocket maximum of 900 SEK per year
including both physician and inpatient user charges.167
Indeed, the countries that impose cost-sharing for physician visits are also those with the highest levels of
pro-rich inequity. In addition to formal cost sharing, informal payments are quite prevalent in Greece,
which may be playing a part in explaining the income-related inequity found for physician visits in that
country. The combination of formal and informal payments for health care services may be the reason
behind the relatively high proportion of individuals reporting to have foregone health care because of costs
(over 6%) in particular among those with poor or very poor health conditions.
Costs for pharmaceuticals may also deter individuals from seeking physician care because of the ‘bundling’
of physician services with prescription drugs in some countries.168 In Austria and Germany there is a flat copayment per item (between €4 and €5) for which pensioners on income subsidies and individuals on social
assistance are exempt in Austria, and general ceilings are offered in Germany. Co-insurance for
pharmaceuticals is used in Denmark, France and Greece, although there are various protection mechanisms
in place such as reduced rates are given for individuals suffering from chronic conditions.169 In Italy and
Spain, individuals over aged 60 (65 in Spain) are exempt from co-payment and co-insurance payments for
pharmaceuticals. In Sweden, individuals must bear the full financial burden of prescription drug costs
although the maximum amount that must be paid in full is 900 SEK, and for costs between 900 and 1800
SEK, the costs are partially subsidised (except for insulin for diabetes, which is never charged).
It is less likely that user charges would deter individuals from seeking inpatient care, although it is possible,
in particular for elective surgery. In Austria and Germany, there is a co-payment per day around €8-9, with
exemptions after 14 days in Germany and 28 days in Austria170. In Sweden there is a co-payment of 80 SEK
per night (about €8.5) (up to the maximum of 900 SEK combined including physician user charges).
However, inequity in inpatient care was not found in the countries that impose charges for inpatient
services.
3.4 Access to care and voluntary health insurance
Another factor impacting the potential financial barriers to access is whether or not the individual is covered
by VHI that may allow faster access to care, or access to better quality services. Barriers to access to
supplementary VHI are high. In all supplementary VHI systems access is on the basis of willingness and
ability to pay, and pricing is on the basis of risk factors such as gender and age. Moreover, cover is usually
not extended to pre-existing conditions. Because primary cover is provided by the public system (or by
167
C.H Tuohy, C.M. Flood, and M Stabile, "How Does Private Finance Affect Public Health Care Systems?
Marshaling the Evidence from OECD Nations," J Health Polit Policy Law 29, no. 3 (2004).
169
170
Ibid.
168
65
substitutive VHI where it exists) governments have not sought to intervene in markets for supplementary
VHI to facilitate access for those unable to pay (the poor and those at high risk of incurring a loss).
In the case of France, complementary VHI covers the costs of co-payments.
The finding from the analysis of SHARE data that individuals who were covered by VHI in France were
almost four times as likely to have visited a physician in the past year could be explained in part by the
removal of a financial barrier for these people.
In the case of Germany, higher income earners (with annual incomes over €40,000) are permitted to opt-out
of the statutory health insurance system and to purchase substitutive VHI (and in general about 7% of the
population do opt out, representing less than a quarter of those who are eligible).171
The finding that individuals with VHI were significantly more likely to have visited a specialist or had an
inpatient stay may be a reflection of the better access afforded to individuals with private alternatives to the
public system.
3.5 Access to care for asylum seekers, refugees and illegal immigrants
As legal residents in most countries, asylum seekers and refugees have publicly-financed access to health
care, although not necessarily within the general public system. The Treaty of Amsterdam of 1999 assigned
competence for asylum and migration policy to the European Community; and following, the 2003 Council
Directive “Laying Down Minimum Standards for the Reception of Asylum Seekers” was passed. This
attempts to harmonize conditions for asylum seekers in schooling, employment and health care, such that
applicants shall “receive the necessary health care which shall include, at least, emergency care and
essential treatment of illness”. Therefore, beyond emergency care there is variation across Member States in
access to other forms of care.172
On the other hand, illegal immigrants are covered in some countries, but not in others. In those where they
are covered they may nevertheless fail to seek or to access care; in those where they are not covered, they
may be able to gain de facto access to care within the public system or through informal, charitable
provision. They will also be able to access emergency care and, in some countries, care for certain named
conditions (for example, infectious diseases).173
In England the entitlement rules that apply to persons ordinarily resident apply equally to asylum seekers
and to those with refugee status (asylum seekers who have been successful in their application). They also
apply to asylum seekers who are in the process of appealing a negative decision on their application to
remain in the country. Thus asylum seekers receive free NHS treatment and are subject to the same
statutory charges and conditions for exemption from charge as persons ordinarily resident. Failed asylum
seekers awaiting deportation from the UK and other illegal immigrants are not eligible for free NHS
treatment, and are subject to the regulations governing overseas visitors’ access to NHS care.
Asylum seekers in Austria are included in the statutory health insurance scheme if they receive no health
cover under other legal provisions, and their contributions are paid by the Federal Government. About 4.5%
of asylum seekers remain without health care cover, which may largely be attributed to the administrative
barriers relating to entitlement, specifically that require asylum seekers to be assigned residence in a federal
state before leaving the reception centre, and to remain there, otherwise cover will be forfeited.174
171
Mossialos and Thomson, Voluntary Health Insurance in the European Union.
T Foubister and M Worz, "Access to Health Care: Illegal Immigrants and Asylum Seekers," Euro Observer 8, no. 2
(2006).
173
Ibid.
174
M Norredam, A Mygind, and A Krasnik, "Access to Health Care for Asylum Seekers in the European Union: A
Comparative Study of Country Policies," European Journal of Public Health 16, no. 3 (2006).
172
66
In Germany, asylum seekers are not insured through the public coverage system but are covered instead
through a separate scheme for asylum seekers. Illegal immigrants, by law, have the same access rights as
asylum seekers, but in practice fail to exercise these rights for fear of disclosure of their status – they are
forced to rely, therefore, on informal provision.
In Belgium, illegal immigrants, in contrast, have no coverage and only have access to emergency care.
Ireland provides cover for asylum seekers as Category 1 (i.e. low income) medical card holders, but barriers
to access nevertheless remain. Italy provides cover for asylum seekers through the NHS. Cover is extended
to illegal immigrants during pregnancy and for six months after the birth of the child. In Italy illegal
immigrants are also entitled to emergency care and to care for a list of named services.
3.6 Geographical access to care
Availability of health care resources is a prerequisite for achieving equal access across the population.
There is no clear pattern between western and CEE countries in the number of hospitals and hospital beds
per 100,000 inhabitants (Table 3.3). The number of hospitals per 100,000 ranges from 0.9 in Sweden to
16.7 in Cyprus, and the number of beds from 255 in Turkey to 892 in Germany. The number of hospitals
and hospital beds are larger among the new Member States than in the EU-15, consistent with the literature
indicating an oversupply of health care resources in this region.
In addition to limited supply of health care resources, geographical distance to hospital might be a barrier in
fulfilling the goal of universal access to health care. In the EU-15 more than 50% of citizens live close to
hospitals (the distance can be covered in less than 20 minutes either by car, public transport or foot). The
proportion lowers somewhat for the new Member States and three Candidate Countries, where 38% of
citizens have easy access to hospitals175. Citizens of the EU-15 are more likely to reach hospitals by using
either their cars or public transport, whereas in the new Member States and candidate countries it is more
common to bridge distances by foot.
Table 3.3 Number of hospital and hospital beds per 100 000 inhabitants in Europe in 2003 or the
latest available year
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Luxembourg
Netherlands
Portugal
Spain
Sweden
UK
Cyprus
Hospital beds per 100 000
Hospitals per 100 000
834.1
699.0
413.4
724.9
780.1
892.7
471.7
351.5
411.8
676.7
457.7
363.7
360.6
522.0
421.8
436.3
3.4
2.2
1.3
7.3
5.3
4.4
3.1
2.5
2.2
8.4
1.2
2.1
1.9
0.9
2.7
16.7
175
J Alber and U Kohler, "Quality of Life in Europe," (Dublin: Health and care in an enlarged Europe European
Foundation for the Improvement of Living and Working Conditions, 2004).
67
Czech Republic
Estonia
Hungary
Lithuania
Latvia
Malta
Poland
Slovakia
Slovenia
Bulgaria
Romania
Turkey
EU-15
NMC
CC3
855.5
595.3
783.5
868.2
781.4
482.2
557.1
732.3
495.6
628.5
656.5
255.7
558.8
658.7
513.6
3.6
3.7
1.8
5.6
5.6
2.5
2.2
2.6
1.4
3.8
1.9
1.7
3.3
4.6
2.5
Source: WHO Health for All 2005
When surveyed, it appeared that easy access to primary care is secured for 85% of the EU-15 citizens but
only for 62% of the citizens in new Member States and candidate countries. In the EU-15 only in Portugal
and Spain more than 30% of the respondents reported to travel more than 20 minutes to reach a primary
care facility. In the new Member States and three Candidate Countries the countries with a smaller
percentage of citizens that report easy access (< 40%) are Estonia, Turkey, Lithuania and Latvia.176
One wave of the Eurobarometer, a survey with the intention to monitor public opinion in the European
Union, asked questions on geographical proximity to health care providers. Figure 3.11 depicts the
percentages of the population in the selected European countries who answer that they have access to a
hospital in less than 20 minutes.177 Whereas ca. 70% of the population in the Netherlands has access to a
hospital within less than 20 minutes only ca. 30% of the population in Hungary has. Overall there seems to
be a relation between more people having access to a hospital and population density. Regarding GP access,
a large majority of the population in selected countries has access to a GP within 20 minutes (Figure 3.12).
176
Ibid.
Moreover Alber & Kohler (2004) provide data for the percentages of the population who lives within walking
distance of both hospitals and GPs and also data on rural/urban differences for these two categories, however, only for
the newly accessed countries and the Candidate Countries (Bulgaria, Romania and Turkey) – we do not show these
data here.
177
68
Figure 3.11 Percentage of respondents who report having access to a hospital in less than 20 minutes
Austria
Belgium
France
Germany
Hungary
Ireland
Italy
Poland
the Netherlands
United Kingdom
10 New Member States
EU 15
0
10
20
30
40
50
60
70
80
Source: Eurobarometer EB 51.1, Candidate Countries Eurobarometer 2002.1
Figure 3.12 Percentage of respondents who report having access to a GP in less than 20 minutes
Austria
Belgium
France
Germany
Hungary
Ireland
Italy
Poland
the Netherlands
United Kingdom
EU 15
0
10
20
30
40
50
60
70
80
90
100
Source: Eurobarometer EB 51.1, Candidate Countries Eurobarometer 2002.1
To achieve equal access to health care, proximity to hospital or primary care should not depend on
individual socioeconomic characteristics such as income and economic activity. However, in some
countries people with a higher income report easier access to hospitals (Figure 3.13). The accessibility gap
in the EU-15 between the highest and lowest income quartile is higher than 20% in Belgium, France, Italy,
69
Portugal and the UK; in the new Member States only Czech Republic, Slovenia, Estonia, Lithuania, and
Latvia the difference is less than 20%, but in Hungary and Slovakia is even larger than 30%. Lighter blue
bars signify new member states, dark blue bars represent the original 15 EU member states, and orange
signifies acceding/candidate countries: Bulgaria, Romania and Turkey.
It appears that in Austria the lowest income groups are more proximate to GPs, however, the reverse is seen
in most other countries (Figure 3.14).
35
30
25
20
15
10
5
IT
M
T
TR
HU
SK
PT
UK
PL
BE
CY
RO
FR
EE
SL
LV
BG
FI
IE
EL
DE
NL
SI
AT
ES
0
LU
DK
LT
CZ
Difference between lowest and
highest quintile
Figure 3.13 Difference between the lowest and highest income quintile in perceived distance to
hospital
Source: Eurobarometer 2002
For proximity to general practitioners the level of income-related inequalities is lower in all countries. The
average difference between the lowest and highest income quartile is 2.7% in the EU-15, and 11.9% in the
new Member States; but large heterogeneity is observed across the EU-15 countries (Figure 19). Individuals
with lower income have significantly easier access in Austria (17.9% difference favouring lower income
groups), but the reverse is true in Greece (14.9), Finland (14.4), Belgium (13.4%), and the UK (12.3). In the
new Member States and the three Candidate Countries, people with higher income live closer to a doctor, in
particular in Cyprus (21.2%), Hungary (15.5%), Slovakia (14.6%), and Poland (12.9%).
Figure 3.14 Difference between the lowest and highest income quintile in perceived distance to GP
20
15
10
5
FI
SK
EL
HU
CY
LT
UK
PL
BE
TR
SI
SE
RO
LV
IT
CZ
M
T
IE
NL
DK
EE
PT
BG
FR
-5
LU
DE
0
AT
ES
Difference between lowest and
highest quintile
25
-10
-15
-20
Source: Eurobarometer 2002
70
3.7 Barriers to access health services in Austria
3.7.1 Financial barriers
Few empirical studies on this topic exist in Austria. The most important ones are a study performed by the
OEBIG (Rosian et al. 2003), a study undertaken by the regional sickness fund of Carinthia in 2004 (Wurzer,
Robnig and Rodler 2004) and various publications of the Institute of Advanced Studies. Other authors
publishing articles related to user charges (and their effects) are Reichmann and Sommersguter-Reichmann
(2004) as well as Streissler (2003). Further contributions to the topic can be found in the journal of Austrian
social insurance, Soziale Sicherheit.
It is difficult to measure the relative burden which user charges represent for the insured because regulations
in the different social insurance laws are very heterogeneous. In addition benefit packages and exemptions
may vary due to provisions in the sickness funds’ statutes making comparisons even more difficult. An
essential requirement for any researcher is to describe the data base used in an empirical study as well as
clarifying the definition of user charges employed. Furthermore to state which data is used, (i.e. insured
including or excluding dependants). Multiple insured ought to be adjusted for178 and the structure of the
insured population (compulsory insured, unemployed, voluntary insured) as well as the age distribution
amongst the population analysed should be taken into consideration.
A study by Hofmarcher and Röhrling179 looks at the different burden of the following groups of insured due
to user charges (prescription charges, medical treatment by office-based physicians and ambulatory care):
ASVG insured, B-KUVG insured, insured of the Insurance fund of the Austrian Railway Industry as well as
of the Social Insurance Authority for Business (self-employed). The last three groups of insured pay a
percentage of treatment costs (usually about 20-30% of the contractual fee) when consulting a physician
instead of a quarterly charge– at the time of the study – which was recently changed to a yearly servicecharge for the e-card.
Figure 3.15 Changes in co-insurance 1988-2001
Source: Hofmarcher, M., Röhrling, G. (2003). Cost sharing in the EU health care systems: Austria, study
commissioned by the EC and the London School of Economics, LSE Health.
For the time span analysed the burden for insured according to the ASVG was significantly lower than that
of the insured paying a co-payment (percentage of treatment costs). In 2001 the average insured with the
ASVG paid €66.2 whereas other insured paid an average of about €153.8. During the period analysed the
178
About 500.000 people in Austria are insured at two sickness funds at the same time (Information of the
Hauptverband der österreichischen Sozialversicherungsträger, HVB on 18/04/2006)
179
Hofmarcher, M., Röhrling, G. (2003). Cost sharing in the EU health care systems: Austria, Study commissioned by
the EC and the London School of Economics, LSE Health.
71
average amount of user charges of ASVG insured more than doubled, the average user charges of the
insured with a co-payment however increased only by about 50%. This was due to the introduction of the
fee for the health insurance voucher as well as the fee for treatment in a hospital’s outpatient department
(the first has in the mean time been replaced by a yearly service charge for the e-card and the second has
been abolished).
The balance sheet of the health insurance funds for the year 2004 displays the following revenues, titled
“fees, co-payments for treatment and share of costs” (Gebühren, Behandlungsbeiträge und Kostenteile) in
million Euros (Table 3.4).
Table 3.4 User charges in Social Insurance (exemplary) 2004 – in million Euros
All
sickness Prescription
Fee for
Co-payments Share
funds
charges
insurance
for medical costs
voucher
treatment
Revenue in
million Euros
512.3
335.2
45.7
79.5
51.9
%
100%
65.43%
8.91%
15.52%
10.14%
of
Source: Hauptverband der österreichischen Sozialversicherungsträger, HVB
It is important to note that user charges in the above table only represent a fraction of the actual user charges
paid by patients, especially for the insured of the regional sickness funds. Apart from these numerous
indirect user charges exist (user charges for services i.e. benefits which are not reimbursed by social health
insurance) and do not figure in the balance sheets of social health insurance funds. These include some
dental services, drugs with a price below the prescription charge or many alternative medicines or
homoeopathic treatments.
The average user charge for each insured (incl. dependants) is given in the table below (structured based on
the positions of the balance sheet).
Table 3.5 User charges per insured (including dependants)
Average user
Total
Prescription Fee for
charges per
charges
insurance
beneficiary
voucher
Sickness fund
CoShare
payments
costs
for medical
treatment
WGKK
53,77
45,78
7,98
0
0
NÖGKK
53,22
46,21
7,01
0
0
BGKK
54,35
48,20
6,15
0
0
OÖGKK
40,82
33,87
6,95
0
0
STGKK
44,69
37,58
7,11
0
0
KGKK
42,17
35,42
6,75
0
0
SGKK
40,85
33,67
7,19
0
0
TGKK
46,53
38,74
7,79
0
0
VGKK
40,64
33,84
6,80
0
0
BKKs
75,40
70,47
4,93
0
0
VAEB
74,65
71,27
3,39
0
0
VAE
124,87
56,88
0
68,00
0
BVA
137,90
47,45
0
90,45
0
of
72
SVAGW
100,00
29,84
0
0
70,16
SVB
67,26
36,71
0
0
30,56
F= highest value, F = second highest value, F = third highest value
Sources: User charges: Hauptverband der österreichischen Sozialversicherungsträger, HVB
Beneficiaries: Database of beneficiaries of the Hauptverband, insurance relationships (Versicherungsverhältnisse),
yearly average 2004
Even though these average values may be interesting it would in order to be able to perform an objective
comparison, be necessary to complement the user charges of the dependants (at least adding direct user
charges for dental prosthesis or hospital care). Furthermore to adjust for the multiple insured and the age
structure of the respective funds. Equally the intensity of services consumed by the patient ought to be taken
into consideration.
User charges in Austria are not aligned, they are developed and exist in an isolated way meaning that no
upper limit exists which considers all user charges (per person per time period) and thus would limit the
social burden placed on certain patients.
The Union of Salaried Private Sector Employees180 published data according to which in 2001 an insured
according to the ASVG paid an average of €181.52 user charges (including fixed dental prosthesis), an
insured according to the B-KUVG €194.84, an insured according to the GSVG €139.21 and an insured
according to the BSVG €136.95. Maybe the difference to the above shown data can be explained by the
different definition of user charges, the one of the Union of Salaried Private Sector Employees being more
comprehensive181. Furthermore dependants were not taken as a denominator but only insured.
The regional sickness fund of Carinthia182 states in its study on user charges that the average burden of
insured related to user charges is very heterogeneous. Insured according to the ASVG pay more than selfemployed or farmers. Insured according to the B-KUVG pay more, but also represent less small-scale
enterprises than the group of ASVG insured. On average user charges for insured according to the B-KUVG
amounted to €195, those of insured according to the ASVG to €182, those insured according to the GSVG
to €139 and those insured to the BSVG to €136.
In their study on user charges published in 2003 Hofmarcher and Röhrling used Data of the European
Community Household Panel (ECHP) in order to perform their analysis. They show that average payments
for user charges in 2000 rise with increasing income, for men and women. Women of each group always
pay higher user charges than men, which originates in the fact that they consume more medical services.
The highest burden due to user charges is borne by women of the income class €1,382-1,962.
The analysis of the ECHP data, comparing average user charges with the level of education shows that
women with the lowest level of education consult general practitioners most frequently. Consultations of
specialists increase with higher levels of education, for both men and women183. Men with the highest level
of education spend on average € 33.4 per year, followed by women with the lowest level of education
paying € 30.6. In comparison to their income (mean gross yearly income) women with the lowest level of
education spend a twice as big share on user charges as do women with the highest level of education. For
men this difference amounts to about a fifth.
The study by the regional sickness fund of Carinthia (KGKK) reports that insured women (at the KGKK) in
the age interval of 20 to 70 years, pay higher average user charges than men. Insured in the lower income
groups pay higher average user charges than those in the higher income groups. 89% of the patients who are
exempt from the prescription charge (8% of the insured of the KGKK) belong to the income group earning
180
Klec, G.(2004). User charges in the health care system. GPA, Union of private employees, accessed at:
http://www1.gpa.at/gesundheit/index1.htm on 03/11/2005
181
Includes user charges for fixed dental prosthesis, for hospital care, charge for outpatient visits, orthodontic
regulations, transportation costs, co-payment for dependants for inpatient care, therapeutic aids and devices, costsharing in integrated institutions of social insurance, treatment by private medical doctors, and spa treatment.
182
Probst, J, User charges – Social and health political contradiction, in Wurzer, A., Robinig, R., Rodler, J. (2004).
User charges, a review for orientation. Klagenfurt, Regional sickness fund of Carinthia.
183
Hofmarcher, M., Röhrling, G. (2003). ″What do new user charges in Austria entail? ″ MIMEO, pp. 1-10.
73
€900 or less a month (81% being pensioners). This group of insured causes, higher expenditures for the
sickness fund (for all age groups), confirming a correlation between poverty and illness. Because of their
exemption from the prescription charge they are also exempt from other user charges and thus display lower
average user charges (for all income groups) than those insured who are not exempt from the prescription
charge.184
Elderly people generally utilize more medical services than younger people. They consult physicians more
often, consume more medicines and experience more hospital stays. In their study Hofmarcher and
Röhrling show that women of the age group 51-65 and men older than 65 consult a physician most
frequently. Wurzer et al. state that insured of the age group 71-80 years cause the highest expenses for the
regional sickness fund of Carinthia185.
Both men and women older than 65 years spend nearly the double amount on user charges compared to
men and women in the age group 15-30 years. For elderly people, especially for women older than 65 years,
user charges represent a larger share of their income than for younger people.
According to a study of the regional sickness fund of Carinthia, average user charges (of expenses) are
highest for the age groups 51-60 and 61-70. 9% of all patients belong to the last group, causing 17% of all
expenses and paying 18% of all user charges. Highest average user charges apply to patients in the age
group of 81-90 and amounts to € 197.
Based on a study published by the Union of Salaried Private Sector Employees186 (data basis 1999) user
charges of pensioners are disproportionately high. Average user charges of insured according to the ASVG
for medical treatment (contract physicians, including dentists) amount to €44.5 for employed and to €67.5
for pensioners. Average user charges for hospital care add up to €36.3 for employed and €155.7 for
pensioners.
In a WHO survey only 4.7% of the questioned Austrian population stated that they could not afford certain
health care during the past year187. In general user charges in Austria are an exception (principle of benefits
in kind) and if they exist they are usually not so high as to pose a real barrier to access health care for the
insured. Moreover they are always accompanied by exemption mechanisms which are supposed to ensure
that they are socially and politically acceptable.
The impact of user charges in Austria is partially related to the behaviour of health care providers. If these
try to maintain the level of income they had before the introduction of user charges, they will, depending on
their reimbursement mechanism, be incentivised to increase the amount of services provided.
When the Institute of Advanced Studies developed a model in which they analysed the outcomes of an
introduction of a €10.00 fee for physician visits (per visit) they found out that income generated by this
measure could, in the short run, eliminate the deficit of the sickness funds, but that it would only be a onetime effect. The adoption of a physician fee would predominantly affect women with low incomes as
women (of all income levels) tend to consult physicians more often than men and as especially women with
a low income display a high number of GP visits. Equally the elderly population (men and women) would
be affected more strongly by such a fee. The willingness to pay user charges is considerably higher for
women as for men and rises with the level of education.188
It is clear which groups are affected most by user charges. However it is only partially possible to find out if
user charges motivate patients in Austria to adopt more cost-conscious behaviour or if they represent real
financial barriers for them, preventing them to access care. Indicators are the temporary reduction in the
184
fund of Carinthia.
185
fund of Carinthia.
186
Klec, G.(2004). User charges in the health care system, GPA, Union of private employees, accessed at
http://www1.gpa.at/gesundheit/index1.htm on 03/11/2005
187
Who pays for your health care, accessed at http://www.gewinn.co.at/kredite/content.php?article=888m on 5.01.06
188
Hofmarcher, M., Riedel, M., Röhrling, G. (2005). ″Focus: Physician fee in Austria – how much will they bring and
who will pay them?″ Health System Watch I:2005, supplement of the Austrian journal of social insurance Soziale
Sicherheit, pp. 7-11
74
number of prescriptions after increasing the prescription charge. Due to the fairly low burden resulting from
user charges and to the numerous exemptions it is assumed that the proportion of population not accessing
care because of financial reasons is very low.
More information on user charges can be found in Appendix 4.
3.7.2 Geographical barriers
The number and distribution of contract physicians is regulated by the Location Plan which forms part of
the general contract negotiated between the Hauptverband, the regional sickness fund and the Medical
Chamber of the respective federal state189. By means of the Location Plan insured should be granted a fair
(in terms of demand) and efficient provision of care through physicians in private practices. If required, new
contract posts are established. Based on § 135 para.2 ASVG the insured should be able to choose from at
least two physicians or group practices appropriate for the kind of care required who can be reached within
a moderate time.
In practice there are significant variations in the provision of medical care in urban and rural areas, whereby
the latter partially exhibit a considerably lower level of specialist care. In general emergency care services
are provided in line with international standards, with regards to other types of care insured in rural areas
may in some cases have to accept longer travelling distances (max. 1.5 hours). Reachability of physicians
and execution of choice of medical providers may be compromised for insured living in rural areas
(compared to insured living in urban areas).
Even in urban areas shortages of specialists arise at certain times as opening hours are not co-ordinated
amongst physicians (evenings, weekends and nights). However physicians are available on a standby basis
throughout Austria (General Practitioners).
For more details on the distribution of health care professionals and facilities, see Chapter 2.9.3.
3.7.3 Cultural barriers
The study on “Social inequality and health care190” (commissioned by the Federal Ministry of Health and
Women) placed a special focus on foreigners and migrants, amongst other groups of individuals. Migrants
are more likely to be endangered by poverty (28%) than people who are born in Austria (11%)191. The
association between poverty and health care is analysed in more detail in Chapter 8.2.3. Access to health
services will, in general be more dependant on the existence of insurance coverage than on the availability
of financial means. This is because user charges for the insured population in Austria do not pose a
significant barrier to utilising health services.
Other barriers (apart from lack in insurance coverage) include language- or cultural barriers (values, beliefs,
role models) which are partially combined with limited knowledge on available benefits of social insurance.
Foreigners may seek medical advice at a later moment in time thus being at risk of having more severe and
chronic sickness spells/illnesses. Legal regulations make it difficult for women following their family
relatives by coming to Austria to find work. Burdens related to past experiences (traumatic events such as
war, violence, political prosecution) and present life (discrimination, language problems) can result in
psychological impacts and damages.
Migrant-specific measures to improve access to health care services are described below.
3.7.4 Barriers in accessing preventive health services192
Barriers preventing people from accessing or utilising the health system may be detected in a number of
areas. Disability is one such example. In the field of gynaecology disabled women have reported being
recommended long term contraceptive methods without first being consulted about their wishes193 and, in
189
Nationwide insurance funds either adopt this Location Plan or use own informal plans
Pochobradsky, E., Habl, C., Schleicher, B., Hlava, A. (2002). Social inequality and health care. Study
commissioned by the Federal Ministry of Health and Women. Vienna.
191
Results from the EU-SILC, see Statistics Austria at www.statistik.at
192
Univ.-Prof. Dr. Anita Rieder, Kitty Lawrence BEng.
193
Viennese Women’s health care report (Wiener Frauengesundheitsbericht) unpublished, Austrian Women’s Health
Report (Österreichischer Frauengesundheitsbericht) 2005/2006
190
75
case of pregnancy, have often been recommended to have an abortion. In a study of gynaecologists the most
frequently cited barriers to treatment of disabled women were access to the practice, which is often not
suitable for disabled, lack of knowledge with respect to disability, and the time taken up being too great.
For the disabled population general barriers to accessing the health system include lack of disabled access
in buildings, brochures not produced in braille, lack of knowledge of sign language, problems in dealing
with women with psychological illnesses. Although, planning standards for obstacle-free building, which
are summarised in the ÖNORM B1600, have been in existence since 1994 they are not mandatory. Within
the scope of the 58th ASVG-amendment of August 2001, provision of disabled access was made mandatory
for group practices. In this respect it must be noted that barriers to mobility in rural areas restrict disabled
women’s lives to a greater extent than in cities and towns.
In 2003 the Main Association of Social Insurance Institutions (Hauptverband der österreichischen
Sozialversicherungsträger) together with the Austrian Medical Chamber, the Austrian Consortium for
Rehabilitation (Österreichische Arbeitsgemeinschaft für Rehabilitation), and the Umbrella Association for
the representation of the interests of disabled persons (Dachverband der Vereinigung zur Vertretung der
Interessen behinderte Menschen) carried out a survey of the actual situation in doctors practices with
regards to ease of access and facilities for disabled persons. Here Vienna was found, in most cases, to be
below the Austrian average in terms of obstacle free facilities for the disabled. In November 2003, the
Viennese Medical Chamber announced that 12% of all contract practices would be adapted to allow
disabled access over the following five years and thereby allow disabled persons greater freedom in their
choice of doctors. A working group comprising representatives of associations for the disabled, doctors, and
the sickness funds was to be set up to identify which conversions are possible and which can be sponsored
by social insurance funds.
Migrants are another group of people experiencing barriers in the health system. Ethnic and cultural
background, as well as language can all act as barriers to accessing and utilising health services. On the part
of the health system there are large deficits in comprehensive translation and interpreting services, as well
as, availability of patient information in the relevant native language. The municipality department for
issues related to integration and diversity (Magistratsabteilung für Integrations- und
Diversitätsangelegenheiten, MA17) was founded in 2004 to meet the increasing needs and demands of
ethnic diversity and integration in Vienna. One of the four areas of responsibility is the field of community,
social aspects and health.
Studies in Vienna194 have shown that women with a migrant background call upon curative services more
often than preventive services.195 E.g. according to the 1998 survey only a third of women originally born in
Turkey, or former Yugoslavia, underwent a cervical smear or breast examination, compared with 90% and
78% of Austrian women respectively. According to the micro-census of 1999 in Vienna, female Turkish
citizens more often seek out the services of paediatricians, but less frequently the services of
gynaecologists, dentist and out-patient departments/clinics than women from former Yugoslavia or Austria.
Special barriers also exist for older migrants, for instance, an individual is only eligible for a pension after
15 years of making contributions within the last thirty years. For many migrants this can only be achieved if
insurance periods in their land of origin are credited, however, this is only possible if an agreement exists
between the two countries, which is often not the case. Eligibility to claim federal nursing care allowance is
linked with the drawing of a pension. Eligibility for nursing care allowance in Vienna is not linked with the
drawing of a pension, but is linked with nationality. Those claiming nursing allowance must have Austrian
citizenship or equivalent. In culinary and cultural terms nursing homes are more aligned to their Austrian
residents. Migrants without Austrian nationality may not be able to cover the costs of a nursing home, and
194
Ludwig Bolzmann Institut für Frauengesundheitsforschung 1998,
Wimmer-Puchinger B, Baldaszti E, et al. (2006). Austrian Women’s Health Report 2005/2006. Federal Ministry of
Health and Women (BMGF) Eds.. Vienna (see also www.bmgf.gv.at)
195
Viennese Women’s Health Report (Wiener Frauengesundheitsbericht) 2006
76
are not eligible for public funds (social welfare), which demands Austrian nationality as a pre-requisite for
support196.
Pochobradsky E, Habl C, Schleicher B, et al. Soziale Ungleichheit und Gesundheit. Österreichisches
Bundesinstitut für Gesundheitswesen (ÖBIG) Oktober 2002197, gives an overview of barriers to access
determined from available literature, including no health insurance, fear of bureaucracy etc.
Explanations for barriers
Looking into the effect that unemployment has on the health of women has yielded differing results. Due to
the remaining commitments that are often still carried out by women, such as, housework, children, caring
for relatives, it is argued that the negative effects of unemployment are not as severe in women as men.
However, studies have shown that women’s reactions to unemployment assimilate those of men in cases
where the job becomes an integral part of the woman’s life. According to the Micro-census of 1999,
unemployed women reported doing less to maintain their health than working women. They placed less
importance on healthy nutrition, health promoting exercise, and undertook less physical activity in their free
time. For men the differences between unemployed and employed persons were not as great.198
Ageing was also found to be a factor amongst women. It was found that visits to the gynaecologist
decreased with increase in age (based on data from Mikrozensus 1999) – see Appendix 5.
In a study carried out by ÖBIG two thirds of private carers receiving nursing care allowance described
themselves as “almost always” or “now and then” overburdened. The responsibility, the excessive demands,
and hopelessness of the situation are psychological burdens and could lead to negligence of the carers own
health.
In 2001 20.5% of families in Vienna there were single parent families, of these 83.9% are women. Although
more single mothers with children younger than 15 years are working compared to married women with
children or women with partners, an above average amount (31%) are at risk of poverty. Studies have
shown that subjective health of single mothers is poorer than that of married women. Self-evaluation of
health is strongly linked with level of satisfaction with income. Within the framework of a study of single
mothers in Vienna, commissioned by the Viennese Chamber of Labour (Arbeiterkammer Wien) and carried
out by the Institute of Conflict Research (Institut für Konfliktforschung) in 2001, it was found that the
combination of financial and time burdens frequently leads to social and psychological isolation. Single
mothers more frequently suffering with health problems or impairments are those with financial problems,
poor social contacts or very young children in particular those with children under three years of age.
Further it was investigated whether those people exempt from prescription charges make more use of the
precautionary health examination than those who are not exempt of prescription charges. Here it was shown
that socially weaker women (43% more), exempt from prescription charges go for a precautionary health
examination. For men the opposite was the case fewer prescription charge exempt men went to the
precautionary health examination.199
Austrian Social insurance is currently developing a call-recall system for their health examination
programme (Vorsorgeuntersuchung). This should target insured based on demographic and socioeconomic
criteria.
Gender has been found to play a role in the use of preventive health care and practice of health promoting
activities. The first Austrian Men’s Health Report 2004 looked into the preventive health care available and
196
www.wien.gv.at/ma47/koste.htm#betrag
198
Viennese Women’s Health Report (Wiener Frauengesundheitsbericht) 2006
199
197
77
use of preventive health care by men. The background and motives behind men’s health behaviour were
analysed by means of a telephone survey. Men were asked about interest in preventive services, main
sources of information, to evaluate their own health, etc. unhealthy lifestyles linked with level of education,
some factors with age, and some, e.g. poor nutrition also linked with living alone. In general men place
most importance on a personal invitation to the precautionary health care examination. Studies have
shown200, that although men are aware of the importance of preventive or precautionary health care they
tend to wait until symptoms have persisted for a longer period of time or they feel unwell before visiting the
doctor201. On a regional level the Viennese Men’s Health Report 1999 (Wiener Männergesundheitbericht
1999)202 found that 9% of Austrian men went to a precautionary health examination. In comparison 6.5%
(below the national average) of Viennese men and 13% (above the national average) of those living in the
Burgenland went to a precautionary health examination.
The Vienna Health and Social Survey 2001 - Wiener Gesundheits- und Sozialsurvey 2001 also researched
health behaviour with respect to gender and also age, as well as professional status. Lifestyle factors
including nutrition, exercise, etc. were examined and to what extent people inform themselves of about
what they can do for their health. Attitude and approach to personal health was found to be dependent on
sex (with women tending to undertake more than men), health promoting activities increase with increasing
age, and are also linked with educational level. Sources of information with regards age and sex were also
looked at. Furthermore precautionary health care, in terms of additional insurance and with respect to age
and sex, household income, professional status and sex, as well as use of precautionary health examination
was investigated.203
For further investigation into utilization barriers see:204
•
•
•
Women and health care institutions (2002)205 – ÖBIG
Health and the risk of illness (2003)206 – ÖBIG
Sozial benachteiligte Gruppen und Gesundheit – ÖBIG
3.7.5 Inequalities in utilization of health services in Austria207
To some extent this question has been addressed by the points made in the section “barriers in accessing
preventive services”, with regards to how socio-economic, educational etc. factors impact on utilization of
health services. The various country-wide health reports (Austrian Women’s Health Care Report
2005/2006, Austrian Diabetes Report 2004, Austrian Men’s Health Care Report 2004, Allergy Report
2006, Adipositas Report 2006), and the Viennese reports (Vienna Health- and Social Survey 2001, Vienna
Men’s Health Care Report 1999, Vienna Women’s Health Care Report - unpublished) contain a large
amount of data regarding the utilization of health services linked to age, sex, educational level, professional
status.
The relationship between the utilization of health care services, need and income has so far not been
analysed in detail. Researchers of the Federal institute for health care (ÖBIG) undertook a comprehensive
200
Eurostat 2002, Alber/Kohler 2003
Habl C, Birner A, Hlava A, Winkler P, et al. (2004) 1. Austrian Report on Men’s Health taking spezial
consideration of Men’s health prevention. Federal Ministry of Social Security, Generations and Consumer Protection
(BMSG) Eds. Vienna. (see also www.bmgf.gv.at)
202
Schmeiser-Rieder A, Kunze M, et al. (1999). Viennese Men’s HealthReport 1999. Magistratsabteilung für
Angelegenheiten der Landessanitätsdirektion, Dezernat II, Gesundheitsplanung Eds. Vienna. Juli 1999.
203
Friedl W, Stronegger W-J, Neuhold C et al. (2001). Vienna Health and Social Survey. Magistrate of the city of
Vienna, Health Care Planning and Financial Management, Health care reporting. Eds., p.1
204
www.oebig.at
205
ÖBIG Eds.(2002). Women and health care insitutions. Commissioned by the Federal Ministry of Health and
Women (BMFG). Vienna. (see also: www.oebig.at)
206
ÖBIG Eds. (2003). Health and risk of illness. Commissioned by the Federal Ministry of Health and Women.
Vienna. (see also www.oebig.at)
207
Univ.-Prof. Dr. Anita Rieder, Kitty Lawrence BEng., Mag. Joy Ladurner MSc.
201
78
analysis of the topic and provide the results of their research in the report “Social inequality and health
care” which was published by the Federal Ministry of Health and Women in 2002.
In principle people in Austria receive equal treatment, independent of their income. Social health insurance
enables direct access to a comprehensive benefits package for nearly 98% of the population. Even though
user charges do exist they hardly pose a significant barrier to access as they are accompanied by extensive
exemption schemes. This is especially important for costly services such as hospital care or emergency
services. Inequalities in the Austrian population related to health care are generally not originated in the
health care system but are primarily based in other factors such as social factors (education, income, social
status, environment and working conditions, long-term unemployment or significance of own health status).
Inequalities are partially counteracted by the system of statutory health insurance which is based on the
principle of solidarity and redistribution.208
Austria experiences an interrelationship between low income and poor subjective health status as well as
varied utilization of health care services209 Individuals belonging to the “lower class” categorise their health
status as poorer compared with individuals belonging to other classes. Persons of this group consult general
practitioners more often but utilize less specialists and dentists. They are sick more frequently and consume
more medication on a regular basis as somebody belonging to a higher social class. The ÖBIG examined
whether there was a relationship between the lower number of specialist visits by poor people and their
place of residence (urban or rural); this made little difference.
Habl210 showed that socially disadvantaged individuals (in this study being the equivalent of persons
exempt from the prescription charge) younger than 70 years visit physicians in private practices more often
than persons obliged to pay the prescription charge. It is crucial to note that about 40% of the exemptions
are based in the existence of a medical condition. For people older than 70 years the utilization behaviour of
those exempt and those not exempt approximates again. This is most likely due to the fact that elderly
people display similar disease patterns.
Individuals exempt from the prescription charge are prescribed more medicines than individuals who are
not exempt. This is independent of their sex and place of residence and applies to all age groups.
Expenditures for drugs are also comparably higher.
Access to ambulatory health services for individuals of a lower social class may be associated with longer
commuting times and waiting times.211 When looking at preventive services it becomes obvious that people
belonging to a lower social class attend health check ups less often and undertake fewer efforts to maintain
their health status. Moreover they may have restricted access to information on health care.212
The regional sickness fund of Carinthia213 analysed its average yearly expenditure for patients according to
their income. It found out that patients of the lowest income group are responsible for more than double the
expenditures of patients of the highest income group. In general patients of lower income groups pay more
user charges. For instance patients belonging to the income group €0-900 are responsible for causing yearly
expenditures of €1,050 and pay €64 for user charges. The average yearly expenditure for patients belonging
to the income group of €901-1,200 amounts to €961. Individuals of this group pay €89 user charges,
representing about 7% of their income.
208
209
Freidl et al. (2001). ″Associations of income with self-reported ill-health and health resources in a rural community
sample of Austria.″ Sozial- und Präventivmedizin 46, pp.106-114
210
Habl, C. (2004). ″Options for reducing social inequalites in health care.″ WISO 2, pp. 93-104
211
212
Habl, C. (2004). ″Options for reducing social inequalities in health care.″ WISO 2, pp. 93-104
213
fund of Carinthia.
79
In comparison patients pertaining to the income group of €3,000 and above produce yearly expenditures of
€499 paying €54 user charges. On average patients of the regional sickness fund of Carinthia cause yearly
expenditures of €852 and pay €68 user charges.
The data showed that patients exempt from the prescription charge on average caused a more than double
amount of expenses than patients not exempt. This may partially be related to the fact that patients are
exempt due to a medical condition. In the income group €0-900 patients exempt from the prescription
charge cause expenditures of €2,136 in comparison to €808 of those not exempt and in the same income
interval (both averages). 81% of the patients exempt from the prescription charge are pensioners.
When analysing the group of patients which is responsible for using 50% of all sickness fund expenditure
(7% of the patients, 6% of the insured), the high users, it was proven that these more frequently come from
lower income classes (€0-900, 8% of men, 7% of women) than from higher income groups (€2,701-3,000:
2% of men i.e. women). Two thirds of the heavy users in the income group €0-900 are women.
Judging by these results it may be deducted that sickness more often occurs in combination with age and
low income.
Summing up, it is recorded that income does play a significant role for the individual health status
(morbidity, mortality) thus also influencing utilization of health care services. However other aspects such
as personal risk factors (disability, sex, lifestyle), factors related to health care provision as well as workrelated factors, living conditions and other circumstances are of great significance.214 Statistics show that
average expenses for health care increase with age and decrease with higher income.
In Austria there is little indication that health services are rather used by individuals with higher income
than by individuals with lower income meaning that consumption tends to be based in need (e.g. individuals
with a higher income visit specialists on average more often than individuals with a low income). It seems
however that no significant financial barriers exist in the Austrian health care system because individuals
with low incomes tend to utilize more services than persons with a higher income.
However is should be noted that socially disadvantaged people reported greater difficulties in terms of
reachability of health services (commuting time) and had to accept longer waiting times in ambulatory
institutions.215 This fact will most likely be more relevant in the context of elective care, but hardly apply to
emergency care. With respect to this topic one can also refer to the reduction in waiting times for
individuals with private health insurance.
Differences across education groups
Based on results of the Micro census undertaken in 1999, participation in health check-ups increases with
higher education. Graduates of schools providing higher technical and vocational education (berufsbildende
höhere Schulen) are the most frequent consumers of health check-ups (22.3%), individuals who attended
Academic secondary schools (Allgemein höher bildende Schulen) and university graduates216 show
comparably lower levels of utilization than persons attending vocational schools for apprentices (Abgänger
einer Pflichtschule mit Lehre), 18.3% and 18.1% respectively compared to 20%.
The average number of visits of general practitioners falls with increasing level of education. Whilst
graduates of vocational schools without apprenticeships visit a general practitioner on average 5.39 times a
year, university graduates display a yearly average of 2.85 visits.
The same applies to visits of ambulatory clinics i.e. out-patient departments. These are equally accessed
more by persons with a lower education.
214
215
216
Including educational establishments, comparable to a university
80
Contrary results are reported for visits of dentists. The average number of yearly visits is higher for people
with a higher level of education (no consistent increase). Graduates of schools providing higher technical
and vocational training consult dentists most often, namely on average 1.57 times a year.
Inequalities at ambulatory care level
In the course of the Micro census 1999 the consumption of various health care services was assessed.
Participation in health check-ups varies regionally, whereby the highest population shares attending it were
found in Burgenland (25.1%) and in Styria (24.4%). Participation was lowest in Vienna (11.4%) and in
Lower Austria (12.2%). Access generally increases with urbanity of the population; it is however
significantly lower in Vienna.
In 2005, for the first time a decrease in the access to health check-ups was experienced. Before that
participation had constantly been increasing. In 2005 participation was highest in Vorarlberg (22.9%),
followed by Tyrol (20.9%) and Carinthia (17.2%), it was lowest in Lower Austria (4.9%), Vienna (8.7%)
and Upper Austria (9.2%).217
The number of average visits of general practitioners per year was highest in Lower Austria, Upper Austria
and Styria, lowest in Vorarlberg and Salzburg. Gynaecologists were consulted most often in Carinthia,
doctors for Internal Medicine by men in Styria and Carinthia and by women in Tyrol, Styria and Lower
Austria. Paediatricians in Vienna experienced most visits, other medical specialists in Carinthia and Lower
Austria (men) and in Lower Austria and Vienna for women respectively.
Ambulatory clinics were consulted most often per year in Vienna and in Styria and least often in Carinthia
and Vorarlberg. Citizens in Lower Austria, Carinthia and Vienna consult dentists frequently, individuals in
Burgenland and Upper Austria visit dentists least.
Inequalities at hospital level
In 2005 an average of 273.21 inpatient stays were registered per 1,000 inhabitants in Austria (excluding 0day stays). Regional disparities were between 202.86 stays in Burgenland and 316.26 in Salzburg. Average
inpatient stays in hospitals funded by the federal health funds in 2005 amounted to 243.66 stays, the least
were registered in Burgenland (188.26), the most in Upper Austria (279.71).
Average length of stay in Austrian hospitals was situated at 6.58 days in 2005218. Tirol experienced the
lowest length of stay at 5.17 days, Lower Austria the highest, at 9.64 days. Average length of stay in
hospitals funded by the federal health funds in 2005 amounted to 5.93 days, whereby patients in Burgenland
spent least time in hospital (4.82 days) and patients in Styria most (6.59 days). Since 1995 the length of
stay has dropped considerably in all federal states.219
The average length of stay for all Austrian hospitals, adjusted for (excluding) the long-term stays (> 28
days) and the 0-day stays, was situated at 6.35 days in 2005 and at 5.80 days in hospitals funded by the
federal health funds. Length of stay was lowest in Vorarlberg (5.26 days in all hospitals, 5.24 in fund
hospitals respectively), it was highest in Styria (7.04) and in Vienna respectively (6.33 days).220
217
ORF, accessed at http://oesterreich.orf.at/stories/136476/ on 14/09/2006
All inpatient days, all admissions (Austria total)
219
Yearly average population: Statistics Austria http://www.statistik.at/fachbereich_03/bevoelkerung_tab1.shtml,
Hospital admissions, length of stay: BMGF, received 21/09/2006, own calculations
220
Jahresdurchschnittsbevölkerung: Statistik Austria http://www.statistik.at/fachbereich_03/bevoelkerung_tab1.shtml,
Stationäre Aufenthalte, durchschnittliche Aufenthaltsdauer: BMGF, erhalten 21/09/2006, eigene Berechnungen
218
81
Inequalities across social health insurance funds
Not only the prescriptions per insured but also the costs per insured (for medicines) were lowest for the
Austrian Social Insurance Authority for Business (SVA) in 2005, being 11.7 prescriptions and €284.23 per
insured and highest for the occupational sickness funds, amounting to 27.1 prescriptions and €502.05 per
insured for medicines221. On average the number of prescriptions per insured of all sickness funds was
situated at 17.0 and the costs per insured (for medicines) at €337.92. Costs per prescription varied between
€17.48 (sickness fund of the farmers) and €24.20 (Austrian Social Insurance Authority for Business).
Medical devises were, in 2004, prescribed most at the regional sickness funds (0.93 prescriptions per
insured), least often at the Austrian Social Insurance Authority for Business (0.30). Costs per insured (for
medical devices) varied between €39.03 (SVA) and €91.62 (occupational sickness funds). The costs per
prescription were situated in the range of €56.44 (regional sickness funds) and €121.98 (occupational
funds). The following funds were above the average of €63.86: Occupational sickness funds, Insurance fund
of the Austrian Mining and Industry, insurance fund of the Austrian Civil Servants, Austrian Social
Insurance Authority for Business (SVA) and the Austrian Social Insurance Fund of the Farmers.
Days spent in hospital per case in 2005 were between 6.8 days and 7.9 days. Insured with the Austrian
Social Insurance Authority for Business (SVA) experienced the lowest average number of days, insured of
the occupational funds and the social insurance fund of the Farmers the highest number of days. On average
insured spent 7.1 days per case in hospital.222
Billed cases per contract physician in Austria (all billing entities, Verrechnungsstellen) amounted to 4,467
cases for all § 2 funds (all medical specialties) in 2005. Fewest cases per physician were billed in
Vorarlberg (4,141), most in Upper Austria (4,664). The fee per case (billed fee per case, for all medical
specialties) ranged between €42.38 in Upper Austria and € 51.70 in Lower Austria. The fee per case in
Lower Austria, Vorarlberg, Salzburg, Carinthia, Burgenland and Tyrol was found to be above the average
fee of all § 2 billing entities. The fee per billed physician (in €1,000) was situated between €193.54 in
Carinthia and €219.14 in Lower Austria. The billing entities of Lower Austria, Salzburg, Tyrol, Styria and
Vorarlberg were above the average of all § 2 billing entities which amounted to €205.62 (all medical
specialties). 223
3.7.6 Measures to improve access to care in Austria
Insurance coverage
Access to health services is guaranteed for most Austrians by means of coverage by social health insurance.
In Austria social insurance is governed by law224 and is based on the principle of compulsory insurance. It
encompasses the branches of health insurance, accident insurance and pension insurance (social insurance
in a narrow sense) as well as, unemployment insurance225 (social insurance in the broad sense). In 2005 97.8
percent226 of the population (about 8.2 million) were covered by social health insurance. Inclusion in the
221
Since 1.1.2005 merged with the insurance fund of the Austrian Railway Industry. The new body is the Insurance
fund for the Austrian Railway and Mining industries
222
Hauptverband der österreichsichen Sozialersicherung (2005). Statistical handbook of Austrian Social Insurance
2005. Vienna
223
Hauptverband der österreichischen Sozialversicherungsträger. HVB, “Red Book” Database, based on the costing
statistics for physicians. accessed 05/01/2006
224
General Social Insurance Law (ASVG), Special Laws GSVG (for the self-employed), B-KUVG (for civil servants),
BSVG (for farmers), FSVG (for independent free-lance, self-employed) as well as respective amendments
225
The insurance of the unemployed is organised by the Public employment service (Arbeitsmarktservice) and is
independent
226
Hauptverband der österreichischen Sozialversicherungsträger, including individuals insured at health care
institutions (Krankenfürsörgeeinrichtungen)
82
community of insured persons follows after starting a job or by fulfilling other compulsory insurance
criteria (compulsory insurance) or by way of a derivative insurance cover (e.g. joint-insured dependants).
For those without compulsory insurance there is the possibility of voluntary insurance.
Pensioners, Unemployed, Asylum seekers under federal supervision are also covered by social health
insurance. In Austria, at the end of June 2003 up to 3.1% of the resident population from age 15 years are
not covered by national health insurance.227 Of these 0.7% had a substitutive private insurance (opting-out
cases) and 2.4% were without any (registered) entitlement to services in case of illness.228
Health insurance benefits
The service coverage of the legal health insurance is comprehensively regulated in the social insurance laws
(ASVG, B-KUVG, GSVG and BSVG).229 Health insurance funds retain only limited scope. Services can be
classified in respect of their legal nature (compulsory services, voluntary services or compulsory duties) or
by the way in which they are provided (allowance in kind or cash benefits).230 The insured person (on
submission of an insurance case as well as fulfilment of certain criteria231) has an enforceable right to
compulsory insurance (e.g. treatment of illness). With the compulsory services, differentiation must be
made between the minimum legal service requirements (type, scope, and conditions are governed by law)
and the statutory additional services (health insurance funds are permitted to define more comprehensive
services in their statutes (according to grounds, level, or duration), as long as these remain within the scope
of the model statutes set out by the Hauptverband). The insured person has no enforceable legal claim to
voluntary services (e.g. measures to consolidate health), these are granted at the dutiful discretion of the
health insurance fund. The insured person has no individual legal claim to compulsory duties (e.g. medical
rehabilitation), these are to be provided at the dutiful discretion of the insurance fund.
Differences in the spectrum of services provided by different insurance funds can occur due to various
reasons:
-
Based on variations in legal regulations (when utilising inpatient care, services according to the
legal health insurance are available for all B-KUVG (civil servants) insured and for some GSVG
insured232 (self-employed) in the private ward (Sonderklasse).233
-
Based on variations in contractual rules234. (Insurance funds have varying contractual arrangements
with providers of health care services. These variations can not be entirely explained by the
individual sickness fund but are also dependent on the contract partner i.e. the representative
association).
-
Services provided (the benefits package) are influenced by the financial situation of the sickness
fund, for instance the regional fund in Vienna does not reimburse Spa treatment.
-
Services can, depending on the sickness fund, require the patient to cover different levels of copayments.
227
Fuchs, M, et al. (2003). Quantitative and qualitative assessment and analysis of individuals not covered by health
insurance in Austria, Final report October 2003, Report commissioned by the Federal Ministry of Health and Women.
228
Maximum values
229
Moreover in the statutes of the Social insurance funds and in the Sickness rules (Krankenordnung)
230
§ 121 ASVG
231
Reiter, G. (2002). ″Compulsory insurance versus the obligation to take out insurance – more than a play of words?.″ WISO 3, pp. 7990.
232
Those consuming benefits in cash.
Actual benefits are defined by law or the statutes of the insurance fund. Regulations apply nationwide as both
insurance funds are nationwide funds.
234
Schrammel, W. (2002). Report of the chair of the expert commission „Compulsory insurance – the obligation
to take out insurance“, accessible at
http://www.auva.at/mediaDB/63990.PDF#search=%22Schramml%20Expertenkommission%20Pflichtversicherun
g%22.
233
83
-
The scope of benefits provided may vary between branches of sickness funds, e.g. in health
insurance (sufficient, appropriate, not exceeding the necessary amount) and in accident insurance
(with all appropriate means) and also depend on the insured event (illness vs. occupational illness).
Principle of benefits in kind
Services are provided either as allowance in kind (in form of tangible assets or provision of service) or as
cash benefits. The first can be called upon by contractual partners (contractual facilities, contract doctors) or
the insurance funds own facilities. The latter may be claimed once or repeatedly (ongoing). Health
insurance primarily provides benefits in kind235, cash benefits predominate in accident and pension
insurance.236 There are variations in the terms for persons entitled to cash benefit insured by the Austrian
Social Insurance Authority for Business (SVA).
Using services as benefits in kind facilitates access to health care services for insured, regardless of their
socio-economic status. Utilising health care services belonging to the benefits package of social health
insurance does, with the exception of partial user charges, not result in any direct costs for the insured
population.
When a contract doctor is consulted there is a regulation prohibiting him to accept extra payments. The
contract doctor is not allowed to, in the same consultation, bill services of social health insurance partially
on the sickness fund and partially privately.
Some benefits of social health insurance are granted as cash benefits and are calculated based on the income
of the insured. These include sickness allowance, which is supposed to substitute income in the event of
illness, daily allowance (Taggeld) based on the GSVG, maternity allowance (Wochengeld), business
assistance/maternity allowance for self-employed/farmers (GSVG/BSVG) or allowances for travel expenses
or funeral expenses. Cash benefits which do not depend on the insured’s income are for instance child care
benefits237, allowances for child care benefits (Zuschuss zum Kinderbetreuungsgeld) or allowances in the
context of rehabilitation treatment e.g. for the adaption of an apartment or car.
Cash benefits are primarily provided in the insurance branches of accident- and pension insurance.
Exemptions from cost-sharing
When using health services through social health insurance insured are, on some occasions, confronted with
user charges. The Austrian system has a variety of exemptions, which can, when patients are in need of
care, enable i.e. facilitate access to care. Exemptions are described subsequently.
Regulations on exemptions are stated either in the social insurance laws or in the directives issued by the
sickness funds or the Hauptverband. Exemptions may originate in the special need of social protection
(income) of the insured, in cases of hardship (contagious or chronic illness, individuals requiring dialysis
treatment) or in the existence of a certain insured event (maternity), the preventive character of the benefit
or the age of the insured.
For a range of services, as already mentioned above, exemptions are granted to insured who exhibit a
special need of social protection corresponding to the directives of the Hauptverband (e.g. for physician
services, pharmaceuticals, therapeutic aids, hospital care).
235
Federal Ministry of Social Insurance, Generations and Consumer Protection, BMSGK (2003). Social protection in
Austria, an overview, Vienna.
236
Seidl, W. (2002), Social Insurance Law. Skriptum, Graz, Neuer Wissenschaftlicher Verlag. Reiter, G. (2002).
″Compulsory insurance versus the obligation to take out insurance – more than a play of words?.″ WISO 3, pp. 79-90.
237
There is a limit on extra earnings of € 14,600 € per year
84
Furthermore there are a number of exemptions for self-employed (GSVG insured) for services provided by
physicians and other health care professionals such as psychotherapists, psychologists, ergo therapists, etc.
which are stated in § 86 para.5 GSVG, amongst others for the treatment of children, notifiable diseases,
dialysis treatment following kidney disease or the donation of organs. For BSVG insured exemptions for
services provided by physicians and other health professionals can be found in § 80 para.3 BSVG.
Therapeutic aids and devices are provided without any user charges for ASVG, B-KUCG, GSVG and
BSVG insured as long as the insured is younger than 15 years of age or is entitled to increased family
allowances. For ASVG insured the same criteria apply for visual aids.
GSVG insured, who are only insured as recipients of an orphan pension do not pay any co-payments for
social health insurance benefits such as dental care, orthopaedic treatment, skeletonised metal dentures
(skeletierte Metallgerüstprothesen), metal crowns or anchor teeth (Klammerzähne) for partial dentures.
No user charges have to be paid for hospital care related to the insured event of maternity or to organ
donation. For co-payments based on both the Hospital Act and the Social insurance Act there usually is a
maximum number of days for which they have to be paid, e.g. 28 days for user charges according to the
Hospital Act.
The following paragraph briefly describes exemptions from prescription charges and exemption criteria for
the utilization of therapeutic aids and devices.
Exemptions of the prescription charge (ASVG, GSVG, B-KUVG, BSVG)
a) By act of law – individuals with notifiable, contagious diseases
b) By directive of the Hauptverband – individuals exhibiting a special need of social protection
• Recipients of income support (net income for single persons < €690.00, for married couples or
cohabitees < €1,055.99)
• Recipients of income support related to a pension of pension insurance
• Recipients of supplementary support (Ergänzungszulage)
• Individuals providing evidence on above-average expenses due to suffering or ailment and
whose monthly net income do not surpass a certain amount of money (singles: €793.50,
married couples or cohabitees €1.214.39)
For each child entitled to maintenance the above mentioned fees are increased by €72.32.
B-KUVG: Once the prescription charge has been paid a refund is possible
BSVG: Particularities for recipients of income benefits according to § 140 para.7 BSVG
These exemptions also apply to the e-card service charge.
Exemptions from co-payments for therapeutic aids and devices (Heilbehelfe, Hilfsmittel)
(ASVG, GSVG, B-KUVG, BSVG)
a) By law for insured or dependants younger than 15 years
b) By law for insured or dependants who are entitled to increased family benefits (irrespective of age)
c) When providing evidence for special need of social protection according to the directive issued by
the Hauptverband (see prescription charge exemptions)
d) In the context of services provided for medical rehabilitation
Particularities for B-KUVG and BSVG insured: see exemptions of the prescription charge
Further financial assistance for insured
Social insurance funds can grant insured who are in situations requiring special consideration financial
allowances of the assistance fund (Unterstützungsfonds) (see § 84 ASVG). This is usually exercised in
85
cases of emergency, e.g. if an insured is confronted with extraordinarily high expenses in the course of
using physician services and is in financial distress. Financial allowances originating from the assistance
fund represent a voluntary benefit of social insurance for which insured do not have a legal title. The funds
are to be provided in proportion with the respective directives, taking the family-, income and assetsituation of the supported individual into consideration.238
Social insurance contributions are defined by Federation and agreed on by parliament. The level of the
contributions is calculated by the contribution base and the contribution rates applicable, which depend on
the type of employment in the different federal laws. Contribution rates for social health insurance are
independent of the personal risk of the insured and situated between 7.1% and 9.1%.239 Deviations result
from historical developments, slightly different benefit packages and distinctions in the characteristics of
the insured groups. About 77% of all insured in Austria are insured under the General social insurance law
(ASVG), 8.5% under the Social insurance law for civil servants (B-KUVG), 6.8% under the social
insurance law for self-employed (GSVG) and 4.6% under the social insurance law for farmers240. For the
employed insured roughly half of the social insurance contributions are paid by the employer, the other half
is paid by themselves. Only in accident insurance the employer covers the whole fee.
For insured under the ASVG and the B-KUVG the earnings limit for chargeable contributions in health-,
accident- and pension insurance amounts to €3,750 monthly, for insured under the BSVG to €4,375
monthly and for insured under the GSVG in health- and pension insurance to €4.575 monthly, the
contribution for accident insurance is a monthly lump sum payment.
Location Plan (Stellenplan)
The Location Plan forms part of the general contract negotiated between the Hauptverband, the regional
sickness fund and the Medical Chamber of the respective federal state and defines the number and the
geographical distribution of contract doctors. By means of the Location Plan insured should be granted a
fair (corresponding to demand) and efficient provision of care through physicians in primary care. If
required, new contract posts are established, sometimes contract posts are also closed down or relocated
(depending on demand and population development). An increase in the number of contract doctors may
though not always be necessary. Frequently patients are only lacking information about the location of the
contract doctor closest to them which they receive from their sickness fund.
Based on § 135 para.2 ASVG the insured should be able to choose from at least two physicians or group
practices appropriate for the kind of care required who can be reached within a moderate time.
Practically great variations in the density of health care providers exist when comparing urban and rural
areas, especially the density of specialists is a lot lower in the latter areas. Financial incentives for doctors to
run a practice in structurally disadvantaged areas are not provided by the sickness funds or the Medical
Chamber but partially by the municipalities. Health insurance funds react to this problem by sometimes
allowing the sharing of a contract physician’s post. In order to assess the equitable provision of services in a
region not only the number of health care providers should be analysed but also their availability i.e. their
opening hours and actual working hours.
238
Web portal of Austrian Social Insurance, accessed at www.sozialversicherung.at, on 17/06/2006
Hauptverband der österreichischen Sozialversicherungsträger, HVB (2006). Social security data (contributions) in
the Austrian Social Insurance 2006. cut-off-date 1 January 2006, Version 13.02.2006
240
239
86
Reimbursement of travel expenses241
In 2005 social health insurance spent a total of €168 million on travel- and transportation expenses (around
1.41% of total expenditure).242
The reimbursement of travel- i.e. transportation costs which the patient incurs in the course of accessing
physician services because of the distance between the medical practice and his apartment, is a voluntary
benefit of social health insurance and can be granted in proportion to the regulations of the statutes of the
individual sickness fund (see § 135 para.4 ASVG). The extent of the reimbursement depends on the local
circumstances as well the cost resulting from the cheapest type of public transport (private car). If necessary
the statutes of the sickness fund can also include regulations to cover travel expenses for a second person
accompanying the patient (for instance in the case of children or fragile individuals).
Partially the reimbursement is dependent on a defined minimum distance or is only free of charge for a
certain group of patients (individuals exempt from prescription charge, certain types of medical treatment).
The regional sickness fund of Vienna stopped covering travel expenses in December 2004.
In case the patient cannot be expected to use public transport due to physical or mental reasons (e.g. the
patient cannot walk) the sickness fund is obliged to cover transportation costs to access services according
to the prearranged contractual fees. This benefit is a compulsory duty of the sickness funds which is to be
provided in accordance with the dutiful discretion of the insurance fund
Transportation expenses (for national transportation) may be granted in the course of inpatient treatment,
for transportation in the nearest appropriate hospital or from the hospital to the apartment of the patient, for
medically induced transferral from one hospital to the nearest adequate hospital, for ambulatory treatment
with the nearest contract physician or contract group practice or in the nearest contract institution i.e. back
to the apartment of the patient or for the formfitting adjustment of medical aids or devices.
The prerequisites for the use of transportation services by means of patient transport ambulance are stated in
the statutes of the insurance fund. Apart from a few exceptions (e.g. emergency) the transportation requires
proof of medical necessity by certification of a physician (see § 135 para.5 ASVG). In their statutes the
sickness funds regulate that the insured has to meet certain co-payments for travel expenses i.e.
transportation costs or define exemption criteria (e.g. for dialysis treatment).
The expenses for air emergency are only reimbursed by the health insurance fund if the patient cannot be
expected to be transported by land either because of his condition or urgency of the case.
Travel expenses in the course of treatment abroad are not covered by all health insurance funds. They are
only reimbursed if it was not possible to perform the necessary treatment within the country and/or they
were preauthorised by the sickness fund. Most health insurance funds recommend signing up for private
travel and repatriation insurance before going abroad.243
In the context of accidents related to sports and tourism recovery costs for transportation to the valley are
not reimbursed. Transportation costs are only covered if the transportation by air would have also been
necessary in the valley. Accidents taking place during school ski courses, excursions and similar events are
generally categorised as accidents at work.
241
§ 135 ASVG (General Social Security Act), Webpages of social insurance funds, accessible via the Web portal of
Austrian social insurance at www. sozialversicherung.at, accessed 19/05/2006
242
Hauptverband der österreichischen Sozialversicherungsträger (2006), Handbook of Austrian social insurance 2006,
Vienna.
243
For coverage of costs for benefits not reimbursed by social health insurance
87
Average distance to health care institutions
The Austrian Federal Institute for health care (Österreichisches Bundesinstitut im Gesundheitswesen,
ÖBIG) administers a database, the “Austrian Health Care Information System “(ÖGIS), which contains a
wide range of health care relevant information. A reduced version, REGIS, is publicly accessible on the
internet and provides users with predefined analysis on the topics: demography, life expectancy, mortality,
hospital admissions, lifestyle and traffic accidents. ÖGIS incorporates a reachability model with which the
user can, provided he knows the institution he is looking for i.e the institution is defined in the system,
calculate the distance between a certain point and the institution. Calculations are performed based on
individual road traffic, not on public transport.244
Inquiries can be handled on request by experts at the ÖBIG and have to be paid for. A number of federal
states contact the ÖBIG on a regular basis.
According to Dr. Fülöp from the ÖBIG other institutions in Austria involved in comparable areas of
research are the Institute for land use planning and rural development at the University of Natural
Resources and Applied Life Sciences (Universität für Bodenkultur) in Vienna as well as the Institute for
urban- and rural research at the Vienna Technical University.
Regulations in the general contract of social insurance
The general contract between the Hauptverband and the federal Medical Chamber includes various
regulations to ensure equal access to providers of medical services. Conditions may vary according to
service provider. Physicians or other health professionals who have signed a contract with social health
insurance are obliged to treat insured patients and their dependants, providing a defined range of benefits,
for account of social health insurance (obligation to treat).245
Furthermore, public hospitals are, according to the Hospital Act, committed to admit patients with social
health insurance coverage requiring inpatient care to the general ward. Moreover Patients whose “physical
or mental condition requires immediate inpatient care because of danger of life or because of the danger of
an otherwise not preventable severe danger to their health” must not be rejected. Mentally ill may be
obliged to accept an admission to hospital.246
Public hospitals are only permitted to deny admission of patients in case no beds are free or if they do not
provide enough i.e. the appropriate medical equipment necessary for treatment (exception emergency).247
Ambulatory contract doctors are however, according to the regulations of the general contact, allowed to, in
justified cases, reject treatment of an insured person. Doctors have (apart from in the event of an emergency
or severe symptoms) no obligation to treat private patients. Private patients may not be favoured to patients
covered by social health insurance (prohibition to discriminate). The physician is only allowed to reject or
interrupt treatment if he states cogent reasons (lack of trust, lack in qualification or training).248 In case he is
not in command of the knowledge or skills necessary he ought to turn down treatment requests based on his
own estimation. Doctors may also deny treatment to new patients as long as this is in the interest of their
present patients and counteracts an overload of their practice.249 On demand doctors have to communicate
and document the reason for the denial of the patient to the health insurance fund.250
244
Dr. Gerhard Fülöp (Österreichisches Bundesinstitut im Gesundheitswesen, ÖBIG). 16/06/2006.
246
247
Web portal of Austrian Social Insurance, accessed at www.sozialversicherung.at,
248
Doctors’ Law (Ärztegesetz)
249
General contract
250
Dr. Gregoritsch (Hauptverband der österreichischen Sozialversicherungsträger, HBV). Interview 25 November
2005
245
88
In the event of an emergency (absolutely necessary first aid) all health care providers are strictly obliged to
provide assistance.
Statutory social health insurance reduces the possibility of risk selection in social insurance (by the insured
or by the insurance fund) by far. Risk selection by contract providers is counteracted by measures such as
regulations in the general contract (obligation to treat, prohibition to discriminate), by regulations related to
reimbursement as well as incentives (e.g. encouraging coordinating activities).
However cases are reported in which for instance private patients on waiting lists for elective surgical
procedures are put at an advantage. Even if the contract doctor of social insurance is, by means of
regulations in the general contract, prohibited to favour private patients over patients with social health
insurance it may still be the case that he favours insured of the latter group who are not insured under the
ASVG over those who are insured under the ASVG because the remaining health insurance funds usually
reimburse their contract partners on a fee-for services basis. To verify this assumption further research
ought to be carried out.
Opening hours/ Waiting times
Contract doctors have to work a minimum of 20 hours per week as contract doctors for social health
insurance. They are obliged to comply with the minimum working hours defined in the general contract
with social insurance. Notwithstanding this regulation, shortages in the provision of care occur for certain
specialties at given times because opening hours are not coordinated regionally or within districts.
In the general contract of the regional sickness fund of Upper Austria the regulation on opening hours is as
follows: “the weekly opening hours should be no less than 20 hours. The practice of the physician has to be
open during at least 5 working days (Monday to Saturday). Consultation hours are to be provided on at least
two afternoons i.e. evenings of the week, beginning at 14:00 (lasting 3 hours) or at 15:00 (lasting two
hours). Either of these consultation periods can be substituted by a two hour consultation period on
Saturday.251”
Contract doctors must inform their patients about any substitutions by other colleagues.
In the evaluation form assessing quality in physician practices the ÖQMed (Austrian Association for
Quality Assurance and Quality Management in Medicine Plc.) asks doctors if patients with acute symptoms
are given an appointment at short notice or, if applicable, are referred to an outpatient’s department or
physician’ emergency service.252
The motivation for physicians is to assess the quality of their practices by filling out a questionnaire (60
questions). The quality indicators in the questionnaire were defined by the physicians in co-operation with a
scientific board of experts. For the time being it only includes criteria belonging to the dimensions of
structure or process quality. The responses are checked if they are plausible. In addition random inspections
of practices take place. By 2008 about 15,000 practices will be evaluated, which are then re-assessed every
two to three years.253 Evaluations started mid April 2006.254 The responsibility for the quality assessment
lies with the ÖQMed Association.
251
Regional sickness fund of Upper Austria (2006). General contract (with physicians). Dated 1 July 2006, Linz.
Austrian Association for quality assurance and quality mangement in medicine Plc. (Österreichische Gesellschaft
für Qualitätssicherung und Qualitätsmanagement in der Medizin GmbH ,ÖQMed), Evaluation questions for doctors,
Version
1.0.
Developed
14
March
2006,
accessed
at
http://www.oeqmed.at/fileadmin/Downloads/LETZTVERSION_Evaluierungsfragen_Mar06.pdf on 17/0672006
253
HÖ (2005). ″ Quality in physician practices.″ Medical Tribune 18, accessed at http://www.medicaltribune.at/dynasite.cfm?dssid=4170&dsmid=63806&dspaid=484448 on November 18th 2005
254
Austrian Medical Chamber (2006). PK „Quality assurance in Austrian physician practices“, dated 15 March 2006,
accessed at: http://www.aek.or.at/cache/000000000020060315112322.xml/PK-Unterlage%202006-03-15.pdf, on
11/04/2006
252
89
Initiatives to reduce cultural barriers
Social insurance institutions increasingly provide information for non-German speaking insured and
patients, for instance examination forms for preventive services (health-check-ups) as well as other forms
are available in various languages (e.g. Turkish, Serbian, Croatian).
Further activities for foreigners i.e. migrants i.e. persons whose native language is not German are
translators’ services, multilingual signs or direction signs or health care centres for migrants. The ZEBRA255
association (Centre for medical, juridical and cultural assistance for foreigners (migrants and refugees) in
Austria) in Graz offers health related services such as counselling and the procurement of medical
treatment.
At road shows on various health related topics in the city hall in Vienna (Gesundheitstage) the regional
sickness funds of Vienna assigns an additional member of staff, speaking Turkish, to their information
booth, thus trying to address the needs of their insured Turkish population.
According to the ombudswoman of the regional sickness fund of Vienna the health insurance funds
cooperate with associations offering assistance to foreigners and migrants, amongst others with the Austrian
Integration Fund or with self help groups.
In connection with migration and intercultural care in the inpatient sector the WHO conducted the project
“Migrant friendly hospitals”.256 12 countries participated in the project coordinated by the Ludwig
Boltzmann Institute for the Sociology and Health in Medicine in Vienna (LBI für Medizin und
Gesundheitssoziologie). In the „Amsterdam declaration towards migrant friendly hospitals in an ethnoculturally diverse Europe“ 26 recommendations were elaborated such as developing co-operations with
community organizations and advocacy groups who are knowledgeable about the issues of migrants and
minority ethnic groups. This should encourage the development of a more culturally and linguistically
appropriate delivery system.257 The reference hospital in Vienna was the Kaiser Franz Josef Spital.258
Other model projects in Austria on this topic are the participation in an EU project to promote equality of
migrants259, a project for intercultural opening at the regional sickness fund of Styria, the opening of
psychosocial counselling centres as well as a project at the hospital for nervous diseases Sigmund Freud.260
Moreover the project “Treatment of Turkish patients in hospitals in Vienna in their native language”261
In the Hanusch hospital of the regional sickness fund of Vienna the gynaecologist Dr. Eichbauer initiated a
project for female Turkish patients. In the beginning Turkish and Austrian women patients were questioned
on various topics. Based on their answers a list of problems was set up- At the same time hospital staff
attended further education seminars in order to become more receptive to the issue. The result of the project
is a catalogue of measures which can be applied universally, in any hospital. Furthermore Dr. Eichbauer and
255
Centre for sociomedical, legal and cultural support of foreigners/migrants, accessed at www.zebra.or.at
Project Webpage of “Migrant friendly hospitals”: http://www.mfh-eu.net/public/home.htm
257
Amsterdam
Declaration,
accessed
at:
http://www.mfheu.net/public/files/european_recommendations/mfh_amsterdam_declaration_english.pdf, on September 9th 2006
258
Milijkovic, M. (2006). ″A wrong gesture and trust is lost, The Vienna Kaiser-Franz-Josef-Spital as example of a
“migrantfriendly hospital.″ Der Standard, 12.06.06.
259
Webpage
of
the
project
„promoting
equal
chances
of
migrants”
at
https://www.wien.gv.at/euf/internet/AdvPrSrv.asp?Layout=psProjekt&Type=K&PROJEKTID=1936
260
Eichbauer, H. (2004). Lived integration in the hospital. Final report, Vienna 2004.
Ludwig Boltzmann Institute for the Sociology of Health and Medicine (Eds.) (2003). Caring for migrant and minority
patients in European hospitals. A review of effective interventions. Vienna, 2003 in Pammer, C., (2005). Migration
und Public Health in Austria in Martin Sprenger Eds. (2005). Public Health in Österreich und Europa, Lengerich.
Pabst Science Publishers.
261
Project description can be accessed at www.wien.gv.at
256
90
his co-workers offer to assist other institutions planning a similar project in reporting their experience or
giving advice.262
The Public company for Health care and hospitals in Upper Austria, Gespag (OÖ Gesundheits- und Spitals
AG, Gespag) offers its employees seminars on „transcultural care of patients with a different cultural
background“ and „transcultural care in the area of obstetrics and gyneacology”. In one of their hospitals, the
Wagner-Jauregg Hospital, a hospital for nervous diseases, the first intercultural outpatient department has
been opened for foreign patients in need of psychiatric care.263
Initiatives aiming at informing and educating the insured population
Health insurance funds inform their insured population by means of personal counselling, information
brochures, their websites, journals or road shows. Needless to say that insured also receive information on
health insurance benefits and possible user charges by their health care providers. Two health insurance
funds have opened health information centres (Gesundheitsinformationszentren, GIZ), the regional sickness
fund of Salzburg and the regional sickness fund of Burgenland. The GIZ in Salzburg264 is mainly orientated
towards insured and offers information on topics such as health, illness and health promotion free of charge.
Replying to a questionnaire the health insurance funds received in November 2005 the majority of them
stated that they thought that their insured had a sufficient amount of information to facilitate choice.
Information sources cited were the health insurance fund’s website, health information centres (described
above) and magazines for insured or personal assistance provided by employees of the sickness fund.
It should however be pointed out that whilst patients are provided with a range of information on health
care providers as well as services granted by social health insurance, that there is no standardized
information on the quality of services provided. In the future health insurance funds are planning to increase
information supply for the following areas: preventive care (screening), case management i.e. disease
management, Diabetes type II, preventive services.
Proactive involvement of patients is intended in some areas, for instance preventive services will be
supplemented by a call-recall system and individuals suffering from Diabetes type II will be given the
option to take part in disease management programs.
Other institutions informing patients about health care services reimbursed by social health insurance are
for instance self help groups, patient initiatives or patient representatives.
Barrier free access to health care services
The year 2003 was the European year of people with disabilities. In this year Austrian social insurance set
itself the target of improving access to medical institutions (barrier free, disabled accessible). Amongst
other activities the barrier free status of physician practices was evaluated, in cooperation with other
associations, in all federal states and an analysis for all sickness funds was performed.265 A symposium on
the topic “physician without barriers” was organised by the Hauptverband, the working group for
rehabilitation and the BIZEPS association on the 16th of October 2003.
Other projects were mentioned within the scope of the symposium, such as a project organised by the
healthy Vienna Fund “Women with disabilities at the gynaecologist”, moreover projects of the BIZEPS
262
Hanuschkrankenhaus (Hanusch Hospital), Dr. Eichbauer, interview 26 June 2006 (telephone)
Rohrhofer, M. (2006). ″No coffee or biscuits during ramadan, transcultural care and psychiatry in a hospital for
paediatrics and a hospital for nervous diseases in Linz, Der Standard. 12.06.06.
264
Somweber, M., (2002). Health Care Information Centre, GIZ–a pilot project of the regional sickness fund of
Salzburg. In Meggeneder, O., Hengl, W. Eds. (2002). The informed patient – claim and reality. Linz, pp. 123-133
265
Stowasser, S. (2004). ″Barrier free access to physician practices– country-wide assessment of the current status.″
263
91
association “disabled persons in hospitals and other health care institutions” or a project of the city Wels in
Upper Austria “Wels paves the way”. Last year in June a reference book with the title “ill, disabled,
unobstructed” was presented to the public in Vienna. The reference book is the result of the BIZEPS project
“Disabled persons in health care institutions in Vienna” and includes 362 health care institutions and 79
pharmacies which were all accurately measured.266
Subsidies for barrier free building are granted by the Ministry of Social Security, Generations and
Consumer Protection or by the federal social welfare office.
In their general contracts some health insurance funds have already defined that from a certain point in time
onwards newly created contract posts (places) have to exhibit barrier free access to their practice. Contracts
already existing at that date are granted a transition period of usually 5 years. Sickness funds have partially
defined a minimum share of practices which have to be barrier free by a defined date. Criteria for barrier
free access are stated in the annex of the group practice framework arrangement with the Austrian Medical
Chamber. The remaining sickness funds are planning to integrate such a regulation in their general contracts
soon. The regional sickness fund of Vorarlberg and the regional Medical Chamber have come to an
agreement whereby newly opened practices have to prove barrier free access. This is already stated in the
advertisement for the post/job. The same applies to the regional sickness fund of Burgenland.
A commitment of the future contract doctor, to make an effort to implement barrier free access, has been
included in the application process for free contract posts, in the ranking criteria
(Reihungskriterienverordnung). By means of written consent the physician agrees to, following the
ÖNORM 1600 “barrier free building” and the ÖNORM 1601 “special building provisions for disabled and
elderly persons” create barrier free access to his practice within an adequate period of time following the
signing of the contract.267
The ASVG regulation on group practices included, for the first time, the legally binding prerequisite of
proving barrier free access in order to sign a contract with social insurance.
An insurance benefit which is supposed to improve i.e. facilitate access to care for disabled or patients with
restricted mobility is the home visit.
In the evaluation form on quality in physician practices the ÖQMed (Austrian Association for Quality
Assurance and Quality Management in Medicine Ltd) asks physicians if patients have the option of
enquiring about any existing barriers before coming to their practice. Beginning with June 2006 startup
practices or succession practices are obliged to perform a consultation with a disability association
according to § 6 Z1 QS-VO 2006. If the physician complies with the requirements for a barrier free practice
he is from January 1, 2006 to be included in the list based on § 16 of this directive after the consultation.
Furthermore the physician is questioned if, given the constructional circumstances, he makes an effort to
facilitate access to his practice for patients with restricted mobility268.
At www.praxisplan.at the Medical Chamber of Vienna offers patients looking for a contract doctor
information on the doctor’s name, post code, sex, specialty, special training/diplomas, other activities,
sickness funds, opening hours and language skills. In addition they provide information on the accessibility
for disabled to the practice (disabled accessible yes/no (personal perception of doctor), performance data on
266
BIZEPS project “Disabled persons in health care institutions in Vienna”, accessed at
http://www.service4u.at/blickkontakt/news.php?nr=6282 on 17/06/2006
267
Regional sickness fund of Vienna (2004), General contract (with physicians), 1 January 2004, Vienna.
Medical Chamber of Lower Austria, application for a free place with social insurance (questionnaire), accessed at
http://www.arztnoe.at/localfiles/5084_.pdf on 17/06/2006
268
Austrian Association for quality assurance and quality mangement in medicine Plc. (Österreichische Gesellschaft
für Qualitätssicherung und Qualitätsmanagement in der Medizin GmbH ,ÖQMed), evaluation questions for doctors
Version
1.0
developed
on
14
March,
accessed
at
http://www.oeqmed.at/fileadmin/Downloads/LETZTVERSION_Evaluierungsfragen_Mar06.pdf 17/06/2006
92
the accessibility of the practice). This information has been collected in cooperation with the association for
disabled, BIZEPS, beginning in November 2005.269
In January 2006 the Federal equalization Act for disabled came into effect. The aim of this law is to
“eliminate or reduce the discrimination against individuals suffering from disabilities thus ensuring equal
participation of the disabled in community life and giving them the option of living a self-determined life”
.270
Internet Applications
The Web Accessibility Initiative (WAI) of the W3 consortium has in 1999 defined guidelines for Web
Content Accessibility (WCAG) – guidelines for barrier free web content - which are valid in the whole
world and are the basis for legalisation on barrier free design of information technology. The aim is to
enable i.e. facilitate access to information for individuals with visual impairments as well as for blind or
deaf people.
WAI guidelines are recommended by the European Commission and have been implemented in many
places in Austria. Three grades of conformity can be distinguished each defining a certain extent of barrier
free access. The grades range from A to AAA whereby AAA is the highest. For example triple A ensures
that text is supplied for each non-text element (picture, graph), that CSS (Cascading Style Sheets) and
markups are used instead of pictures, colour contrasts as well as scalable formats of writing. In addition
tables are to be avoided for layout, headings and listings should be provided with the respective
explanations.271
In Austrian Social Insurance (web portal of the Austrian Social Insurance at www.sozialversicherung.at) the
content (display of content only, not including services) meets conformity level A. The new applications
meet WAI conformity level AAA. The reorganization to WAI AAA is planned for the second term in 2006
i.e. early in 2007.272
3.8 Patient pathways
Countries differ in the typical patient pathway through the health system, with different initial points of
contact, referral arrangements, waiting time guarantees, private alternatives, and cover of second opinions.
In light of these differences, typical patient pathways from a selection of European countries are depicted
individually in Appendix 6.
3.8.1 Patient pathway in Austria
Before describing the pathway of a patient in the Austrian health care system it should be pointed out that
the Austrian system grants not only contract partners but also patients a great deal of choice with respect to
treatment. A comprehensive description of the huge variety of patient pathways cannot be performed in the
course of this study. The reader should acknowledge that the following description only takes up very
limited aspects of the patient’s pathway through the health care system. A patient’s treatment is not only
dependent on their socio-economic status, place of residence i.e. place of work (urban or rural area) or their
type of illness (acute, chronic) but is also influenced by a multitude of other factors (e.g. age and sex).
269
Kraßnitzer, H. (2006). ″ Vienna: Accessing the physician practice without barriers.″ Medical Tribune,
Ärztemagazin 17, accessed at http://www.medicaltribune.at/dynasite.cfm?dssid=4169&dsmid=73550&dspaid=570836 on 09/05/2006
270
Accessed at http://www.gleichstellung.at/rechte/bgstg.php on 17/06/2006
271
Internet without barriers, accessed at http://www.iob.at/ on 16/06/2006
Web Accessibility Initiative, accessed at http://www.w3.org/ on 16/06/2006
272
Christian Schuller (Hauptverband der österreichischen Sozialversicherungsträger, HVB). 9 June 2006 (via email)
93
The following pathways represent ideal pathways, which do not necessarily correspond to the actual
pathway or a standardized process. Frequently deviations can and will occur which ought to be discussed in
the context of the individual situation.
No emergency
In Austria, in many cases the consultation of a general practitioner is the first contact of a patient with the
health system. The patient can choose the physician freely and usually consult him after arranging an
appointment (specialist). Sometimes the general practitioner asks patients to come during his office hours
without prior notice. Until recently the patient had to claim a health insurance voucher from his employer
before consulting a physician (a general practitioner, a specialist or a dentist). For each voucher he had to
pay a fee of €3.63 (2005). For the insured population of the Austrian Social Insurance Authority for
Business (SVA) or the Insurance fund of the civil servants this was not necessary (they received a certain
amount of health insurance vouchers by mail). Pensioners also had their insurance vouchers sent to their
homes and were exempt from the fee. However with the introduction of the e-card (electronic health care
voucher) this procedure has become obsolete for the majority of the insured.
Sometimes treatment for the patient is already completed after the appointment at the GP. If the illness is
treated by means of medication the patient usually goes to the pharmacy closest to him and receives the
medication by presenting the prescription issued for him by the physician. In some cases a checkup at the
GP within a certain time period may be necessary to assess treatment progress.
Under certain circumstances it is essential that the patient, in the course of clarification of his diagnosis or
therapy obtains further medical statements from specialists or other diagnostic institutions (laboratories,
institutes). He is referred to these by his GP; the reason of the referral must be stated on the referral note
(this is currently still a slip of paper). It is quite common that the GP recommends a certain specialist to the
patient.
Points of first access for patients are, next to general practitioners, also paediatricians (GP for children),
gynaecologists (for women), dentists and ophthalmologists. Individuals working in larger companies
frequently use the company physician’s services available to them.
In the Austrian health care system the patient is entitled to directly (without referral from the GP) access a
specialist, an outpatient department of a hospital or an ambulatory clinic. The patient is obliged to display
his e-card. Direct access is not granted to all specialists (e.g. radiologists, laboratory physicians, doctors of
physical medicine only with restrictions). The insured is limited to the use of one specialist of the same
specialty within a quarter of a year (when seeking reimbursement of treatment through social health
insurance). Exceptions are granted but require a prior claim by the insured. Direct consultations of
specialists (without referral from a GP) have increased considerably in the past; the number of referrals has
gone down.
After consulting a specialist and completing treatment the therapy in the ambulatory setting is sometimes
already concluded. On occasions a final check up at the specialist (e.g. after performing laboratory tests) or
at the GP may be required.
If the patient needs an elective medical intervention in hospital, the ambulatory doctor completes a
hospitalisation note for the patient.273 In case treatment in a hospital is not necessary, but medical treatment
is, yet the option of care at home is not provided, this has to be specifically stated on the hospitalisation
note. In principal the patient should, according to regulations in the general contract with social health
insurance, be transferred to the closest hospital providing the appropriate care. In practice the physician tries
to take individual patient’ requests into consideration. The hospital in which the patient is ultimately treated
(at least for patients without private health insurance) is chosen based on available bed capacity. The
referring physician usually clarifies if the hospital has a free bed for his patient.
273
In principle any physician can write a hospitalisation note, equally any outpatient-department
94
Depending on distance, transportation into hospital should generally take place by means of public
transport. The use of an ambulance is only permitted in cases medically justified, the necessity has to be
certified by the contract doctor.
Upon arrival the hospital contacts the patient’s health insurance fund to confirm if it will cover the expenses
resulting from the treatment (insurance coverage enquiry). Before discharge of the patient, when inpatient
care is no longer medically induced, the attending physician writes a note of discharge as well as a letter of
discharge. The latter is for the referring physician or the physician responsible for future treatment so that
he can perform any necessary treatment following discharge. It should provide details as well as
recommendations related to future treatment. Moreover give instructions for any health care professionals
(e.g. nurses) involved. After clarification with the patient the physician letter is given to him personally or
sent to either his family doctor or any institution or other health care professional in charge of further
treatment and care (by mail or email).
Patients may be discharged from hospital in order to be admitted to another hospital, provided that the
transferral is necessary and granted. The transferral is executed by an ambulance organization in an
ambulance vehicle (responsibility of the municipality or private companies) which is notified by the
hospital.
In case the patient requires further care after discharge i.e. cannot be left to himself, hospitals are, according
to the law (§ 24 KAKuG), obliged to get in touch with public welfare organizations in due time before
discharge. Discharge management in hospitals varies considerably in its specifications and intensity. There
is a considerable lack in continuity of care, especially for patients who require more extensive care such as
chronically ill patients. Some health insurance funds274 employ “care coordinators” who are notified before
the patient’s discharge and help the patient to prepare for the time after his inpatient stay (giving
information on benefits of social health insurance, medication therapy, etc.).
Emergency
One of the options in case of an emergency is that the patient himself calls the ambulance (i.e. the radio
service for doctors/ doctors’ emergency service during weekends or on holidays. After talking to a doctor
on the telephone, the decision is taken for the appropriate means of transport.
Alternatively, in case the patient falls ill, the family doctor (general practitioner, specialist) can arrange an
admission into hospital by ambulance for the patient.
If the patient is not able to call an ambulance himself he is picked up by an emergency ambulance which is
usually notified by somebody else. The following procedures can vary in the different federal states. Here
the approach in Vienna is described. The emergency ambulance picks up the patient (having been informed
about his sex and a possible diagnosis), checks on his condition and performs necessary documentation
work. In Vienna a paramedic calls the control station/ central reception for bed availability to inform them
about the type of bed required. He receives a case number whilst bed availability is checked. The patient
may state personal preferences; however these can only be taken into consideration if the respective hospital
has a free bed. If the ambulance does not secure a bed beforehand the hospital may reject the patient upon
arrival.
When arriving at the hospital the patient is seen by the doctor in charge for admissions/ the doctor on duty.
The paramedic gives the doctor the case number and describes the case. Consequently the doctor either
decides where the patient is taken or still examines him personally. Afterwards the patient is transferred to
the ward.
Depending on the type of emergency the decision of the ambulance care used is taken (with respect to staff
and medical equipment). On demand an emergency physician can be sent to the place of accident at a later
274
Regional sickness fund for Styria, Insurance fund of the Austrian Mining- and railway Industry
95
stage. In the event of an accident, before transferring the patient, a consultation with the central reception
has to take place in order to clarify if the accident/emergency ward of a hospital is open or not.
If a patient comes to the hospital in a condition of emergency the hospital is not allowed to reject him but is
legally obliged to at least provide first aid. Afterwards a transferral to another hospital may be arranged.
There are a range of companies offering patient transport ambulance services. The person placing the call
decides which company to notify. Transportation expenses are, depending on the diagnosis for
transportation, covered either by the social health insurance fund, privately or, in the event of a transferral,
by the transferring hospital.
96
4. REGULATION OF THE HEALTH SYSTEM
The past couple decades have witnessed a substantial growth in the volume of new regulatory mechanisms
in the health sector. These have largely been a response to the needs of both intentionally and
unintentionally generated entrepreneurial activities such as the ‘purchaser-provider split’ in England in the
1990s, choice of sickness fund in Germany and the Netherlands, and reformed payment mechanisms such
as global budgets and DRGs for hospitals. It has proven incredibly difficult for governments to design
effective regulation, in large part due to the mix of values as well as technical issues that underline
regulatory decisions.
Due to the complexity in conceptual and technical terms, there is no standard definition of regulation and no
standard accepted rationale for introducing regulation. However, there is broad agreement about the source
and general mechanisms of regulation.275 These mechanisms can be grouped into two broad categories:
tools and strategies. Among the tools include legislation, administrative decree, guidelines, and emergency
measures; the strategies refer to the use to which the tools are put. Some potential regulatory strategies are:
•
•
•
•
•
•
•
•
Command-and-control;
Self-regulation and enforced self-regulation;
Incentive-based regimes (e.g. taxes and subsidies);
Market-harnessing controls (e.g. competition laws, franchising, contracts);
Disclosure regulation;
Direct governmental action;
Legal rights and liabilities; and
Public compensation/social insurance schemes.276
And beyond tools and strategies there is the important but difficult process of implementation.
Within health systems, there are two different possible public purposes for introducing regulation: social
and economic policy objectives; and health sector management mechanisms. Within the former include:
equity and justice; social cohesion; economic efficiency; health and safety; informed and educated citizens;
and individual choice. Within the latter include regulating quality and effectiveness, patient access, provider
behaviour, payers, pharmaceuticals, and physicians.277
A wide range of bodies can be involved in regulations: the legislature and government; other governmental,
quasi- and non-governmental actors; regional or local authorities (e.g. Land in Germany); and selfregulatory private-sector entities such as the medical profession.
A continuum of state authority and supervision can be observed, ranging from the command-and control
approach characterised by entities with full state ownership (e.g. hospital directly managed by the health
service) and a range of steer-and-channel regulation. Within the more arms-length approach of the latter,
there are many possibilities, ranging from:
•
•
•
Entities with full state ownership but managerially independent (e.g. NHS trusts in the United
Kingdom; public hospitals in Austria and Germany);
Private not-for-profit entities with statutory responsibilities (e.g. sickess funds)
Private not-for-profit entities without statutory responsibilities (e.g. not-for-profit hospitals in
Belgium, Germany, the Netherlands);
275
R.B Saltman and R Busse, "Balancing Regulation and Entrepreneurialism," in Regulating Entrepreneurial
Behaviour in European Health Care Systems, ed. R.B Saltman, R Busse, and E Mossialos (Copenhagen: WHO
Regional Office for Europe, 2002).
276
R Baldwin and M Cave, Understanding Regulation: Theory, Strategy and Practice (Oxford: Oxford University
Press, 1999).
277
Saltman and Busse, "Balancing Regulation and Entrepreneurialism."
97
•
•
Private for-profit providers with continuous service relationships with the public payers (e.g.
office-based specialists in Germany, for-profit hospitals contracted by public payers in Italy and
Portugal); to
Private for-profit companies (e.g. pharmaceutical companies, private insurance companies).
4.1 Performance indicators
One possible strategy within health sector regulation is collecting performance indicators and, in some
cases, making these publicly available. Performance data that is released to the public arguably serves to:
increase public accountability of health care organizations, professionals and managers; and to maintain
standards and improve quality.278 There are several assumptions underlying this argument that may or may
not be met in practice:
•
•
•
•
•
Patients make rational choices
Information asymmetry between purchasers/providers/patients is minimal or, at least, not highly
influential
Purchasers contract on quality (including safety) not just price
Providers respond to a reduction in patients by improving quality instead of cream-skimming
That there is a direct relationship between strategies of care and outcomes
Evidence that reporting performance to the public improves quality is mixed. The evidence suggests that in
some countries patients do not routinely use performance data to choose providers (Denmark, some in the
US). However, early evidence from the US, Denmark and New Zealand suggests providers respond to
publicly reported performance data. And recent evidence from the US shows that some purchasers are using
information on performance to incentivise providers when negotiating contracts.279
It is important to consider the country context when evaluating the success of a regulatory mechanism. For
instance, in Denmark national reporting at the provider level was introduced in an attempt to standardize
care nationally for six disease groups.280 In the Netherlands, national reporting of individual insurers and
providers was intended to simulate payer and provider competition, and patient choice. Finally in Canada
and New Zealand, national reporting of province/regional levels served to improve public accountability,
and thereby incentivise provider performance on certain indicators such as waiting times. Table 4.1
describes some of the efforts underway in several countries to collect performance data from the insurance,
provider and hospital level and release that information to the public.
The Danish indicator project was established in 2000 as a mandatory, multidisciplinary quality
improvement project to improve care in six disease groups nationwide: stroke, hip fracture, acute surgery,
schizophrenia, heart failure, lung cancer, and diabetes. They measured quality of care at unit, county,
national and international levels. In terms of public reporting, they found that provider organizations are
sensitive and responsive to published information; that quality reports act as a catalyst for activities; and
that it is associated with improved processes and outcomes of care. The evaluators of this project concluded
that the publication of performance data is professionally accepted when coupled to audit comments; can
278
M. N. Marshall et al., "Public Reporting on Quality in the United States and the United Kingdom," Health Affairs
22, no. 3 (2003).
279
A.M. Epstein, T.H. Lee, and M.B. Hamel, "Paying Physicians for High-Quality Care," The New England Journal of
Medicine 350, no. 4 (2004), N.I. Goldfarb et al., "How Does Quality Enter into Health Care Purchasing Decisions?,"
(New York: The Commonwealth Fund, 2003), Jan Mainz et al., "Nationwide Continuous Quality Improvement Using
Clinical Indicators: The Danish National Indicator Project," International Journal for Quality in Health Care 16, no.
S1 (2004).
280
Mainz et al., "Nationwide Continuous Quality Improvement Using Clinical Indicators: The Danish National
Indicator Project."
98
enhance improvement activities; has clear effects on priority setting; yet lacks any impact on patient
empowerment.281
Table 4.1 Countries that collect and release
Insurance funds/regional
authorities
United States
Comparative performance
of health care insurance
plans is publicly available
The
Netherlands
Denmark
New Zealand
France
Canada
performance indicators to the public
Health care
Hospitals
providers
In 2005, the
Safety-related reporting,
Ambulatory care
such as adverse incidents
Quality Alliance
and hospital acquired
selected a ‘starter set’
infection rates. Hospitals
of 26 clinical
voluntarily report data on
performance measure
indicators of the quality of
for the ambulatory
care for acute myocardial
care setting.
infarction, congestive
heart failure and
pneumonia.
Information on contents,
Information on prices, The Dutch inspector for
prices and services are
quality and waitinghealth care (IGZ) has
collected.
times are collected.
developed a data-set on
the quality of Dutch
hospitals. It is now
working on a minimum
set of demands.
Information about the performance of, and quality of care provided by, health plans,
hospitals, primary care groups and nursing homes is freely available.
Publicly disclosed
Waiting times for surgery
information is at regional
and cancer treatment.
and sub-regional levels.
Key outcomes, e.g.
improved health
(particularly chronic
disease management), and
reducing inequalities, are
collected
Performance data from A technical Agency for
public and private
Information on Hospital
providers is mandatory Care (ATIH) was recently
and publicly disclosed set up to manage the
through accreditation
information
reports. Providers are
systematically collected
evaluated on several
from all hospital stays.
dimensions including
quality of care,
information given to
the patient, medical
records, general
management, risk
prevention strategies.
Data for an agreed set of
indicators on health status,
health outcomes and quality
281
Jan Mainz and Paul D. Bartels, "Nationwide Quality Improvement--How Are We Doing and What Can We Do?,"
International Journal for Quality in Health Care 18, no. 2 (2006).
99
Germany
of service from the
provinces/territories are
reported in a central public
website.
Regional authorities use
performance data to
identify low- and highperforming hospitals.
In 2007, Germany will
begin a national
quality benchmarking
project in ambulatory
care.
The 2001 national
benchmarking program
monitors the safety and
quality of care in
hospitals; quality of care
for 26 conditions or
procedures, using 10-15
evidence-based indicators
for each. Data are
collected electronically
and shared among
participants.
4.2 Regulating the health system in Austria
Austrian’s Social Insurance system is characterised by various models of health care provision which are
defined by the relationship between the social health insurance fund and the health care provider.
Not only are there integrated providers (in Austria these are called “proprietary/own institutions of social
insurance”) but also contractual relationships with various providers of health care services. Direct
reimbursement of providers also takes place, mainly in the context of a partial refund paid by social
insurance to the insured for services consumed at providers who have not signed a contract with social
health insurance.
Integrated provision of care – institutions of social insurance
Social insurance funds provide health care services to their insured population, in accordance with existing
legal regulations, in both their own inpatient and outpatient institutions/clinics. These institutions are fully
integrated with respect to supply and reimbursement. Institutions of the insurance funds are ambulatories,
accident hospitals, spas and rehabilitation clinics.
In the field of inpatient care social insurance funds operate one general hospital (Vienna regional sickness)
with 468 beds, seven accident/emergency hospitals (AUVA) with 916 beds, 30 hospitals providing
specialised care (primarily in the area of rehabilitation) (Sonderkrankenanstalten) with 4,049 beds, 12
sanatoria with 986 beds and 5 convalescent and recreation homes with 525 beds.282 Details on regional
distribution of these can be found in Appendix 7.
In the ambulatory setting social insurance funds run 159 outpatient clinics (46 general specialist outpatient
clinics, 82 outpatient clinics for dental care and 31 institutions for preventive services and other
institutions).283
Contractual relationships
Relations between health insurance funds and their contractual partners are regulated by contracts (under
private law) and in laws (sixth part of the General Social Security Act, hospital laws of the Federation and
the federal states). In individual cases always both sources should be consulted. The health insurance funds
sign contracts with various health care providers in order to meet their legal obligation to supply their
insured population with services in kind. Contractual partners of social insurance are defined as all
individual persons or health care institutions providing medical or comparable services on the bill of social
282
283
Hauptverband der österreichischen Sozialversicherungsträger, reporting year 2005, published July 2006
Hauptverband der österreichischen Sozialversicherungsträger, reporting year 2005, published July 2006
100
insurance, including amongst others doctors, dentists, midwives, pharmacists, truss makers, orthopaedic
technicians, psychotherapists, psychologists, hospitals and Patient Transport Ambulance Services.
Within Social insurance a distinction is made between general contracts and individual contracts, the first
can be either curative or other general contracts.
Subject to the condition that the health care provider has a representative lobby (representation of interest
i.e. professional organization), initially a general contract is signed284 and at a later stage individual
contracts with the single health care providers. In case no general contract is accomplished or if a general
contract is cancelled, services for patients are provided as benefits in cash instead of kind, meaning they
have to pay when accessing i.e. consuming services. They are entitled to a partial refund by social insurance
at a later stage if they send the invoice of the consultation to their sickness fund (80% of contractual tariff).
In the event of a situation without a valid general contract (vertragsloser Zustand) all individual contracts
loose their validity. For the psychotherapists a special solution was created, as up to today no contract was
accomplished with the Hauptverband, whereby the regional sickness funds have signed contracts with the
professional associations (Vereine).285
In 2005 Austrian social insurance had 8.145 contract doctors representing 55% of all free-lance doctors286
(4.285 general practitioners and 3.860 specialists) and 2.894 contracts with dentists representing 81% of all
free-lance dentists. Details on the number of contract doctors can be found in Appendix 8.287
The signing of an individual contract with social insurance by a health care provider does not result in the
creation of an employment status. The provider continues to work on a self-employed basis.
Lump sum payments
For the hospitals funded by the federal health care agencies (fund-hospitals) the agreement according to
article 15a of the Federal Constitutional Act is regularly signed by the Federation and the federal states. The
new article 15a- agreement which was negotiated between representatives of the Federation and the federal
states during the second term in 2004 is valid for 2005-2008 and has the title “organization and funding of
the health care system”.
In contrast to the Federation and the federal states, whose contributions represent fixed cash payments and
fixed percentages of the respective revenue generated by value added tax288, social health insurance funds
render a lump sum towards the funding of public hospitals, which is based on § 447 para.1 ASVG and
covers all services of hospitals funded by the federal states’ health agencies (Landesgesundheitsfonds)
including inpatient care, semi-inpatient services, day-clinical services and services provided in outpatient
departments, always taking account for technological advances289. This lump sum covers around 42% of the
fund hospitals’ expenditures and is adjusted yearly according to the increase in social insurance
contributions. In the year 2005 Social insurance paid 3.384 billion Euros to the federal health agencies.290
Profit-orientated hospitals i.e. sanatoria which are not funded by the federal states’ health care agencies are
funded by uniform performance orientated methods. Every year health insurance funds pay a prospective
budget of 72.67 million Euros into a fund which was established in 2002 at the Chamber of Commerce,
284
Between the representatives, e.g. the regional Medical Chamber for the doctors working in practices in that
federal state and the Hauptverband for the respective sickness fund.
285
„The Hauptverband has to, according to § 597 Abs. 5 ASVG (together with the Federal Association of
Psychotherapy) „in preparation for a general contract develop a concept for psychotherapy, which has to include a
comprehensive economic cost-benefit analysis. The validity of existing contracts about the delivery of benefits
related to psychotherapy is not affected by this.“ The concept was developed by the Institute of Advanced Studies
in the course of the project „Concept for Psychotherapy” and analyses the provision of psychotherapeutic care in
Austria. The study report is available at the Hauptverband (source: Hauptverband, report for the conference of the
insurance funds on 30 November 2005, covering the topic; concept for psychotherapy, further proceedings
286
Excluding dentists
287
Hauptverband (2006). Handbook of Austrian Social Insurance 2006. Vienna
288
Tripold, M. (2005). Das österreichische Gesundheitssystem von 1945 bis in die Gegenwart. In Sprenger, M.
Eds. (2005). Public Health in Österreich und Europa, Lengerich, Pabst Science Publishers.
289
Services/benefits not covered in the course of the mother-child-pass examinations are services of out-patient
care. Furthermore benefits which social insurance and the federal states have explicitly decided to exclude.
290
101
(Privatkrankenanstalten-Finanzierungsfonds, PRIKRAF). The above mentioned fund, which is based on a
general contract between the Hauptverband and the Chamber of Commerce, includes 48 hospitals.291
Direct payments i.e. refunds by social insurance
Insured consulting health care providers who have not signed a contract with social insurance have to pay in
cash for the services consumed. After the consultation the insured has the option of sending the invoice to
his health insurance fund claiming a partial refund. The cash refunds are usually a maximum of 80% of the
costs which would have resulted had the insured accessed a contract provider, reduced by possible user
charges payable by the insured.
According to the statistics of the Austrian Medical Chamber (December 2005) Austria has 7,312 private,
non-contract doctors with a practice. Out of these 2,013 are General Practitioners, 4,526 specialists and 773
dentists.292
The number of consultations of private providers without a contract with social insurance has risen over the
past years; nevertheless, for most of the health insurance funds, they hold a share of less than 10% of the
total consultations.293
4.2.1 Independent monitoring agencies
The Austrian health system does not have an independent supervisory commission that is comparable to the
Audit Commission in the UK. The Austrian system is hierarchical whereby duties and responsibilities are
primarily defined by law. It is mainly organised in a federal way, not only in the area of social insurance
funds but also in hospital care. Depending on the region the sanitary agencies of the federal states may have
a range of duties and responsibilities, primarily in the area of hospital care but formally also in the area of
community care (physicians in surgeries).
The central responsibility in the health system lies with the federation, which assigns it’s duties within the
framework of the related federal administration to the federal states or, in form of self-administration, to the
social insurance funds.
Within the framework of self-administration, the social insurance funds operate free of directives but under
the state supervision of the appropriate ministry (see also §§ 448 ff. ASVG). External supervisory bodies of
social insurance are, amongst others, the audit board, which is responsible for financial control.
The supervisory bodies of the social insurance funds are the Ministry of Health and Women (BMGF) (since
1.05.03, earlier the Ministry of Social Security and Generations) for the national health insurance and
accident insurance, as well as, the Ministry of Social Security, Generations and Consumer Protection for the
legal pension insurance and the Main Association of Austrian Social Insurance Funds (Hauptverband). The
Ministry of Finance protects the financial interests of the federation, is involved in the budgets for hospitals
and care facilities, and is the supervisory body of the Main Association of Austrian Social Insurance funds
(pension insurance funds). The Ministry of Justice and the Ministry of Defence are carriers of some
hospitals, the Ministry of Education, Science and Culture is responsible for securing medical education at
the university (human medicine, dentistry). The Ministry of Social Security, Generations and Consumer
Protection has the directive over unemployment insurance.
Where the regional area of an insurance fund only encompasses a single federal state and does not exceed
its boundaries, then the head of that federal state is responsible for the immediate supervision, of health
insurance funds only when they have less than 400 000 insured persons.294
291
Mag. Sinabell (Austrian Medical Chamber). 23 January 2006. Status December 2005 (via email)
293
Answers of the sickness funds to the questionnaire sent to them in November 2005
294
292
102
The supervisory bodies have a duty, within their area of responsibility, to ensure that the legal requirements
of health care are fulfilled and complied with. In addition they oversee the financial conduct of the
insurance funds or the Association of Austrian social Insurance funds and test the expediency of the
administration (see §§ 448 ASVG).295 They have the right to veto and the right to inspection. The
supervisory bodies have the right to send delegates to meetings of the administrative bodies or the
Hauptverband (advisory function and right to veto). Important resolutions require the consent of the
supervisory body. It is not the duty of the supervisory body to carry out quality control.
Establishment of an independent institute for research and planning – Health Care Austria Plc.
On the 20th of April 2006 the Council of Ministers decided on the merger of the Healthy Austria Fund
(Fonds Gesundes Österreich, FGÖ) and the Austrian Federal Institute for Health Care (Österreichisches
Bundesinstitut für Gesundheitswesen, ÖBIG) to the “Health Care Austria Plc”. The “Federal Institute for
Quality in Health Care (Bundesinstitut für Qualität im Gesundheitswesen, BIQG) will also be integrated
into the Plc. The decision of parliament was taken on the 23rd of May, accompanied by severe criticism of
the opposition.
The legal basis is the Federal Law on the Health Care Austria Plc (Bundesgesetz über die Gesundheit
Österreich GmbH, GÖGG).
According to the Minister of health, Rauch-Kallat, the new company should be an independent national
institute for research and planning for the entire health care system.296 The new institute will be responsible
for providing the basis for decision-making for structural planning in health care provision as well as for
developing guidelines for quality assurance and health care promotion. Duties are regulated in § 4 GÖGG
and are divided according to business divisions (division ÖBIG, division BIQG, division FGÖ).
Bodies of the Plc. are, based on § 7 ÖGGG, the general assembly, the managing director, the institutional
assembly and the board of trustees. Moreover advisory boards are to be established. The company has to
nominate a managing director (by means of public advertisement for a max. of 5 years), who may, by
decision of the federal minister of health and women, be complemented for a defined limited time period by
the prior managing directors of the ÖBIG (until latest 31 May 2009) and the FGÖ (until latest 30 September
2006).
The institutional assembly is made up of 27 members originating in equal shares from the Federation, the
federal states and Social Insurance (9:9:9). The chair is held by the Federal Minister of Health and Women.
Among the members 2 substitutes are elected (from the group of the members of the federal states and from
the group of the members of Social Insurance respectively).
Already during the phase of assessment the merger of the institutions (ÖBOG, FGÖ, BIQG) was rejected by
all sorts of groups involved. Several federal states, the Chamber of Commerce, the Chamber of Labour and
the Hauptverband stated their rejection. Especially the choice of the legal form of a Plc. was criticised. 297
The employees of the ÖBIG warned that the costs of the Ltd have been underestimated and that the
consequences have not been considered.298The SPÖ and the Green Party voted against the law. The Medical
Chamber gave an extremely negative statement.
295
Federal Ministry of Health and Women 20.04.2006 11:31 Rauch-Kallat: Health Care Austria Plc. Will be a
strong institution for research and planning for the health care sector.“, accessed at www.bmgf.gv.at on
30/05/2006
297
Statement of the Chamber of Labour to the Federal Ministry of Health and Women, sent on 7 April, accessed
at http://www.konvent.gv.at/pls/portal/docs/page/PG/DE/XXII/ME/ME_00401_42/fname_061366.pdf on
30/05/2006
298
Statement of the ÖBIG-employees regarding the draft of the law by which the Health Care Austria Plc. is
brought to life. Accessed at
296
103
Doubts are raised in relation to the impartiality of the institute which will be owned by the Federation to
100%. The Plc. will operate completely independent and without being accountable to other institutions
(weisungsfrei).299 According to § 14 (1), the company should be managed based on commercial principles
(profitability, frugality, fitness for purpose). Work of the ÖQMed will not be affected by the new
institute.300
4.2.2 Extent of decentralization of regulatory functions
This section describes responsibilities in the Austrian health care system, detailing which actor performs
which activities. Furthermore it is discussed if these are implemented by the person/organization
himself/themselves or if they are referred to another position/ institution. In case of the latter, information
on the type of decentralization is given. A table was chosen as means of presentation in which functions i.e.
areas of service provision are assigned the institution responsible for implementation as well as the type of
referral of authority applied.301 The examples listed in Table 4.2 are not exhaustive.
In the Table 4.2, adapted from a study by Hofmarcher and Rack (2006), the authors describe the main
decision-making authorities in the Austrian health care system whereby they distinguish between different
areas of services provided. For each area they list the sources of funding, the share of the Austrian health
care expenditure consumed (in %) as well as the responsibilities i.e. authorities with regard to the provision,
the quality assurance and the reimbursement of the service. The table includes ambulatory-, inpatient and
long term care.
Responsibilities are either centralised (authority of the Federation), delegated (transferred to lower levels)
or given over to higher levels by means of devolution. Deconcentration (the transmission of administrative
responsibilities i.e. power to regional authorities which remain accountable towards the higher levels i.e.
are subordinate to a higher body) is hardly applied in Austria.
Many cases concerning the transferring of duties i.e. decision-making authorities could also be described as
regionalization, for instance if these are given to the federal states or the health insurance funds. Numerous
functions in the health care system are undertaken by private entities (e.g. private hospitals, welfare
institutions, self-help groups, organizational privatization of public hospitals) or by private individuals (e.g.
dependants).
http://www.parlament.gv.at/pls/portal/docs/page/PG/DE/XXII/ME/ME_00401_04/imfname_060866.pdf, on
30/05/2006
299
Dannhauser, C. (2006). ″Power struggle: turbulences related to the health care Austria Plc.“, Die Presse,
19.05.06, accessed at www.diepresse.com, on 30/052006
300
Ärztemagazin, accessed at http://medical-tribune.at on 30/05/2006
301
Based on table 10 in the Chapter Decentralization of the Austrian’ Health Care in Transition Report 2006
(Hofmarcher, M., Rack, H.M., 2006).
104
Table 4.2 Decision-making authority and public funding for different types of services in the
Austrian health care system, 2005
Public
funding
in%
of
PHEa
19.3
11.0
1.2b
Type of service
Provision
General
practitioners,
Medical specialists,
Dentists in their
practices, Other
health care
professionals,
Ambulatory clinics
Drugs
Medical devices
Rehabilitation
Hospitals including
outpatient
departments
0.9
Health care
promotion
Prevention
Reimbursement
Regionalization,
delegation to health
insurance funds,
Scope for voluntary
services of health
insurance, partially
integrated provision of
care
Regionalization and
delegation to health
insurance funds for
reimbursable drugs
Federal laws
Professional
bodies including
the health
insurance funds
Delegated to health
insurance funds,
general contracts
determine the
individual contracts
Federal laws,
Authorization of
pharmaceuticals,
Monitoring,
Social insurance
Delegated to social
insurance funds;
Partially integrated
provision of care
Regionalization;
Responsibility of the
federal states based on
the B-VG and KAKuG;
For occupational
accidents delegated to
social insurance funds
and integrated
provision of care
Federal law
Delegated to health
insurance funds:
reimbursement,
pricing negotiations
are undertaken by
the Hauptverband,
Calculation of the
average price in the
EU (upper price
limit), authority of
the Federation
Delegated to social
insurance funds
Authority of the
Federation and the
federal states; partially
delegated to social
insurance funds
Federal Laws:
Fund Healthy
Austria (Health
Care Austria Plc.),
partially delegated
to the federal
states and social
insuranced
Provisions in
federal and
regional laws
Sanitary control
by the Federation;
Authorization of
the hospitals by
the federal states
Contributions: 40%
Taxes: 60%
41.1
Quality work
Day-to day
operations:
regionalised and
delegated to
regionally organised
funds;
Decentral
mechanisms of
distribution to
hospitals (per case
payments),
subsidies and
investments:
regionalised,
responsibility of the
federal states i.e
funds
Partially delegated
to the regional
sickness funds,
General contracts
105
Taxes
18.3c
Public Health
Services
(e.g. Public Health
Officers, social
services,
environmental
medicine)
Authority of the
Federation,
the federal states and
the local governments /
municipalities
Long-term care
Federal states
Private providers
Dependants
(informal care)
Federal and
regional laws, in
terms of
organization
mostly delegated
to the federal
states, further
transferral to the
local authorities
Regional laws for
nursing homes
Devolution to the
federal states
Further transferral
to the local
authorities (local
sanitary authority)
Decentralised
allocation of the
nationally uniform
cash benefit (based
on need) – long
term care allowance
- by the pension
insurance funds
B-VG=Law of the Federal Constitution (Federal Constitutional Act), KAKuG= Federal law for hospitals and
convalescent homes
a
PHE=Public health expenditure: including federal cash allowances for long-term care, 2003
b
only medical rehabilitation in health insurance
c
including expenditures of the federal states for health promotion
d
health promotion and prevention strategy of social insurance 2005-2010.
8.3
Sources: IHS Health Econ 2005; Hofmarcher, M., Rack, H.M. (2006). Health Systems in Transition. Austria.
Copenhagen, World Health Organization on behalf of the European Observatory on Health Systems and Policies.
In the health care system a great variety of methods i.e. instruments are used to exert regulation. The
following table lists some of these as well as giving examples of areas of application in the Austrian health
care system. The list is exemplary, not exhaustive.
Table 4.3 Regulatory instruments in the Austrian health care sector
Regulatory instrument
Examples of health care regulations
-
Legislation/ command and
control
-
Self regulation and enforced
self regulation
-
Incentives
-
Establishment/ Authorization/Extension of health care institutions
Training-/ Eduction provisions, -requirements
Sanitary control of health care institutions
Obligations for documentation
Obligation to report (communicable diseases)
Requirements for statutory insurance
Obligation to treat
Social insurance (e.g. collection of contributions, Filling of free posts
as contract partners for social health insurance)
Quality control of community physicians by ÖQMed
Continuing further education for doctors and other health care
professionals, e.g. pharmacists (representative bodies, Chambers)
Partially on the level of Municipalities/ Districts, to encourage doctors
to work in structurally disadvantaged areas
Subsidies of health insurance funds when introducing/implementing
new IT
Various subsidies for establishment of barrier free access
Incentives of health insurance funds in the general contract i.e. the fee
structure, e.g. performing some additional training in order to bill
certain services with the health insurance fund
106
-
Market harnessing
-
Disclosure
-
Direct Action
-
Rights and liabilities
-
Compensation
-
Free choice of doctor
Fees of private health care providers
Private health insurance
Hospital associations
Quality reporting302
Surveys on patient satisfaction
Health care information centres (e.g. of some health insurance funds
Development of guidelines and treatment pathways by specialist
associations (of medical specialties) or health insurance funds
Advertisment and allocation of free posts with social health insurance
Websites (of health care providers, e.g. of hospitals)
Licensing of medication
Price range for medicines
Education/ Training related matters
Public Health
Health care planning
Monitoring institutions (hygiene)
Quality assurance303
Contribution of the Federation for Social Insurance (SVAgW, SVB)
Patient Charta
Contracts with health care providers (z.B. General contract with
physicians)
Disagreement register for organ donations
Obligation to report (statutory insurance, adverse side-effects of
medication, communicable diseases)
Obligation for continuous education and training
Obligation to treat emergencies
Obligation to treat based on general contract
Medical error (liability insurance, extra-judical agreement)
Accident insurance (Integrity compensation / Integritätsabgeltung gem.
§ 213 a ASVG)
4.2.3 Regulating purchasing
The Fiscal Constitution law (Finanz-Verfassungsgesetz) composes the general framework of the financial
relationship between the Federation, the federal states and the local governments (municipalities). It states
that the regulation and collection of taxes is primarily to be performed by Federation, the revenue is
distributed among the Federation, the nine federal states and the communities according to the Financial
Equalization Act (Finanzausgleichsgesetz). The latter defines that each local/regional authority has to in
principle cover its own expenses. Furthermore it enables central government to allocate rights of taxation
and defines that the performance of the local/regional authorities is to be considered in the context of the
financial equalization.304
Another significant legal foundation for the system of funding, particularly for inpatient care, pertaining an
important co-ordinating function is the agreement reached between the Federation and the federal states
pursuant to article 15a of the Federal Constitutional Act. This agreement is negotiated on a regular basis
(every 4 years).
302
Not yet published by the BMGF (Federal Ministry of Health and Women)
Austrian Federal Institute for Quality Assurance (Bundesinstitut für Qualitätssicherung), in future part of the
Health Care Austria Plc. (Gesundheit Austria GmbH)
304
303
107
Funding within Social insurance is equally regulated by law, namely in the General Social Security Act
(ASVG) and in the relevant Social Security Acts for the other professions (Self Employed, Civil servants,
Farmers, etc.). These include any regulations related to contributions (§§ 44 ASVG et sqq.) as well as the
benefits package of Social health insurance (§§ 116, 117 ASVG). Concerns on reimbursement of health
care providers by social insurance are covered in the sixth part of the ASVG, furthermore in contractual
arrangements (general contracts, individual contracts, reimbursement schemes, etc.) and other arrangements
(for instance Musterkataloge (sample catalogues of benefits) of the Hauptverband).
42% of fund-hospital expenditure is covered by Social health insurance. The funding structure of the socalled fund hospitals between 1996 and 2002 is demonstrated in Figure 4.1.
Figure 4.1 Sources of funding for inpatient care – returns of the Austrian fund hospitals, 1996-2002
100%
90%
80%
Sonstige
70%
Patienten
Private KV
60%
Rechtsträger
50%
Sozialhilfe
40%
Gemeinden
Land
30%
Bund
20%
SV
10%
0%
1996
1997
1998
1999
2000
2001
2002
SV=Social insurance, Bund= Federation, Land= Federal states, Gemeinden= Local governments/municipalities,
Sozialhilfe= Social welfare, Rechtsträger= hospital carrier, Private KV= Private health insurance, Patienten= Patients,
Sonstige= Other
Other: mainly payments for medical services provided by one fund-hospital carrier for another or payments between
fund-hospitals of the same hospital carrier (Mag. Pazourek, 29/09/2006)
Source: Hauptverband, Database „White book“ accessed 30/03/2006
Physician services are mainly funded by social health insurance, partially also by private households (noncontract doctors). The areas of prevention and health promotion are financed by social insurance
contributions and by tax payments. Social welfare payments are covered mainly by the federal states and
the communities, long term care services by the Federation and the federal states.
A budget for private hospitals (PRIKRAF fund) is defined on a regular basis between the Chamber of
Commerce (representative of the private hospitals) and the Hauptverband (representative of sickness funds).
This fund is used to cover the inpatient services provided for insured in 48 private hospitals.305
Role of government in relation to purchasers
The Austrian Constitution regulates that central responsibility for the health care system lies, apart from a
few exceptions, with the Federation. Government delegates most of these tasks to the federal states by
indirect federal administration arrangements or to Social insurance by way of self governance.306
305
108
One of the few areas for which central government does not assume total responsibility is in the hospital
sector. Here the basic law is defined by the Federation; the regional states are in charge of enacting and
implementing it whilst central government accounts for sanitary supervision (see Article 12 B-VG).
Legislation and implementation of laws in Social Insurance is, according to Article 10, paragraph 1 Z of the
Federal Constitutional Act, responsibility of central government. Organization is, as already mentioned
before, carried out by means of self-governance. Central government maintains a certain right of
surveillance. Regarding issues of financial equalization the Ministry of Finance is responsible. Furthermore
it is supervisory body of the Hauptverband (the pension funds). The Austrian Court of Audit and the tax
authorities perform external controls.
The legal basis within Social insurance represents the General Social Insurance Act (ASVG) as well as the
Social Insurance laws for professions other than the employed. As already indicated all issues related to
contributions are covered in the above stated legal documents in great depth.
The basic legislation concerning social welfare is the authority of central government, enacting legislation is
responsibility of the federal states, whereby social welfare is partially completely assigned to the federal
states’ sphere of competence (Art. 15B-VG).
Activities of private health insurance companies are subject to control of the Financial Market Authority.
Budgets of purchasing organizations
Funds of the Federation are generated by tax revenue and are, as already mentioned before, divided between
the Federation, the nine federal states and the communities according to the terms stated in the financial
equalization Act.
Financial resources in social insurance are not distributed by a central fund but are generated primarily by
income-based contributions of the insured population. Austria has 21 insurance funds (9 regional funds, 7
occupational funds, the Insurance Fund of the Austrian Railway and Mining Industry307, the Social
Insurance Fund of the Farmers, the Austrian Social Insurance Authority for Business308, the Insurance Fund
of the Civil Servants and the Insurance Fund of the Austrian Notaries). Each fund is responsible for the
collection of the contributions of its insured population.309
Austrian Social insurance is funded by various sources. Insurance contributions310, amount to 81.0%, the
share of the Federation represents 11.0% and other revenues came up to 8.0% (allowances for income
support (Ausgleichszulage), other allowances, cost sharing, etc.). 311 In the year 2005 the effective returns of
Social Insurance added up to around 39.374 billion Euros.
The Austrian Social insurance system is a pay-as-you-go system. Resources needed during a certain period
of time are funded by contributions generated in the same time period. The insured does not finance his
personal services but contributes solidarity to the funding of the whole system. The pay-as-you-go system
facilitates solidarity equalization between healthy and ill (mainly health insurance, accident-, pension
insurance) as well as between generations (pension insurance), referred to as the generation contract.312
Furthermore between men and women as well as insured without dependants and insured with dependants.
306
ibid
Merger of the Insurance fund of the Austrian Railway Industry with the Insurance Fund of the Austrian Mining
Industry in 2005
308
the merger of the Social Insurance Fund of the Farmers with the Austrian Social Insurance Authority for Business
(SVA) is currently taking place and should be finalised by the beginning of the year 2007.
309
Partially transfer payments (Kostenersätze) are made between the different types of funds (health insurance and
accident insurance)
310
Including contributions of the equalization fund for the pension insurance funds.
311
Hauptverband der österreichischen Sozialversicherungsträger (2006). Handbook of Austrian Social insurance 2005.
Vienna
312
307
109
Figure 4.2 Sources of income in social insurance, 2005
8%
11%
Insurance contributions
Federal government
Other income
81%
Source: Statistical handbook of Austrian Social Insurance 2006
The Federation renders a contingent liability (Ausfallshaftung) in pension insurance, provided that the
contributions of the insured do not cover all the expenses. With the self-employed, Federation substitutes
the employer and pays the difference between the own contribution and the total sum. The state subsidy
also covers any deficit caused by people changing insurance funds313 or financial resources for substitute
qualifying periods314 which are not met by third parties as well as expenses for granting compensatory
allowances for reduced earnings. With accident insurance the federal state covers part of the contributions
of the insured of the Farmers sickness fund.
In social health insurance close to 83% of the income is made up of insurance contributions (out of this
roughly 47.2 % for employed, 5% for self-employed, 1.7% for unemployed, 22.6% for pensioners and 1.0%
for voluntarily insured) and about 5% are generated through additional contributions (for dependants in
health insurance). About 4.3% are generated by additional contributions (in health insurance, for
dependants). 315
When collecting contributions sickness funds are quite frequently confronted with the problem that
contributions are either paid too late or are uncollectible. If contributions were paid duly this could result in
a surplus for the sickness funds instead of being confronted with a deficit. Only in the 2005 the regional
sickness funds had to amortise 155 million Euro as uncollectible contributions, representing about the
fivefold amount of the total deficit the sickness funds made (31.7 million Euros). To improve the payment
behaviour one is thinking of increasing interests for delay.316
Private health insurance companies fund their services by means of the contributions of their insured
population. The market is dominated by few (8) market participants. UNIQA held a share of nearly 50% in
2004, Wiener Städtische of about 20%, Merkur and Generali each a little bit more or less than 13%. The
remaining private health insurers each occupy shares of less than 3%. The largest items in terms of
expenditure are payments for hospitals, dental care and physician services.317
313
Equalization payments in pension insurance if a person changes his insurance fund
times for raising children, for the care of relatives, for unemployment, for military service
315
Hauptverband der österreichischen Sozialversicherungsträger (2006). Statistisches Handbuch der
österreichischen Sozialversicherung 2006. Wien
316
Kurier, 25.04.06, health insurance funds in debt, accessed at http://www.kurier.at/wirtschaft/1348273.php, on
26/04/2006 No author (2006). ″Sickness funds – lost contributions.″ Ärztemagazin 17:2006, accessed at
http://www.medical-tribune.at/dynasite.cfm?dssid=4169&dsmid=73550&dspaid=570851 on 09/09/2006
317
Association of private insurance companies (Versicherungsverband Österreich) (2006). Yearly Report 2005.
Accessed at www.vvo.at, on 27/04/2006
314
110
Private households cover around 27% of health care expenditure, out of which about 57% are indirect user
charges and 43% are direct user charges.318 Expenditures of private households include expenses for
inpatient care, ambulatory care, medical products, appliances and equipment.319
Risk pooling or revenue sharing arrangements
In Austrian Social Insurance various instruments for financial equalization are adopted, not only between
the different branches of insurance (health-, accident-, pension insurance), but also between the different
funds. The intention of these systems is to promote co-ordination between the funds as well as equalization.
The Hauptverband is in charge of equalising and distributing financial resources. Before describing two of
the equalization funds used in health insurance in detail it is important to state that these equalizations funds
only dispose over minor amounts of financial resources, which obviously reduces the equalization effect
obtained.
Equalization fund of the regional sickness funds320
The equalization fund of the regional sickness funds should, according to § 447a ASVG guarantee an equal
financial performance i.e. liquidity of the regional sickness funds and render payments to the funds in
accordance with the available financial resources and the legal definitions.
Originally the equalization fund included all health insurance funds which were considered relevant due to
their size (the insurance fund of the Austrian Mining Industry, the Austrian Social Insurance Authority for
Business, the Social Insurance Fund of the Farmers (from 1.1.2001), the Insurance Fund of the Civil
Servants (from 1.1.2003), the Insurance Fund of the Austrian Railway Industry (from 1.1.2003). In March
2004 the Constitutional Court ruled that the equalization fund as well as regulations on the equalization of
structural differences and agreements on goals were partially not compatible with the Constitution. Due to
this the respective regulations were abolished.
The equalization fund was unconstitutional because it caused a disadvantage inherent to the system i.e.
favoured individual sickness funds. Because of higher contribution rates i.e. additional sources of revenue
(e.g. user charges) individual sickness funds assumed an above average burden through the mechanism of
the equalization fund. Sickness funds experiencing a comparably favourable financial situation were put at a
disadvantage not only with respect to the contributions into the fund but also with respect to the transfer
payments of the fund. The Constitutional Court decided that the inclusion of the following sickness funds
violates the basic equality right and thereby is unconstitutional: Insurance Fund of the Civil Servants,
Insurance fund of the Austrian Railway Industry, Insurance Authority for Business (SVA), Social Insurance
Fund of the Farmers.321
318
319
Statistics Austria, accessed at www.statistik.at, on 27/04/2006
320
§ 447a und § 447b ASVG, 1483 of the appendices to the stenographical protocols of the National Asssembly XXII.
GP Report of the Committee for Labour and Social Affairs on the government draft (Regierungsvorlage) (1408 of
appendices): Federal Law changing the General Social Security Act, the Social Security Act of the self-employed, - of
the Farmers, -of the civil servants, Unemployment Act 1977 und das Special Support Act
(Sonderunterstützungsgesetz) (Law to change Social Security Laws (Sozialrechts-Änderungsgesetz) 2006 – SRÄG
2006), accessed at http://www.parlament.gv.at/pls/portal/docs/page/PG/DE/XXII/I/I_01483/fname_063470.pdf on
21/06/2006
321
Holzweber, D. (2004). ″Re-organization of the health care insurance funding unconstitutional.″ Soziale Sicherheit
4, pp. 126-127
111
The regional sickness funds and the sickness funds of the miners still remained part of the equalization
fund.
In the year 2005 a restructuring of the equalization fund was agreed upon, based on the result of a project
headed by the regional sickness fund of Salzburg which aimed at formulating a scientific model for the
structural equalization between the regional sickness funds in the context of the regional equalization fund.
The funding of the regional sickness funds’ equalization fund which is situated at the Hauptverband remains
the same and takes place by:
1. Insurance contributions of the regional sickness funds– 2% of the income generated by the regional
funds through insurance contributions according to § 447 a para.3 ASVG
2. A lump sum according to § 1 para.2 GSBG322
3. Contributions according to § 3 DAG323
4. Revenues on assets (Vermögenserträgnisse)
5. Other revenues
The additional income generated by tobacco tax is transferred to the equalization fund by the Minister of
Finance. Two thirds of the sum are forwarded to the equalization fund for hospital financing (§ 447f), one
third goes towards the fund for preventive services and health care promotion (§ 447h).
10% of the equalization fund’s yearly revenue is allocated to a reserve which is only to be used for the
coverage of extraordinary expenses.
Revenues of the equalization fund should, apart from very few exceptions, be distributed to four areas
whereby the conference of the sickness funds (Trägerkonferenz) has defined the distribution between
respective areas.
For the year 2005, after deducting the earmarked financial resources for administration of a general hospital
(30 million Euro), 45% of the remaining sum are used for structural equalization, 45% for equalization of
liquidity and 10% for meeting special equalization demands. The distribution of financial resources of the
equalization fund to the regional sickness funds follows diverging regulations.
The resources of the equalization fund are, according to § 447a para.6 ASVG, to be used for equalization of
different structures, different liquidity and for covering special equalization needs.
The equalization of structural differences is performed based on § 447b ASVG, the equalization of liquidity
is based on the net assets of each insured entitled to access services and the coverage of a special
equalization need is met based on a defined distribution key.
Risk equalization (§ 447 para.1 ASVG) not only considers the revenue generated by contributions and by
the prescription charge but also the average cost for each insured (by age and sex) as well as for insured
who cause extraordinarily high costs. In addition to these aspects certain supply related factors such as
regional burdens are taken into consideration. Moreover burden resulting from the funding of hospitals
based on § 447f. ASVG.
Equalization fund for hospital financing
Within the scope of the equalization fund for hospital financing, according to § 447f, the sickness funds (all
but the insurance fund of the Austrian Notaries) pay a lump sum for hospital services324 to the health care
322
323
Law for subsidies for health care and social care (Gesundheits- und Sozialbereich-Beihilfengesetz)
Employer payments Act (Dienstgeberabgabegesetz)
112
agencies established in the federal states (Landesgesundheitsfonds). The size of the lump sum is negotiated
on a regular basis in the course of the negotiations on hospital financing related to the article 15a of the
Federal Constitutional Act. Every year the sum is adjusted according to the increase in insurance
contributions. The equalization fund for hospital financing has been administered by the Hauptverband
since 1978.
Financial transfers to the health care agencies of the federal states are executed in partial amounts, the
height of the payable amounts as well as the initial financial resources paid into the agency by the health
insurers is regulated by a predefined distribution key. The capital of the agency is generated by an
additional health insurance contribution as well as supplementary transfers of the sickness funds (based on a
distribution key). According to the financial equalization Act, additional financial resources for hospitals in
the period of 2005-2008 will be generated by increasing the contribution rate by 0.1%, by using income
from tobacco tax and by increasing the earning limit for chargeable contributions.
For the 48 private hospitals a fund was established at the Chamber of Commerce (representing the private
Hospitals and spa-institutions) in 2002, the so-called PRIKRAF Fund. It covers private hospitals with beds
which are not funded by the funds of the federal states. The PRIKRAF Fund represents a yearly lump sum
payment of the sickness funds of around 72.7 million Euros. 325
Further equalization instruments
A further equalization instrument is the “calculation group pension insurance” (Rechenkreis
Pensionsversicherung), which is in charge of the orderly processing of transfer payments to the pension
insurance funds made via the Hauptverband. The group is made up of all pension insurance funds apart
from the insurance fund of the Austrian Notaries.
In addition to the just described equalization mechanisms an equalization fund for the distribution of the
financial burden of the sickness funds related to expenses for hospital care (obstetric care) was introduced.
The legal basis is § 322a ASVG. This fund was established to compensate any unequal burden of sickness
funds arising through increases in insurance contributions, when paying the lump sum for hospital services.
Another fund is the fund for preventive services and health care promotion, according to § 447h ASVG
which is used for preventive services as well as measures of health promotion co-ordinated by the
Hauptverband.
4.3.5 Regulating provision
Health services for the care of the general public are, to a large extent publicly funded, mainly through
contributions of social insurance fund and tax money from the federation. Services are rendered by the
state, private non-profit organizations, and private individuals or organizations. The legal foundations in
which responsibilities in health care are defined are the Federal Law for Hospitals and Clinics
(Bundesgesetz für Kranken- und Kuranstalten), the corresponding federal state laws, the General Social
Insurance Law (Allgemeines Sozialversicherungsgesetz) as well as the special laws in social insurance
(GSVG, B-KUVG, BSVG, FSVG). Furthermore, agreements between the federation and the federal states,
above all the agreement according to Art. 15a B-VG, currently effective for the period 2005-2008, are
highly pertinent to hospitals. Fundamentally, almost all areas of the health care system are assigned to the
expertise of the federation, with the exception of hospitals. Here the federation provides the framework
324
The lump sum and cost-sharing of insured covers all services in hospitals used by insured or their dependants,
specifically inpatient services, semi-inpatient services, day clinic and ambulatory hospital services. Thereby taking
medical progress into consideration.
325
Hauptverband der österreichischen Sozialversicherungsträger, HVB (2006). Handbook of Austrian Social Insurance
2005, Vienna.
113
(KAKuG, Österreichischer Strukturplan Gesundheit, etc.), the responsibility for implementation lies with
the federal states. In general the federation does not carry out all the duties itself, but delegates many duties
to other players in the health system.
In Austria social insurance plays a central role when it comes to the provision of medical services for the
general public. Organised as a form of self-administration, the insurance community or rather its
representatives (divisions) are assigned numerous fields of expertise by the federation, such as the
collection of contributions or the negotiation of contracts with service providers. Through the signing of
contracts (general or individual) under private law directly with service providers or their legal
representatives, the social insurance assures area-wide medical care. In addition it has, in some areas, (e.g.
clinics, hospitals) its own facilities which supplement the network of contract partners.
Statutory health insurance must, in accordance with § 116 ASVG, ensure the provision of certain services.
The range of services can be voluntarily extended through the statutes (Satzungen) of the health insurance
funds. The service commitment or rather the range thereof is based on the recommendations of the Supreme
Sanitary Council (Oberster Sanitätsrat) and various internal expert bodies of the social insurance. The final
decision rests with the political decision makers.326 Aside from health insurance services, accident insurance
(§ 148a ASVG) services and pension insurance (§ 222 ASVG) services also play a role in the provision of
medical care.
The Contractual partners of social insurance are doctors, i.e., general practitioners and specialists (in 2005
8,145 or 55% of freelance doctors327 had contracts with the social health insurance328) and dentists (on
31.12.2005 2,936 dentists had a contractual relationship with social insurance, that is equivalent to 81% of
freelance dentists).329 Beyond this, contractual partners include clinical psychologists and psychotherapists,
pharmacists, hospitals (socalled fund-hospitals330, private hospitals and convalescent institutions),
rehabilitation centres, orthopaedic shoemakers, hearing aid acousticians and midwives.
In the field of hospital care it is, according to federal law (KAKuG), the duty of the federal states to assure
hospital care for the general public. The federation is responsible for policy legislation, the federal states for
execution legislation. This area of responsibility encompasses the construction and operation of public
hospitals or the completion of agreements with legal representatives from other hospitals to ensure
institutional care. The federal states must see to it that sufficient beds are available at standard tariff rates (in
the general wards) for those people requiring inpatient care. Capacity planning at federal state level must be
carried out in consultation with federal planning (Austrian structure plan for health (Österreichischer
Strukturplan Gesundheit), formerly the Austrian hospitals and equipment plan) or rather, must follow its
guidelines.
Provision of services in the field of public health (vaccinations, health care, health promotion, counselling
(amongst others for pregnant women, HIV sufferers)), as well as, social services and long term care services
is assured primarily by the federal states, and in part by local authorities and/or social health insurance.
Public health activities, above all, concentrate on sanitary control, provision of expert opinions and the
development of health promotion and prevention programs. Social insurance also provides measures for
health promotion; here the periodic health examinations (precautionary health examinations, juvenile
examinations) are inherently significant. Federal state health bodies (Landesgesundheitsplattformen) were
likewise allocated health promotion and prevention functions within the scope of the health reform 2005.
Furthermore, the implementation of health promotion measures was assigned to the Healthy Austria Fund
(Fonds Gesundes Österreich, FGÖ) within the framework of the Health Promotion Law
(Gesundheitsförderungsgesetz).
326
327
excl. dentists
328
2005, Vienna.
329
ibid
330
These are funded by the funds of the Federal Health Agencies in the federal states
114
The Federal Nursing Allowance Law (Bundespflegegeldgesetz, BGBI. Nr. 110/93) passed in July 1993,
together with the nine regional Nursing Allowance Laws (Landespflegegeldgesetze) form the legal basis for
precautionary or preventive care (long term care). The Federal Nursing Allowance Law also regulates
claims to non-cash care benefits for long term care. “The federal states commit themselves to a
decentralised and area-wide construction and expansion of out-patient services, part in-patient and inpatient social services in consideration of minimum standards”.331 In addition the federal states are
responsible for the networking332 of these services as well as the provision of information and counselling.
The federation is responsible for the protection of individuals requiring long term care by means of social
insurance.
The field of emergency rescue and recovery is actually, with regards legislation and execution, the concern
of the federal states. However the federal states transfer the management of local rescue services
(ambulance, first aid) to the regional councils. These, in turn, mostly place contracts with welfare
organizations in order to fulfil their allocated duties.
Emergency medical assistance is provided by various facilities and organizations within the health system.
Hospital out-patient departments and public hospitals play an important role in primary emergency care.
Other facilities having a central role in the field of emergency care are rescue organizations. In Austria the
rescue and ambulance services are, above all, run by the Austrian Red Cross, besides this, there are other
recognised organizations. The responsibility for the national rescue and ambulance services lies with the
federal states, which can however transfer these duties, by means of contractual agreements, to qualified
physical or legal persons. Air rescue falls within the competence of the federation.
Primary care
Primary care is provided by doctors (general practitioners or specialists) in their own, mainly individual
private, practices. A portion of primary care providers operate in group practices333 or community practices.
Service providers either have a contract with social insurance (contract doctors or contract group practices)
or offer their services privately (private doctors, private group practices). Besides independently practicing
doctors there are other facilities for out-patient treatment which are either run by social insurance334 or as
private ventures. These include out-patient clinics335, institutes or laboratories. In addition, hospital outpatient departments cover a large portion of primary care. The ownership structures in hospitals are dealt
with in the next sections.
Health service providers on a par with doctors (e.g. psychologists, psychotherapists, speech therapists,
occupational therapists, midwives) operate, like doctors, either as private individual undertakings with or
without any contract with social insurance, or are employed by health care establishments (e.g. hospitals).
Public health care is provided by public establishments (government health departments of the federal
states, health bureaus of the district administrative bodies, public health officers, specialist departments in
the communities).
331
Federal Ministry of Social Security, Generations and Consumer protection (2004). Long-term care in
Austria.Vienna
332
health and social parish
333
Since 2002 there is the opportunity to set up group practices. Legal basis is given in the second amendment to the
doctors law (BGBl. I No. 110/2001) as well as 58th ASVG amendment (BGBl. I Nr. 99/2001) and the parallel
amendments to ASVG.
334
In 2005: 46 general specialist outpatient clinics, 82 dental clinics and 31 juvenile and health examination centres
and other miscellaneous facilities (source: Hauptverband)
335
Independent outpatient clinics are, according to law, hospitals
115
Secondary care
In 2005 about half (131) of the 264 hospitals were public hospitals disposing of about 70% of all beds.
From the hospitals funded by the federal health funds 123 out of 136 hospitals were public i.e. about 90%.
Figure 4.3 Hospitals in Austria (ownership status)
Carriers
7,79
Private entities
% of total number of beds
19,32
17,25
15,91
Religious orders/-communities
% of total number of hospitals
11,11
9,85
Local government, municipalities
51,61
Federal States
32,20
1,59
3,79
Associations/ Foundations
8,04
Accident- and Pension insurance
12,50
Health insurance funds and health care institutions
(Fürsorgeverbände)
Federation
1,69
2,65
0,93
3,79
0,00
% of total hospitals / beds
10,00
20,00
30,00
40,00
50,00
60,00
Source: Yearly average population: Number of hospitals, number of beds: BMGF, received 21/09/2006, own
calculations
The federal states or rather the regional associations are the legal representatives for 32% of the hospitals
with 52% of the beds. 10% of hospitals with 11% of the beds are sponsored by the local government.
Sickness funds, welfare associations, accident and pension insurance funds operate 15% of the hospitals
with 10% of the beds. Religious orders and denominations are legally responsible for 16% of the hospitals
with 17% of the beds. 23% of the hospitals with 9% of the beds are assigned in legal terms to private
individuals, private associations, societies or foundations. Sponsorship of the remaining hospitals (4% with
around 1% of the beds) rests with the Federation (army hospitals, hospitals of reformatory establishments).
Over the past years the proprietary structures of hospitals have undergone significant change, namely
successive privatization of the management of public hospitals in the form of hospital operations
management agencies. This development has occurred in all federal states. Hospital operations management
agencies are responsible for the administration of about 50% of all hospital beds.336 The function of these
agencies is to fulfill the care requirements & orders set out by the federal states and, on behalf of the federal
states, put into effect strategic decisions.337
336
Hofmarcher et al. (2001). ″Focus: The Austrian Hospital Sector – One System or Nine?″ Health System Watch I in
Fidler, A.H., Haslinger, R.R., Hofmarcher, M.M., Jesse, M., Palu, T. (2005). ″Incorporation of public hospitals: a
“silver bullet” against overcapacity, managerial bottlenecks and resource constraints? Case studies from Austria and
Estonia.″ p.5, accessed at http://vega.medinfo.hu/civiltajekoztatas/kepek/ho/anyagok/incorporation.doc on 09/01/2006
337
116
Tertiary care
Tertiary care (long term out-patient and in-patient care) comprises the areas of medical measures for
rehabilitation, psychiatry, and nursing.
Psychiatric care takes place both in in-patient and out-patient form (hospitals, specialists for psychiatry,
psychologists, etc). The assurance of care with extramural services rests with the federal states.
In the field of rehabilitation social insurance funds in Austria run 30 specialist hospitals.338 Moreover there
are 19 contract partner establishments.339 Beyond this there are 12 convalescent homes and sanatoria and 5
recuperation homes.340
In the year 2000 about half of the old peoples homes and nursing homes in Austria belonged to the public
sector (federal states, local authorities, social services associations), about 27% belonged to the non-profit
making sector (private facilities which offer their services on a -profit making basis) and about 22% to the
profit oriented sector (private, profit-oriented institutions).341
Social services are offered by private and mostly non-profit organizations.
The role of government in relation to providers
The federation uses planning instruments for Health care planning. The most important planning instrument
is the Austrian Structural Plan for Health (Österreichischer Strukturplan Gesundheit, ÖSG), formerly the
Austrian Hospital and Major Equipment Plan (Österreichischer Krankenanstalten- und Großgeräteplan,
ÖKAP or ÖGGP) passed on the 16th December by the Federal Health Commission in accordance with
article 4 of the 15a B-VG agreement. The plan presents a mandatory Austria-wide basis for the integrated
planning of the care structure in the Austrian health system and covers the areas of in-patient and outpatient care as well as rehabilitation and nursing interfaces. The planning for services offered is set out up to
a planning horizon of 2010. Therein Austria is split into four overall care zones which are, in turn, divided
up into a further 32 care regions. The federal states have developed detailed plans based on the ÖSG, which
sets out the basic conditions. The last agreed status of the ÖKAP/ÖGGP was evaluated up to mid 2005 and
remained effective until the end of 2005.
Important for social insurance is that for the first time the Hauptverband was given a formal right to
participate in the development of planning guidelines.
The provision of services is linked with the fulfillment of quality criteria (incl. minimum number of
consultations and accessibility) whereby the majority of the quality criteria pertaining to structure still
comply with those in the ÖKAP of 2003. Also part of the new ÖSG is capacity planning at a regional level
for hospitals financed by the agencies for health care in the federal states and an up to date plan for large
scale medical equipment.
The ÖSG is constantly being revised and developed further. The aim is an integrated care plan. That means
that areas of health care beyond those of acute hospitals are to be included in planning, e.g. medical care for
out-patients, additional in-patient and out-patient rehabilitation. The ÖSG 2006 provides basic planning
directives at federal state level. It is then the duty of the federal states, hospital agencies, and social
338
Mag. Romana Ruda (Hauptverband der österreichischen Sozialversicherungsträger, HVB). Interview 31 March
2006
339
Hauptverband der österreichischen Sozialversicherungsträger Eds. (2006). Handbook for Medical Rehabilitation.
Edition 2005/2006
340
2005, Vienna.
341
Nam, H. (2003). ″Nursing homes and homes for long-term care in Austria: ownership structure, supply structure
and employment, first results from the project „Employment in the Austrian Non-Profit Sector“.″ Vienna University of
Economics and Business Administration, Department for Social Policy.
117
insurance funds to undertake the detailed planning. This development allows the individual players greater
room for maneuver whereupon it is hoped that integrated planning will result.342
As has been the practice up to now, sanction measures will come into operation in cases of a deviation from
the terms of the Austrian Structural Plan (see articles 35 and 36 of the agreement).
For implementation of the health plan the federation uses the services of the Austrian Institute for Health
Care (Österreichisches Bundesinstitut für Gesundheitswesen, ÖBIG).
In the course of the health reform 2005 funds were made available for a cooperative body (Reformpool)
which facilitates the definition of mutual structural changes or projects, which result in the shifting of
services between intramural and extramural care. A precondition hereto is prior settlement or rather a
precise agreement between the Federation-concerned social insurance with regards to the particular
measures. Collective trials for the development of new cooperative models were developed as well as
mechanisms to ensure the funding of the health system. In 2005 and 2006 the reform pool will be allocated
a minimum of 1%, and in 2007 and 2008 a minimum of 2%, of the total intra and extramural funds.343
The Federal Health Agency (Bundesgesundheitsagentur) (replaces the Structural Fund (Strukturfonds, in
existence up to 2005) has numerous duties in the fields of planning, regulation, and financing (see Article
15a B-VG Agreement, article 11), including the formulation of quality specifications for provision of
services, planning of services, definition of scope for interface management between sectors or the
formulation of guidelines for the Reformpool.344
Beyond this, within the framework of the health reform 2005, the federation issued new terms for quality
assurance (Quality of Health Law (Gesundheitsqualitätsgesetz)) as well as for the handling of data (Health
Data Transmission Law (Gesundheitstelematikgesetz)), which could lead to significant changes in service
provision. The provision of high quality care as well as the initiation of systematic and comprehensive highquality work has top priority in Austria. In the field of health data transmission there are directives on ehealth, the electronic health act (ELGA) and electronic prescriptions (e-prescription).
Due to numerous legal directives, the federation additionally exerts influence on the activities of service
providers. Amongst others, this includes the areas of education, hygiene (sanitary control), data protection,
documentation, quality assurance. These may partly be found in the occupational laws of the health
professions, partly in individual laws e.g. medical product law, pharmaceutical law, etc.
Licensing of (public and/or private) health care facilities
Construction and operation of hospitals requires authorization from the appropriate Federation. Legal basis
is the Hospital Law, 3§§ 3ff. In this paragraph requirements for gaining authorization are set out, amongst
others, formal criteria must be met (applications must describe in detail the intended purpose of the
establishment and services offered, proprietorship or right of user of the facilities must be proven, certain
building, fire, and health policy regulations must be adhered to). Furthermore the need must be
demonstrated with due consideration given to existing care structures, and there must be no concerns with
regards the operator. For establishments financed by funds (from the federal health agencies) or those
operated by health insurance funds additional special regulations apply (e.g. § 339 ASVG).
During the course of the authorization procedure an assessment certificate must be obtained from the State
Governor, which addresses sanitary control. Sanitary control is transferred to the district administration
authorities by means of indirect federal administration and managed by public health officers. Issue of
authorization is further bound to the existence of the required equipment (both medical and technical), the
fulfilment of health and safety regulations as well as compliance with provincial legal planning agreements.
Conformance to quality criteria in terms of structure must also be proven.
342
Ministry of Health and Women, www.bmgf.gv.at, accessed on 08/05/2006
In 2002 this was around 14.4 Bill. Euro (Federal Ministry of Health and Women, BMGF)
344
Health Reform Law 2005, § 59a, para.1
343
118
The Federation must be notified of any planned changes to the premises or any other significant changes
(e.g. services provided).
In order to set up a practice a doctor must be eligible to carry out his profession independently and be
registered at the Austrian Medical Chamber. Should he be employed elsewhere and wish to continue in this
job, approval of the legal representative of the establishment is required. Upon notification of the Medical
Chamber a second practice may be opened at any time.345
The doctor must also notify the Medical Chamber when the practice opens. An official sanitary inspection
is not carried out at this time however the doctor remains subject to supervision by the sanitary authorities.
In accordance with § 56 of the Doctors Law the doctor is obliged to maintain his practice in compliance
with the hygienic requirements. A practice inspection may be carried out by the public health officer of the
district authorities whenever deemed necessary. In doing so a representative of the Medical Chamber is
called upon. In the case of deficiencies the doctor is given a time period within which to rectify these. In the
case of serious deficiencies, which may threaten the lives and health of patients, the practice may be closed
until such a time as the problems have been resolved.346
The number and distribution of contract doctors with social health insurance are regulated in Austria by a
Location Plan (Stellenplan) which is negotiated between the Hauptverband, the regional sickness fund and
the respective regional Medical Chamber. The general contract regulates, amongst other things, stipulation
of the number and regional distribution of contract doctors, the choice of these as well as the rights and
obligations of contract doctors. Details regarding the practice site, practice opening hours and possible
special agreements are given in the individual contracts with doctors.
Allocation of available posts takes place according to so called priority criteria (incl. proof of professional
competence, certain structural requirements347).
Only a few health insurance funds (e.g. the regional sickness fund of Vorarlberg) carry out an inspection of
the practice prior to contract completion.348 Some health insurance funds couple the award of a contract
with the existence of barrier free access in accordance with ÖNORM B 1600.
The contract doctor is obliged to fulfil all legal requirements (hygiene, security, documentation, data
protection, etc.) and undergo inspection when deemed necessary.
All authorised establishments/facilities such as hospitals, convalescent homes, care facilities, sanatoriums,
etc. are supervised by the sanitary authorities. The district authority decides how often and to what extent
sanitary inspections take place.349
Licensing of doctors, dentists, nurses and allied practitioners
Licensing of doctors rests with the Austrian Medical Chamber (delegated by the Federal Minister of Health
and Women) and is followed by registration in the Directory of Doctors, which lists all licensed doctors
authorised to practice in Austria and is publicly available. The legal basis is the Doctors Law (§ 27). The
directory contains information with respect to name, job title, other academic titles, diplomas awarded by
the Austrian Medical Chamber and regional Medical Chambers, contracts with Social insurance funds, or
health care facilities as well as place of work, practice address, service address or home address.
345
Medical Chamber of Lower Austria, planning the private practice, accessed under:
http://www.arztnoe.at/localfiles/4286_.pdf, on 09/06/2006
346
Doctors Law (Ärztegesetz) 1998 (BGBl. Nr. I 169/1998)
347
Promise by the applicant to make a serious effort to provide disabled access in accordance with the ÖNORM
B1600 „Barrier free building“ as well as ÖNORM B 1601 „Special building requirements for disabled and elderly
people“ from commencement of the contract.
348
Dr. Gregoritsch (Hauptverband der österreichischen Sozialversicherungsträger, HVB). 9 May 2006 (telephone)
349
119
Personal I.D. and/or educational certification must be presented in order to practice medicine, whether
freelance or as an employee. Furthermore, proof of nationality, suitability in terms of health, as well as, a
copy of any criminal records, are also necessary.
Entry in the Directory of Doctors is confirmed by the issue of a photo identity card (doctors I.D.). Medical
practice may only be commenced upon receipt of confirmation. The appropriate district authorities are
notified of new entries by the Austrian Medical Chamber.
Special conditions apply for the accreditation of qualifications gained abroad. An evaluation of
comparability with Austrian qualifications is carried out by the Austrian Medical Chamber.
The licensing procedure or any requirements for re-certification in other non-medical health professions are
not explained further within the scope of this report, for these the relevant professional laws or education
and training regulations should be referred to.
Periodic re-licensing of facilities/practitioners
Revalidation via an examination is not required in Austria. However the doctor must fulfil certain
requirements regarding continuing professional training. Within the framework of the voluntary Diploma
program for continuing medical education (Diplomfortbildungsprogramm, DFP) run by the Austrian
Medical Chamber (150 hours in three years) a “non-verification” is not threatened with loss of licence. In
the areas of doctors with their own practice there are partial quality evaluations. It is not expected that
revalidation will be introduced in the near future.350
Licensing of medical equipment and drugs
New products must be approved by the European Agency for the Evaluation of Medical Products, EMEA
(Europäische Agentur für die Beurteilung von Arzneimitteln) for all other medication reciprocal approval of
nationally licensed pharmaceuticals within the EU is planned. It is intended that this measure will speed up
the licensing procedure.
From the beginning of 2006 the Austrian Agency for Health and Nutritional Safety (Österreichische Agentur
für Gesundheit und Ernährungssicherheit, AGES)351, founded in 2002, will progressively be assigned new
duties. This will occur under the heading “PharmMed-Austria” and to support the Federal Ministry of Health
and Women. These duties include all tasks related to licensing of pharmaceuticals as well as testing
pharmaceuticals and medical products. High-level or sovereign duties rest with the Federal Office for Safety
in the Health System (Bundesamt für Sicherheit im Gesundheitswesen) a subordinate department of the
Ministry of Health and Women. Prior to 2006 the “Section III Health Care” within the Ministry of Health and
Women, with the support of the Federal Institute for Pharmaceuticals, was responsible for licensing of
drugs.352
“The AGES PharmMed fulfils the operational duties of the Federal Administration with respect to
pharmaceuticals and medical products in accordance with legislative order, as set out in the Pharmaceutical
Law (Arzneimittelgesetz, AMG), the Medical Products Law (Medizinproduktegesetz, MPG), Law for the
Introduction of Medicines (Arzneiwareneinfuhrgesetz, AWEG), Blood Safety Law (Blutsicherheitsgesetz,
BSG) as well as in the ordinances of these”.353
350
Mag. Holler (Austrian Medical Chamber). Interview 12 January 2006
Dr. Holzgruber (Medical Chamber of Vienna). 31 March 2006 (via email)
Rowe, A., García-Barbero, M. (2005). ″Regulation and licensing of physicians in the WHO European Region.″ WHO
Report, p. 42
351
The Austrian Agency for Health and Nutritional Safety carries out a wide range of duties in the field of nutritional
safety for the Republic of Austria (www.ages.at)
352
Austrian Agency for Health and Nutritional Safety, accessed at www.ages.at on 08/05/2006
353
The
Austrian
Agency
for
Health
and
Nutritional
Safety
(AGES),
accessed
at
http://www13.ages.at/servlet/sls/Tornado/web/ages/content/397CCFF0057354E5C125715D003720A4
120
Both the licensing of pharmaceuticals and the regulation of pharmacies and wholesale remain matters for the
Federation. Negotiations regarding reimbursements for pharmaceuticals are the responsibility of the social
insurance funds.
In Austria the most important legal foundations in these areas are the Pharmaceutical Law
(Arzneimittelgesetz) (licensing of pharmaceuticals) and the Medical Products Law (Medizinproduktegesetz)
(medical equipment), plus numerous EU regulations.
Certification of safety (radiation, fire, environmental and occupational hazards)
Organizations are subject to certain legal obligations, amongst other things, they must determine risks
within the organization and evaluate these, as well as, define measures for their elimination. In many areas
E-norms (E-standards), ÖNORMEN, or other norms or standards are applicable and must be adhered to.
The legal bases in the field of safety at work are the Employee Protection Law (Arbeitnehmerschutzgesetz),
the general Employee Protection Regulations (Arbeitnehmerschutzverordnung), the Workplace Regulations
(Arbeitsstättenverordnung), the Electrical Protection Regulations (Elektroschutzverordnung), the
regulations on noise and vibrations, the fire regulations, safety regulations concerning electrical equipment
or other dangers like gases, steam or radiation, noise protection regulations.
In the Employee Protection Law (Arbeitnehmerschutzgesetz) provision is made for medical and safety
supervision for all employees at work. This is independent of size of the organization. Here the accident
insurance funds are responsible for the supervision of small businesses. This supervision is free of charge.
The AUVA has set up prevention centres in its federal and satellite sites for this purpose.354 For larger
businesses or small businesses which do not call upon these services, there is the possibility of employing a
person for the job of prevention (occupational medical doctor, safety staff).355
The AUVA runs the safety-related test centre (Sicherheitstechnische Prüfstelle, STP), an accredited
registered laboratory and control centre. The inspection scope ranges from tools and supplies for work (e.g.
ladders), flammable and explosive properties (e.g. of dust) and workplace conditions (e.g. noise, vibrations,
harmful substances, and magnetic fields).356 Furthermore, the workplace safety inspection is carried out by
private institutions such as the TÜV Austria357, an accredited test centre for the inspection of machinery,
machine parts, technical equipment and products.
Other institutions358 dealing with safety in the health system include health insurance funds, some
ministries, professional representative bodies, professional medical associations359, the Austrian Academy
for Occupational Medicine (Österreichische Akademie für Arbeitsmedizin), the works inspection, the
Austrian Institute of Standards (Österreichische Normungsinstitut) or rescue organizations.
The Ministry of Health and Women has the following responsibilities in the field of radiation protection:
•
•
Matters of radiation hygiene, medical radiation protection and medical radiology
Medical evaluation of the implementation of ionised and non-ionised radiation as well as
radiopharmaceuticals
Legal foundations are the Radiation Protection Law (Strahlenschutzgesetz) (BGBl. 1969/227), the Radiation
Protection Law – Alignment with the EU (Strahlenschutz-EU-Anpassungsgesetz) 2002 (BGBl. 146/2002)
and 2004 (BGBl. 137/2004), the Radiation Protection Regulations (Strahlenschutzverordnung) (BGBl.
1972/47), the Patient Protection Guidelines (Richtlinie Patientenschutz) 97/43/Euratom, Guidelines to the
Radiation Protection basic standards (Richtlinie Strahlenschutzgrundnormen) 96/29/Euratom, as well as, the
decree on the immediate applicability of guidelines in the area of radiation protection in the medical field
354
Austrian Social Insurance for Occupational Risks, www.auva.at, accessed on 09/05/2006
AUVA, Safety-related and occupational medicine cost-free support service, AUVAsicher, issue 2005/2006,
accessed at http://www.auva.at/mediaDB/102426.PDF on 09/05/2006
356
Austrian Social Insurance for Occupational Risks accessed at www. auva.at, on 09/05/2006
357
Technology Watchdog (Technischer Überwachungsverein)
358
Works inspection (Arbeitsinspektion), accessed at http://www.arbeitsinspektion.gv.at/AI/default.htm on09/05/2006
359
Fachgesellschaft
355
121
from 13th May 2000. In addition there are the Medical Radiation Protection Regulations (Medizinische
Strahlenschutzverordnung) 2004 (BGBl. II 409/2004), as well as, diverse ÖNORMEN on radiation
protection. Information on this topic is also available from, amongst others, the Austrian Association for
Radiation Protection (Österreichischer Verband für Strahlenschutz).360
Voluntary external quality assessment and improvement programs
In Austria quality certification or accreditation are not yet standard, but are something special. Quality
oriented thinking is becoming increasingly more significant in the health system and with it the trend of
implementation of diverse quality models. In Austria, amongst others, the following models/instruments for
quality control and quality improvement are being implemented.361
Certification362:
* ISO –9000 ff. Certification of health related institutions
Accreditation:
* EFQM - accreditation
* Accreditation in accordance with the Joint Commission (since 1999 also offered in form of international
accreditation)
Others:
* Quality indicator project363
* Peer review/ Visitation
* Quality circles of the Medical Chamber
* Quality group of the AUVA for medics in the workplace by AUVAsicher
Further initiatives in quality assurance or quality control (exemplary):
* Quality report compilation (Qualitätsberichterstattung, QBE) of the federation (BMGF)364
* Uniqa Gut Drauf Preis365
* Approval for activities/events, accreditation of activities/events within the framework further vocational
training programs of the Medical Chamber366
* Quality measures or projects: of the social insurance funds367, the Ministry, others
In an article, published in November 2004, in the journal Clinicum, it was noted that certification in
accordance with ISO 9001 is the most widely used method in Austria. The International Standards
Organization (ISO) is a voluntary amalgamation of standards institutes of 156 countries.368 The aim is to
develop uniform standards/norms. Through this method the organization can attain a seal of approval for its
quality management system. Although this standard stems from industry it is nevertheless often adopted in
360
Austrian Association for Radiation Protection (Österreichischer Verband für Strahlenschutz), accessed at
http://www.strahlenschutzverband.at/
361
Poznanski, U. (2004). ″quality for sure (Qualität mit Brief und Siegel), Clinicum 11:2004, accessed at
http://www.medical-tribune.at/dynasite.cfm?dssid=4171&dsmid=59942&dspaid=417186 on09/05/2006
Czypionka, T., Riedel, M., Röhrling, G. (2006). ″Europe in motion: Quality of care in physicians’ practices.″ in Health
System Watch I-2006, supplement to the Austrian journal of Social insurance Soziale Sicherheit
362
Third party confirmation, that a facility is maintaining certain standards, taken from Czypionka, T., Riedel, M.,
Röhrling, G. (2006), ″Europe in motion: Quality of care in physicians’ practices.″ in Health System Watch I-2006,
supplement to the Austrian journal of Social insurance Soziale Sicherheit
363
Project description of the QIP (Quality indicator project) project
364
Quality reporting: www.qbe.at
365
Dr. Geyer (Federal Ministry of Health and Women). questionnaire 29 December 2005, associated website:
http://www.give.or.at/gesundheitspreis/gdp_2002.htm
366
Academy of Doctors, program of continuous medical education (Diplomfortbildungsprogramm, DFP):
http://www.arztakademie.at/fileadmin/template/main/med02PDFs/03_2002DFPAkk.pdf
367
e.g. contract partner control, hospital audits by social insurance (Spitalseinschau)
368
International Organization for Standardization, accessed at www.iso.org, on 09/05/2006
122
other areas, amongst others, the health system (mostly in parts of the organization). Some departments are
more suited to ISO certification than others, e.g. technical/scientific laboratories. An inspection takes place
once a year, a so called audit. In Austria in 1999 a total of 3400 ISO certificates were awarded and only 18
denied.
Accreditation in accordance with the Joint Commission369 was developed in the USA, in contrast to the ISO
method, especially for the health system. In the course of accreditation not only individual departments, but
the hospital as a whole, is part of the quality assessment process. Central pillars of the system are patient
expectations, patient rights, and patient safety. The accreditation is valid for three years. In November 2004
two Austrian hospitals were accredited (LKH Villach, NTK Kapfenberg).
The EFQM (European Foundation for Quality Management) Model orients itself in line with the TQM
(Total Quality Management) approach and covers all parts and functions of a business with respect to both
structure and process. It is based on a self assessment approach whereby an organization can aim for a
maximum target of 500 points. External assessment is made possible through participation in a Quality
Award. The model is suitable as a basis for benchmarking with other organizations. In Austria there is the
AFQM (Austrian Foundation for Quality Management).
At the peer review or independent assessment the divisions of other colleagues are visited. These carry out
external, neutral quality control, based on specific indicators. At the time of publication this model was not
very common however in the meantime it has gained more prominence, both in hospitals and out-patient
facilities.
The international Quality Indicator Project (QIP) was developed in 1986 in Maryland (USA) as a model for
continual quality improvement in hospitals. Worldwide more than 1900 hospitals are taking part in this
project, 140 of these outside the USA and of these more than 30 Austrian hospitals (above all in the region
of Upper Austria). The aim of this project is the measurement and evaluation of the care processes as well
as benchmarking against other institutions based on various indicators. The system pursues quality
improvement by means of self assessment, whereby hospitals receive continual feedback about their own
and anonymous reference values. The methodology is uniform worldwide and covers medical indicators as
well as measurement of organizations and coordination processes. Data are collected quarter yearly
similarly feedback is given at these time intervals.370
“Quality groups are working groups of 6-12 doctors, who adhere to the basic principles of voluntary,
continual, topic-based, experience-based, and target-based work. Their work includes the analysis of day to
day medical practice, collegial comparison and exchange of experiences of the “lone fighters”, raising
awareness of agreement and disparity in the various areas of work”. In March 2003 there were 175 active
quality groups across Austria, with almost half of these in Styria.371
369
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
International Quality Indicator Project (QIP), accessed under http://www.forumq.at/Downloads/QiP.pdf, on
09/05/2006
371
Austrian Medical Chamber, accessed under
http://www.aerztekammer.at/?type=module&aid=convert&url=%2Fsrv%2Fdav%2Foak%2Fakwebsite%2FIQS%2FIQSQZ.htm, on 09/05/2006
370
123
5. ALLOCATIVE EFFICIENCY AND RESOURCE ALLOCATION
Allocative efficiency can be defined as an economy that provides its members with the amounts and types
of goods and services that they most prefer. Improvement in allocative efficiency can be achieved by
reorienting care from hospital to outpatient, primary and social care, for example. Typically there are three
ways to examine allocative efficiency: allocation between health care and other sectors of the economy;
how money is allocated to different sectors within the health care system, such as between acute care and
preventive services; and how resources are allocated to specific clinical services, such as which drugs to
reimburse and how much.372 Allocative efficiency is difficult to measure because data are limited and there
are methodological problems.
One indication of the allocative efficiency of the health system is the level of expenditure by sector.
However, the analysis depends largely on judgments about the relative value and effectiveness of different
sectors. It is important to highlight that determining the extent to which this allocation improves population
health relies on detailed data on outcomes, which are not forthcoming.
Data from the OECD have suggested that the relative size of the ambulatory and acute sectors varies
between countries but does not systematically differ according to the predominant source of funding. In
most health systems in recent decades, the pharmaceutical sector has grown faster than any other sector.
However, aggregate data do not clearly show whether the growth in pharmaceuticals has substituted for
other expenditure. For example, did the increase in drug expenditure reduce admissions and lengths of stay
in inpatient settings or did it just reflect waste and increased profit for drug companies?
While Table 5.1 outlines the distribution of health spending across the different health sectors in a selection
of European countries, data are incomplete and in some cases unreliable. Therefore it is very difficult to
draw conclusions about allocative efficiency based on aggregate data from one year. However one can see
that spending on inpatient care in some countries remains quite high despite the trend of
deinstitutionalization and increasing use of day care as opposed to more expensive inpatient care; the range
of spending on inpatient care is from 26% of total health spending in Spain to 42% in Austria. Also,
spending on pharmaceuticals is higher than on physician care in many countries, and constitute over 20% of
total health spending in Slovak Republic, Poland, Spain, Czech Republic, Hungary, and Italy. Whereas,
spending on public health and prevention is surprisingly low, less than 2% in most countries.
Table 5.1 Spending on health in different sectors (as a proportion of total health spending) in selected
European countries, latest available year
Inpatient
Physicians
Dentists
Pharmaceuticals Public
care
health
Austria
41.7
15.7
6.6
13
2
Czech Republic
36
22.9
5.4
22
2
Denmark
30.1
18.7
4.5
9.4
0.5
Finland
34.8
28.6
5.8
16.3
3.9
France
33.8
11.7
4.9
18.9
2.9
Germany
34.7
10.1
7.6
14.6
4.7
Hungary
29
4
8.4
27.6
Italy
42.4
21.4
0.6
Luxembourg
33.1
18.3
3.8
8.5
1.2
Netherlands
37.6
4.9
Poland
28.1
14.7
5.4
29.6
1.7
Slovak Republic
30.4
38.5
1.6
Spain
25.9
26.1
5.1
22.8
1.4
Sweden
31.3
6.6
12.3
372
124
Pooling and resource allocation are important instruments in achieving appropriate risk protection, equity
and allocative efficiency. Strategic resource allocation refers to the challenge of distributing national-level
health care funds to health care plans or ‘purchasers’ in order to maximise efficiency and equity.373 Four
main types of health care financing systems can be identified: competitive insurance plans or sickness funds
(Belgium, Germany, the Netherlands); employer-based insurance plans (Austria, France, Greece); local
governments (Denmark, Finland, Italy, Norway, Sweden); and centralised government (Ireland, Portugal,
Spain, UK).
Methods of funding the health plans in Europe have been gradually moving away from full retrospective
reimbursement towards reimbursing using a fixed schedule of fees (e.g. diagnostic-related groups; DRGs)
and using fixed budgets to fund prospectively in order to increase efficiency and curb expenditure growth.
Within the fixed-budget resource allocation mechanism, there are four methods of distributing funds based
on the size of the plan’s bid, political negotiation, historical precedent, or an independent measure of health
care needs. The last method, which takes a more scientific approach, has become increasingly common,
especially in the form of capitation payments.
Capitation with risk adjustment is preferred to others methods mainly due to equity and efficiency
considerations. Because people’s health needs vary depending on personal and social characteristics, risk
adjustment is needed in order to enable the cost of each member to reflect their relative health care
expenditure needs. Recent efforts have been made to increase equity in resource allocation. The resource
allocation formula used in England was adapted in 1995 to take into account inequalities in health (see
below). Also, a new formula for allocation was introduced in 1992 in the Stockholm area in Sweden, in
order to target populations with poorer health and certain socio-economic characteristics.374
Competition between sickness funds was introduced in the Netherlands in 1988 and in Germany in 1996,
which led to sickness funds employing risk adjustment mechanisms. The Dutch risk adjustment scheme
adjusts for age, sex, region, employment and disability status; the German scheme accounts for income and
average expenditure by age and sex.375
Despite this increasingly scientific approach to resource allocation, there remains considerable scope for
altering the budgetary schemes, both prospectively and retrospectively. For instance, retrospective
negotiations with the central payer occurs in Italy and Spain, premiums or local taxes paid by plan members
may be altered, as in Scandinavia, and delaying or rationing health care occurs in Norway, Sweden and the
UK. Also, while resource allocation in Portugal is based somewhat on capitation, this method only
accounted for about 8% of the total budget in 1998, with the remainder determined through incremental
budgeting based on past levels of spending. It appears that attempts to determine budgets through objective
assessments of needs may be impeded by historical and political pressures.
According to a survey of resource allocation schemes in Europe, most countries use a capitation system
with risk adjustment, however variations exist. Only Austria, Greece and Ireland have no element of
capitation. Instead, Austria and Greece have employment-based insurance, which are self-financing in
Austria and partly subsidized in Greece through political negotiation and historical precedent, and Irish
reimbursement is based on activity such as DRGs.376
373
N Rice and P Smith, "Strategic Resource Allocation and Funding Decisions," in Funding Health Care: Options for
Europe, ed. E. Mossialos, et al. (Buckingham: Open University Press, 2002).
374
F Diderichsen, E. Varde, and M Whitehead, "Resource Allocation to Health Authorities: The Quest for an
Equitable Formula in Britain and Sweden," British Medical Journal 315 (1997).
375
R Busse, "Risk Structure Compensation in Germany's Statutory Health Insurance," European Journal of Public
Health 11, no. 2 (2001), K Okma and J.D. Poelert, "Implementing Prospective Budgeting for Dutch Sickness Funds,"
European Journal of Public Health 11 (2001).
376
Rice and Smith, "Strategic Resource Allocation and Funding Decisions."
125
Where capitation methods are used, there are associated risk-adjustment mechanisms based on patterns of
health care utilization, with the exception of Spain, Norway, Portugal, and Scotland. The needs factors that
are included in the risk adjustment formulas include demography, employment and disability status (e.g. in
the Netherlands and Northern Ireland), geographical location, morbidity, (e.g. in Portugal, Belgium, Finland
and the Netherlands), mortality (e.g. in Belgium, Italy, Northern Ireland, Norway, Scotland and Wales), and
social factors such as unemployment (Belgium, the Netherlands and Stockholm county), marital status
(Norway and Stockholm county), family structure (France and Norway), housing quality (Belgium) and
income (Finland).
England has a well developed system of risk adjustment for the allocations to purchasers – primary care
trusts. This method of resource allocation has been in place since 1977, following recommendations from
the Resource Allocation Working Party (RAWP) to address geographical inequities in hospital supply and
better match resources with local needs. The factors used to ‘weight’ the payments have become more
extensive over time. At first only age structure, local input costs and standardized mortality rates were used
to adjust allocations, however later risk-adjustment mechanisms included morbidity, unemployment rates,
elderly people living at home, ethnic origin and socio-economic status. The current weighted capitation
formula consists of four components: hospital and community health services, prescribing, primary medical
services, and HIV/AIDS (which became part of revenue allocations from 2002/03).377 These are combined
using national expenditure weights, which based on 2005/6 expenditures are: hospital and community
health weighting representing 77.4%; prescribing 13.2%, primary medical services 8.8% and HIV/AIDS
0.6%.
5.1 Health technology assessment
Health technology plays an integral role in the EU health care system. During the past half-century, all
member states have increased their technological base for health care, both in terms of knowledge and
investments in equipment, devices, and pharmaceuticals. Although many innovations carry the potential to
bring significant value to patients in comparison with existing practice, the adoption and financing of such
technologies, especially those entailing significant investment costs, can prove problematic in resourceconstrained health care environments. In fact, the continual introduction of new medical products has been
accompanied by a steady increase in health care costs in many countries378. The burgeoning growth in
health technologies increases the need to ascertain the value of new innovations and validate their
appropriate position in the spectrum of care.
While countries employ a wide array of approaches to control the costs of health technology and support the
optimal use of such products, health technology assessment (HTA) has assumed an increasing role in
national priority-setting and health policy processes. The general objective of HTA is to ascertain the
effects of technology on health, resource use, and other aspects of the health system (e.g., health care
budgets, national economy). Moreover, HTA is also concerned with the societal, organization, legal, and
ethical consequences of implementing health technologies or interventions into the health system. From a
policy context, HTA provides a range of stakeholders with accessible, useable, and evidence-based
information, typically in the form of assessment reports, to support various decisions surrounding a given
health technology or intervention.
In almost all countries of the EU, programs for HTA have been established either through the provision of
new agencies or institutes, or in established academic units or governmental and non-governmental entities
(Table 5.2).
377
http://www.dh.gov.uk/assetRoot/04/11/20/67/04112067.pdf
Organization for Economic Co-operation and Development, "OECD Heath Data: A Comparative Analysis of 30
OECD Countries," (Paris: OECD, 2002).
378
126
Table 5.2 Institutions and advisory bodies responsible for HTA activities in the EU
Federation of Austrian Social Insurance Institution/Drug Evaluation
Austria
Committee
Ludwig Boltzmann Institute Health Technology Assessment
National Institute for Sickness and Invalidity Insurance
Belgium
Denmark
Reimbursement Committee
Finland
Pharmaceuticals Pricing Board
France
Economic Committee for the Health Products/Transparency Commission
Germany
Federal Joint Committee/Institute for Quality and Efficiency in Health Care
Italy
Pricing and Reimbursement Committee of the Medicines Agency
Netherlands
National Health Insurance Board/Committee for Pharmaceutical Aid
Norway
Pharmaceuticals Pricing Board
Spain
Spanish Agency for Health Technology Assessment
Sweden
LFN Pharmaceutical Benefits Board
Switzerland
Swiss Federal Office of Public Health/Confederal Drug Commission
United Kingdom
National Institute of Clinical Excellence/National Coordinating Centre for
Health Technology Assessment/Scottish Medicines Consortium
Most review bodies can be categorized as serving either an advisory or regulatory role in the decisionmaking process, depending on the intent and type of assessment required.379 For example, some countries,
such as the Netherlands and Denmark, require the use of economic evaluations in reimbursement decisionmaking, while others (e.g., France) employ the assessments primarily to inform budgetary planning or guide
clinical practice.380 The heterogeneity of HTA bodies in the EU reflects the differentiated environments of
European health care and political systems, with variances in mandates, funding mechanisms, and roles in
policy formulation.
The use of HTA in heath care priority-setting entails both opportunities and challenges. Overall, HTA
programs have generally enhanced transparency in decision-making processes through mechanisms such as
independent systematic reviews, stakeholder involvement, and the production of guidance. However,
different aspects of the HTA process introduce potential barriers to the effective use of economic
evaluations. Specifically, issues have been raised on the following characteristics: 1) responsibility and
membership of HTA entities, 2) assessment procedures and methods, and 3) the role in decision-making.
Responsibility and membership of HTA entities
The mandates or responsibilities of the assessment bodies vary by their general mission and overall policy
objectives381. As one component in the broader health care decision-making process, HTA programs
typically reflect the current policy landscape, such as the need to contain costs or improve access to a given
area of intervention or service. Consequently, economic evaluations often coincide with policies regarding
the pricing and utilization of medial technologies.382
379
A. Zentner, M. Valasco-Garrido, and R. Busse, "Methods for the Comparative Evaluation of Pharmaceuticals,"
GMS Health Technology Assessessment 1, no. Doc09 (2005).
380
J. Hutton et al., "Framework for Describing and Classifying Decision-Making Systems Using Technology
Assessment to Determine the Reimbursement of Health Technologies (Fourth Hurdle Systems)," International Journal
of Technology Assessment in Health Care 21, no. 1 (2006).
381
A. Anell, "Priority Setting for Pharmaceuticals," European Journal of Health Economics 5 (2004).
382
Hutton et al., "Framework for Describing and Classifying Decision-Making Systems Using Technology
Assessment to Determine the Reimbursement of Health Technologies (Fourth Hurdle Systems)."
127
In many countries, the appraisal process is overseen by the health ministry, although separate institutions
(e.g., NICE) are often involved to manage various aspects of the assessment. In many social insurancefunded health systems, however, the process is driven predominately by insurance organizations.
Differences also exist in the execution of the evaluation(s). Some HTA bodies, for example, conduct the
actual assessment via in-house committees, while others coordinate independent reviews by external bodies,
such as university research institutions.383 The use of independent reviews presents both benefits and
drawbacks to the assessment process. More specifically, independent reviews may lend greater transparency
and help prevent or resolve potential disputes to resultant decisions. Conversely, they may introduce certain
methodological challenges, such as use of particular study designs (i.e., RCTs) and potential disconnects
between the economic model and systematic review. HTA entities also differ in their role in the decisionmaking process once the assessment is complete. For example, in some countries, the HTA body has the
responsibility to develop guidance and recommend reimbursement status (e.g., UK), while in others, such
decisions are primarily determined and promulgated by national authorities or insurance representatives
(e.g., Finland). Moreover, some HTA committees are involved in negotiating product price and
reimbursement with manufacturers.
The composition of HTA entities and relevant processes involve a variety of stakeholders, including
physicians, pharmacists, health economists, insurance and industry representatives, and patients. Anell
found that most reimbursement status recommendations are determined first by scientific members (i.e.,
physicians, epidemiologists) with expertise in evaluation of medicines. Such decisions are further
corroborated with academic entities, representatives from patient organizations, health economists, and in
the case of NICE, managers within the NHS. The involvement of these groups differs across HTA bodies,
although all agencies have some level of stakeholder involvement. It has been advocated that there be
greater participation of patients and consumers, the ultimate end-users of a given technology, in the HTA
process384. While stakeholder involvement is resource-intensive, it may lead to better assessments, reduce
the number of appeals, and result in better implementations of HTA recommendations and guidance.
Assessment procedures and methods
HTA processes differ on a variety of issues regarding the actual assessment process, including topic
selection; data requirements; and methodological approach(s) employed. Most HTA agencies struggle to
keep pace with newly approved or introduced technologies. As a result, some type of prioritization process
typically guides which medical products are evaluated. The topic agenda of some review bodies are set by
national authorities or Departments of Health, while the Scottish Medicines Consortium (SMC), for
instance, considers every new drug. As is it generally considered cost-ineffective to evaluate all existing
technologies, review bodies incorporate various approaches to ensure the efficiency of the assessment
process. For example, NICE allows groups of similar technologies to be compared, while certain procedures
are required in the Netherlands to guide proper use of drugs that are not appraised. Although the range of
topics covered by HTA agencies is quite broad, some areas, such as lower-technology and preventive
technologies, tend to be understudied. Moreover, concerns have been raised regarding the transparency of
the topic selection process. A perceived lack of transparency may exacerbate existing tensions between
manufacturers and the stewards of health care budgets in terms of balancing access to technologies, product
innovation, and health expenditures.
HTA systems vary regarding the type and quality of evidence required for economic evaluations.385
Typically, manufacturers are required to submit a comprehensive summary of data on a product’s
effectiveness and cost-effectiveness. Review entities differ, however, on the role of industry data in the
assessment process. In Austria, Norway, and the Netherlands, for instance, HTA bodies review and
validate all data provided by industry, which must be based on a systematic review of available clinical and
383
Anell, "Priority Setting for Pharmaceuticals."
A. Coulter, "Perspectives on Health Technology Assessment: Response from the Patient's Perspective,"
International Journal of Health Technology Assessment 20, no. 1 (2004).
385
384
128
economic evidence.386 Other organizations (e.g., NICE) perform the systematic review in-house,
independent of data provided by manufacturers. Some countries, such as France and Finland, do not require
systematic reviews (although preferred), basing assessments primarily on a definite number of studies
provided by industry.387
In addition to data requirements, countries employ different analytical frameworks and methods for the
assessment and subsequent decision-making process.388 Most evaluations are guided by a variety of criteria
including safety and clinical effectiveness, patient need and benefit, cost-effectiveness, budget impact, and
cost of therapy.389 Some HTA bodies also frame the evaluation around equity considerations, product
innovation, and public health impact. However, transparency of the criteria used in guiding the analytical
framework is often lacking in most countries. A recent analysis by Anell found that some review entities
rarely, if never, explicitly outline the relative weight and importance of the criteria used in the assessment.
Moreover, while there are similarities across HTA bodies in terms of methodological approaches (e.g., use
of randomized controlled trials, use of cost-utility analyses), assessments often differ on the following
issues:390
• Sub-group analysis
• Measures of quality of life impact
• Costs included in the analysis
• Discounting
• Classification of product benefit (benefit vs. harm)
• Modelling techniques
• Choice of comparator
• Use of sensitivity analysis
• Approach to missing and incomplete data
The choice of methods employed can significantly influence the result of the assessment and the
comparability across studies and countries, which may ultimately impact the utility of HTA in the decisionmaking process.391
HTA role in decision-making
The results of HTA are used, with varying levels of impact on decision-making, to plan capacities, to shape
the benefit catalogue, or guide treatment provision. Almost all countries require assessments to ascertain
reimbursement status, although differences exist regarding the importance of economic evidence in the
decision process.392 France, for example, rarely considers such information when determining
reimbursement status. Moreover, some reimbursement committees may only require assessments for
patented drugs and new indications, or apply varying requirements to different types of products, such as
generic drugs. HTA information is also used to restrict the use of products, especially innovative and
expensive technologies. Specifically, reimbursement of such technologies can be conditioned to certain
indications, patient populations, treatment settings, and therapeutic positioning (i.e., first- or second-line
therapy).393 As aforementioned, HTAs play a role in the pricing of products and in negotiating special
agreements (e.g., price-volume, cash rebates) with manufacturers.394 However, countries differ in terms of
how closely the reimbursement and pricing process are linked. In particular, reimbursement decisions are
386
Zentner, Valasco-Garrido, and Busse, "Methods for the Comparative Evaluation of Pharmaceuticals."
Ibid.
388
389
Anell, "Priority Setting for Pharmaceuticals.", Zentner, Valasco-Garrido, and Busse, "Methods for the Comparative
Evaluation of Pharmaceuticals."
390
391
S. Boulenger et al., "Can Economic Evaluations Be Made More Transferable?," European Journal of Health
Economics 6 (2005).
392
393
394
387
129
sometimes made prior to pricing, while in other cases, both the reimbursement and price of a product are
considered simultaneously before a final decision is determined.
The effectiveness of HTA in national priority-setting and health care policy-making depends on several
considerations, including the quality of evidence used in the assessment, mechanisms for disseminating the
decision, transparency of the evaluation, and processes for monitoring and reappraisal of the evidence.395
For example, a lack of trust in the methods used in the assessment or insufficient long-term outcome data
can increase the complexity and uncertainty of the decision process or result in appeal procedures396.
Moreover, broader system issues, such as decentralized management and ideologies on rationing care, may
impede optimal implementation and use of economic evaluation.397
It is of import to ensure the optimal use of HTAs in decision-making processes, as requirements for
economic assessments and their integration into benefit catalogues and practice guidelines potentially
increases the costs for medicines, delays patient access to needed treatments, and stymies product
innovation. To meet this end, a variety of measures should be considered across the aforementioned areas,
including consistent application of HTA across countries; increased use of stakeholder groups; enhanced
transparency regarding topic selection, methodologies, and criteria used in decision-making; strengthened
international collaboration; and, greater alignment of manufacturer incentives to promote product
innovation and the introduction of safe, effective, and affordable technologies into the marketplace.
5.1.1 HTA in Austria
Over the past years Health Technology Assessment (HTA) has, with some delay in countries relying on
social insurance, gained considerable prominence and is applied at both an academic level and in the
decision making processes. HTA should be used to decide whether new services should be
included/reimbursed or whether existing services should be re-assessed or excluded from reimbursement.
A few years ago the status of the area of health technology assessment in Austria was described by experts
as follows “With respect to the application of evaluations as a health political tool for the assessment of
health services, Austria can be described as a developing country.”398 Systematic approaches were missing
in this area.
Some years ago a unit for Evidence Based Medicine was set up in the Hauptverband, which, on request,
synthesised the existing and evaluated, basic scientific knowledge of particular topics. The Hauptverband
was one of the pioneers encouraging development of knowledge and resources in the area of EBM. In the
field of medication, efforts are being made to contain costs, which in part stem from health economic
evaluations. In general instruments such as HTA, economic evaluation or EBM have more importance in
the area of pharmaceuticals than for health services, for example when evaluating medical services. The
latter area could take advantage of the knowledge and experience acquired in the field of pharmaceuticals.
Over and above this there are a few expert groups, which carry out an assessment of the technology and
offer their services.399 Evidence based medicine, HTA and health economic evaluations are only slowly
gaining ground in Austria.400
Social insurance uses a dual system when considering whether new services should be included in the fee
structure, whereby decisions are partially assisted by methodical evaluation. The question of reimbursement
takes precedence after the conditions according to the legal definition of illness have been met. Although
395
396
J. Neumann, Using Cost-Effectiveness Analysis to Improve Heath Care: Opportunities and Barriers (New
York: Oxford University Press, 2004).
397
F. Rutten, W. Brouwer, and L.. Niessen, "Practice Guidelines Based on Clinical and Economic Evidence,"
European Journal of Health Economics 6 (2005).
398
Wild, C., Gibis, B. (2003). ″Evaluations of health interventions in social insurance-based countries: Germany,
the Netherlands, and Austria″, Health Policy 63, pp. 187-196.
399
Ludwig Boltzmann Institute for Health Technology Assessment (Dr. Claudia Wild)
400
Wild, C., Gibis, B. (2003). ″Evaluations of health interventions in social insurance-based countries: Germany,
the Netherlands, and Austria″, Health Policy 63, pp. 187-196.
130
economic analyses are carried out, this does not mean that decisions are inevitably based on the results of
these analyses.401
5.2 Resource allocation in Austria
Funding responsibilities in the Austrian Health care system are fragmented, especially in the area of
hospital care, in which social insurance funds, the federal states, the Federation as well as the municipalities
occupy an important role.402 In the estimate for the federal budget 2006, following the classification based
on areas of expenditure, €834 million are planned for health care.403 Earmarked subsidies based on the
Hospital Act account for €411 million.404 Federal states and municipalities are in charge of calculating their
own health care expenditures.
More than once political discussions took place questioning if the increase in health care expenditure should
be aligned with the increase in GDP. Hofmarcher, Riedel and Röhrling (2004) calculated that, accumulated
for the years 2004-2007, this would result in a funding gap of around €4.8 billion. In their model calculation
the Health Econ researches come to the conclusion that a freezing of the health care budget would lead to
negative distribution effects putting primarily private households at a disadvantage.405
Financial resources of social insurance are raised and used in a decentralized way. 81% of the funds are
generated by contributions of the insured, 11% by contributions of the federation and 8% by other income.
In the year 2005 social insurance accumulated a revenue of € 39,374 million. Financial means of social
insurance are not related to the GDP or the federal budget.406
Funding of hospital care is partially organized by budgets. The Federation occupies primarily a steering
function, the federal states are responsible for securing health care provision.
Social insurance pays, in comparison to the Federation and the federal states, whose contributions are fixed
amounts of money and fixed percentages of the revenue generated by VAT407, a lump sum payment for
inpatient care according to § 447 para.1 ASVG. This covers all services of hospitals funded by the federal
health care agencies in the field of inpatient care, semi-inpatient care, day-clinical care and care in
outpatient departments, including services due to advances in medical technology.408 The lump sum
reimburses about 42% of the total costs of fund-hospitals and is adjusted according to the increase in
insurance contributions of the social insurance funds. In the year 2005 social insurance funds paid € 3.38
billion to the federal health care agencies.409
Furthermore social insurance pays a yearly prospective sum of €72.67 million to a fund
(Privatkrankenanstalten-Finanzierungsfonds, PRIKRAF), set up in the Chamber of Commerce in 2002, for
the hospitals not funded by the federal health agencies and for-profit hospitals i.e. sanatoria. Funding takes
place by national performance related principles.
401
Dr. Endel, Dr. Schiller-Frühwirth (Main Organization of Austrian Social Insurance Funds, Hauptverband).
Interview 18 November 2005
402
Fuentes, A., Wurzel, E., Wörgötter, A. (2006). ″Reforming federal fiscal relations in Austria.″ OECD Economics
department Working paper No.474, pp. 1-34
403
Federal Ministry of Finance (2006). Budget 2006, Figures – Background – interrelationships, accessed at
https://www.bmf.gv.at/Budget/Web_Zusammenhaenge_2006.pdf. on 20/06/2006
404
Federal Ministry of Finance (2006). Federal Finance Act 2006, Working guide – general overview, accessed at
https://www.bmf.gv.at/Budget/Budget2006/Gesamtueberblick_2006_Web.pdf on 10/06/2006
405
Hofmarcher, M., Riedel, M., Röhrling, G. (2004). ″ Focus: Health remains precious to us – so what?″ Health
System Watch I, supplement to the Austrian Journal of social insurance, Soziale Sicherheit, pp. 8-14
406
Hauptverband der österreichischen Sozialversicherungsträger (2005). Handbook of social insurance in Austria
2004. Vienna
407
Tripold, M. (2005). The Austrian Health Care System 1945 up to the present in Sprenger, M. (Ed.) Public Health in
Austria and Europe, , Pabst Science Publishers, Lengerich, 2005
408
Outpatient services provided in the course of the mother-child pass investigations and services explicitly excluded
by mutual consent of social insurance and the relevant federal states are not reimbursed
409
Hauptverband der österreichischen Sozialversicherungsträger (2006). Handbook of Austrian Social Insurance
2006. Vienna
131
In the ambulatory setting social insurance has the obligation to provide health care services. Social
insurance representatives negotiate contracts as well as fee schemes with the professional organizations or
with the individual contract partners respectively. Funding of ambulatory care and of inpatient care is
organised separately thus creating incentives for shifting of services between the different areas.
5.2.1 Decisions about the health care budget
The legal basis for state budgeting is the Federal Constitution. Government is obliged to present a
preliminary budget for the following year to parliament by latest ten weeks before the end of the year. The
decision on the budget is to be taken before turn of the year.410
The Federal Health Care Agency replaces the former Structural Fund and is a fund governed by public law,
an incorporated enterprise (mit eigener Rechtspersönlichkeit). The Federal Health Care Agency is
responsible for setting up quality guidelines and for planning the supply of services for all sectors.
Moreover the agency is committed to elaborate guidelines for budgeting for the hospital carriers and for
social insurance and to develop performance-orientated remuneration systems.411
Furthermore it has, according to § 59a KAKuG, the duty of developing guidelines for the transparent
presentation of the entire budgeting process and balance of accounts of the hospitals i.e. the hospital
associations. In addition for social insurance for the ambulatory setting.
The Federal Health Care Agency grants, based on § 57 KAKuG, the resources for the funding of public
hospitals and distributes them to the agencies for health care of the federal states according to a defined
formula (distribution key).
The health care agencies in the federal states are responsible for planning, steering and funding of health
care in the federal states. In the course of the above mentioned activities they are obliged to take into
consideration the input of the Federal Health Care Agency.
Use of financial resources of health insurance funds is, apart from inpatient care, handled autonomously by
the individual sickness funds and is based on the obligation to provide services stated in the social insurance
laws.
5.2.2 Allocation of budgets
The amount of financial resources used for public health care is decided by the different funding
institutions, namely social insurance funds, central government, the nine federal states, the municipalities
and the legal representative e.g. religious orders.
In the federal states the health care agencies have budgets for hospital care which are funded by social
insurance, central government, communities and the federal states according to the regulations of the article
15a agreement of the Federal Constitutional Act.
The transferal of the resources for hospital care from the health insurance funds to the health care agencies
in the federal states is performed based on a defined distribution key. In the area of health insurance
financial resources are not allocated to regions but to the individual funds which generate them
autonomously by collecting insurance contributions. Contribution rates are defined by law, the right of
budgeting (passing a resolution on the annual estimate and the annual report of the management board
(Vorstand)) is, according to § 433 ASVG duty of the legislative organ of the insurance fund, the general
assembly (Generalversammlung).
410
Federal Ministry of Finance (2006). Budget 2006, Figures – Background – interrelationships, accessed at
https://www.bmf.gv.at/Budget/Web_Zusammenhaenge_2006.pdf. on 20/06/2006
411
Article 15a agreement of the Austrian constitution, Article 11, Duties of the federal health care agency
132
5.2.3 Decisions about capital investments
Expenses for investments in the area of inpatient care are met by the hospital carriers, which are usually the
federal states or Federation.412 In their capacity of owners of hospitals the federal states cover expenses for
investments and maintenance, furthermore the daily running costs. The Federation renders financial
allowances to the hospitals according to § 57 KAKuG and, in the case of university hospitals, substitutes
any additional costs resulting from the construction, design and expansion of necessities resulting from
teaching. The latter costs are called “klinischer Mehraufwand”, additional clinical expenses.
In the area of social insurance the management board is responsible for the management of the insurance
fund (§ 434 ASVG), whereby certain duties may be delegated. Further details are stated in the statutes of
the individual insurance funds.
According to § 436 ASVG the control assembly (Kontrollversammlung) of the individual insurance fund is
responsible for the audit of the financial activities (Gebarung), including the examination of accounting and
cash administration procedures (Buch- und Kassaführung). The management board necessitates the consent
of the control assembly in order to perform permanent assessments. Based on § 437 para.2, a resolution on
changes in real estate, especially on the construction or enlargement of buildings also requires the approval
of the control assembly, the same is applicable to decisions on the construction of institutions dedicated to
administration, medical care, dental care, inpatient care, preventive services for adolescents and adults,
treatment of accidents, for rehabilitation, for measures for health promotion, for disease prevention or health
care examinations, in own or foreign buildings as well as for rebuilding in case this is linked to a change in
the purpose of use.
Maintenance or overhauling activities as well as replacement of the inventory do not necessitate the consent
of the control assembly, only if there is a causal relationship to the above mentioned projects.
5.2.4 Hospital planning
An important planning instrument for all sectors of care, based on article 4 of the 15a B-VG agreement, is
the Austrian Structural Plan for Health (Österreichischer Strukturplan Gesundheit, ÖSG) passed on
December 16, 2005. The plan replaces the Austrian Hospital and Major Equipment Plan (Österreichischer
Krankenanstalten- und Großgeräteplan, ÖKAP and ÖGGP). It represents a mandatory Austria-wide basis
for the integrated planning of the care structure in the Austrian health system and covers the areas of
inpatient and outpatient care as well as rehabilitation and nursing interfaces. The planning for services
offered is set out up to a planning horizon of 2010. Therein Austria is split into four overall care zones
which are, in turn, divided up into a further 32 care regions. The federal states have developed detailed
plans based on the ÖSG, which sets out the basic conditions. The last agreed status of the ÖKAP/ÖGGP
was evaluated up to mid 2005 and remained effective until the end of 2005. An important achievement for
social insurance is that, for the first time, the Hauptverband was given a formal right to participate in the
development of planning guidelines.
An essential difference to the ÖKAP/GGP is that the ÖSG aspires a nationwide planning of health care
provision according to groups of diagnosis and services, going away from a planning based on beds or
specialties in the direction of displaying the provision of whole regions.413 Statements for expected numbers
of services are provided. Planning of major equipment is an integrated part of the planning of service
provision and is not carried out separately. Federal states, social health insurance funds and hospital carriers
receive more possibilities of influencing the design of health care provision due to the fact that the planning
procedures have to be handled amicably.414
412
Fuentes, A., Wurzel, E., Wörgötter, A. (2006). ″Reforming federal fiscal relations in Austria.″ OECD Economics
department Working paper No.474, pp. 1-34
413
32 health care regions (based on the NUTS III regions), these are allocated to four health care zones (West, North,
East and South)
414
Federal Ministry of Health and Women (BMGF) (2006). Advantages resulting from the Austrian Structural Plan for
Health
(ÖSG),
accessed
at
http://www.bmgf.gv.at/cms/site/attachments/4/1/1/CH0118/CMS1091614011590/oesg_2005.doc on 20/0672006
133
The provision of services is linked to the fulfillment of quality criteria (incl. minimum number of
consultations and accessibility) whereby the majority of the quality criteria pertaining to structure still
comply with those in the ÖKAP of 2003. Also part of the new ÖSG is capacity planning at a regional level
for hospitals financed by the agencies for health care in the federal states and an up to date plan for large
scale medical equipment.
The ÖSG is constantly being revised and developed further. The aim is an integrated care plan. That means
that areas of health care beyond those of acute hospitals are to be included in planning, e.g. medical care for
outpatients, additional inpatient and outpatient rehabilitation. The ÖSG 2006 provides basic planning
directives at federal state level. It is then the duty of the federal states, hospital agencies, and social
insurance funds to undertake the detailed planning. This development allows the individual players greater
room for manoeuvre whereupon it is hoped that integrated planning will result.415
As has been the practice up to now, sanction measures will come into operation in cases of a deviation from
the terms of the Austrian Structural Plan (see articles 35 and 36 of the agreement).
For implementation of the health plan the federation uses the services of the Austrian Institute for Health
Care (Österreichisches Bundesinstitut für Gesundheitswesen, ÖBIG). See also section on the regulation of
the provision of health care.
5.2.5 Geographical differences in per capita health expenditures
In Austria geographical differences in per capita health expenditures exist, data or research on the topic is
however very limited. Moreover it is extremely difficult to get data as it is considered highly sensitive.
When performing an analysis it is crucial to also keep in mind supply side factors such as variations in the
amount of services provided or in costs which may originate in these differences.
Using the service information system of social insurance (Leistungsinformationssystem, LIVE) it is possible
to assign the cost for services to the place of residence of the insured. Results of comparative analysis
should be treated with great caution as the systematics of data collection may vary for the individual health
insurance funds. In principle these analysis can be performed, however there is room for improvement and a
lot of future potential.
In the course of the activities of the working group “risk adjustment” (at the regional sickness fund of
Salzburg, founded in the context of the re-organization of the equalization fund of the regional health
insurance funds) various analyses were undertaken. These could be used within social insurance to analyse
differences in per capita spending.
When looking at the expenditure of different sickness funds the following becomes apparent. Great
variations between the funds in terms of expenditure per insured/beneficiary do exist.
In 2005 the costs per insured (for medicines) were lowest at the Austrian Social Insurance Authority for
Business (SVA), being €284.23 per insured and highest at the occupational sickness funds, amounting to
€502.05 per insured for medicines. On average the costs per insured (for medicines) of all sickness funds
was situated at € 337.92. Costs per prescription varied between €17.48 (sickness fund of the farmers) and
€24.20 (Austrian Social Insurance Authority for Business).
Costs per insured for medical devices varied between €39.03 (SVA) and €91.62 (regional sickness funds).
The costs per prescription were situated in the range of €56.44 (regional sickness funds) and €121.98
(occupational funds). The following funds were above the average of € 63.86: Insurance fund of the
415
Federal Ministry of Health and Women (BMGF) (2006). Advantages resulting from the Austrian Structural
Plan for Health (ÖSG), accessed at
http://www.bmgf.gv.at/cms/site/attachments/4/1/1/CH0118/CMS1091614011590/oesg_2005.doc on 20/0672006
134
Austrian Mining and Railway Industry416, Insurance fund of the Austrian Civil Servants, Austrian Social
Insurance Authority for Business (SVA) and the Austrian Social Insurance Fund of the Farmers.417
The fee of a case per billed contract physician in Austria (All billing entities, Verrechnungsstellen, all
medical specialties) ranged between €42.38 in Upper Austria and €51.70 in Lower Austria. An above
average fee was found for Lower Austria, Vorarlberg, Salzburg, Carinthia, Burgenland and Tyrol. The
average fee per billed physician, in € 1,000, varied between €193.54 in Carinthia and €219.14 in Lower
Austria. The average fees per physician were above the average of €204.62 (all § 2 funds) for the billing
entities of Lower Austria, Salzburg, Tyrol, Styria and Vorarlberg.418
As already mentioned, huge regional variations in per capita expenditure do exist. However it is very
difficult to find evidence related to the variations as data is highly sensitive and access is very restrictive.
In the course of the calculation of health expenditure based on the system of health accounts, it is in future
planned to calculate expenditures not only on a national but also on a regional level.
416
Since January 2005 merged with the insurance fund of the Austrian Railway Industry. The new fund is the
Insurance fund for the Austrian Railway and Mining industries
417
Hauptverband der österreichischen Sozialversicherungsträger (2006). Statistical handbook of Austrian social
insurance 2006. Vienna
418
Hauptverband der österreichischen Sozialversicherungsträger (2006). Ärztekostenstatistik, Yearly results 2005,
finalised 31. August 2006
135
6. TECHNICAL EFFICIENCY
There is considerable controversy surrounding the development of an appropriate measure of efficiency in a
complex human service sector like health. Economic theory presents one of the main measures of efficiency
as technical efficiency, which is concerned with outputs, and not the distribution of those outputs (see
section on allocative efficiency). It can be argued that efficiency can be broadly ascertained through an
examination of the resources committed to the health system – costs and utilization rates.419 Others have
attempted to generate a single measure of efficiency, or productivity of the health system.
Health system productivity can be defined as the level of output generated by a given set of inputs. The
United Kingdom has been innovative in developing a measure of health system productivity attempting to
incorporate elements of quality of care into the measurement of the output of the system – the NHS. The
quality indicators that have been used include survival rates, waiting times, patient experiences, and longerterm survival rates for myocardial infarction. These quality indicators are combined with more objective
indicators of output such as activity levels at various levels of the system. This is still a premature attempt at
analysing performance, but with further work should provide some insight into the costs and benefits of the
NHS.
Using data from the OECD, one study examines the extent different countries use their health care
resources efficiently to achieve favourable health outcomes.420 By measuring health outcomes with life
expectancy and infant mortality, some countries were found to be using their healthcare inputs efficiently to
produce its current levels of both outputs, including France, Greece, Ireland, Norway, Spain, Sweden and
the UK. Other countries were performing better for infant mortality than for life expectancy, including
Denmark, Finland and Portugal. Put another way, these three countries could produce higher levels of life
expectancy given their level of inputs and current social environment (measured by school expectancy,
income inequality and population characteristics). Other countries were found to be inefficient for both
outputs, including Austria, Belgium, Germany, the Netherlands and Switzerland. Overall, these findings
provide an alternative method of calculating outputs of health systems in a way that can provide insight into
making possible improvements, either by increasing resources, or by maintaining the same level of
resources and improving efficiency. However it is important to note that this method of measuring
efficiency is based on aggregate measures of spending and health outcomes, therefore should be interpreted
with caution.
6.1 Administrative costs
It is also worthwhile examining differences in administrative costs across different countries’ health
systems which may give an indication of relative (in)efficiency. Administrative costs reflect part of health
care funding that is not directly related to improving health. Included in these costs are the planning,
management, regulation, and collection of funds and handling of insurance claims.421 Table 6.1 shows that
on average social health insurance countries tend to have higher administrative costs (i.e. Germany,
Luxembourg, the Netherlands), with costs in Austria being relatively lower and closer to those of taxfunded systems.
The lower level of administrative costs in Austria and France could be attributed to the lack of choice
permitted between sickness funds, with the exception of Luxembourg.422
419
D Retzlaff-Roberts, C.F Chang, and R.M Rubin, "Technical Efficiency in the Use of Health Care Resources: A
Comparison of OECD Countries," Health Policy 69, no. 1 (2004).
421
422
Ibid.
420
136
Table 6.1 Total expenditure on health administration and insurance as a percentage of total health
expenditure in selected European countries, 1990, 1995, 2000-3
Country
1990
1995
2000
2001
2002
2003
2004
Austria
3.8
4.1
3
2.5
2.5
2.6
Belgium
6.3
Czech Republic
3
2.6
2.7
2.5
3.2
Denmark
0.8
0.9
0.9
0.9
1
1.9
2.1
Finland
2
2.3
2.1
2.1
2.1
2.1
2.2
France
1.6
1.7
1.9
1.9
7.8
7.7
7.5
Germany
6.3
5.3
5.4
5.3
5.5
5.6
Hungary
2.8
1.9
1.6
1.6
Italy
0.4
0.3
0.4
0.4
0.3
0.3
0.3
Luxembourg
3.4
3
2
11
9.6
Netherlands
4.9
4.5
4.9
4.6
4.3
4.3
4.4
Poland
2.2
1.4
2.4
Portugal
1.4
1.3
1.1
1.1
1.8
Slovak Republic
2.9
2.6
0.6
0.4
Spain
2.7
2.5
2.5
2.5
3.2
3.2
Sweden
0.6
0.4
0.4
0.4
0.5
0.5
Source: OECD health data 2006
Note: countries selected based on availability of data
6.1.2 Administrative costs in Austria
Compared to other European countries Austria spends a high share of its health care expenditures on
hospitals (43%).423 The costs of hospitals funded by public sources (nine health funds of the federal states)
amounted to around € 8,911 million in 2005. Costs doubled in all federal states between 1991 and 2004.
The increase over time lies slightly above the consumer price index. Increasing rates for costs could be
reduced by mid of the Nineties. Between 1997 and 2004 the federal states experienced increases of 23%
(Vienna) to 38% (Lower Austria, Burgenland). More than half of the hospital costs are staff costs. The
increase in cost is also related to the employment of better qualified personnel (doctors). Costs for
medicines make up about 5% of total costs, over the past years strong increases have taken place. About
three quarters of the costs are for inpatient care, roughly 13% for outpatient care and 10% for other areas of
care, partially not directly related to the hospital duties.
423
Hofmarcher, M.M., Lietz, C., Schnabl, A. (2005). ″Inefficiency in Austrian inpatient care: identifying ailing
providers based on DEA results.″ Central European Journal of Operations Research, to be published
137
Figure 6.1 Costs in hospitals funded by the federal health funds 1991-2004 (1991 = 100)
Line= total costs for hospitals, triangle= personnel costs, circle= costs for medicines
Source: BMGF (2006). Hospitals in figures accessed at www. bmgf.gv.at on 15/06/2006424
Expenditure of social health insurance for administration is very low. In 2005 it figured about 2.93% of
total expenditure.
Table 6.2 Administration costs of social health insurance
Absolute
% of total
expenditure
Index
% change to
the previous
year
2000
2001
2002
2003
2004
366
343
358
327
351
3.76
3.37
3.40
3.02
3.12
100.00
93.72
97.81
89.34
95.90
-6.28
4.37
-8.66
7.34
2005
346
2.93
94.54
-1.42
Source: Handbook of Austrian social insurance 2006, own calculations
424
Source: BMGF: Hospital-Cost accounting (hospitals funded by the federal health funds)
Statistics Austria: Consumer price index
138
6.2 Physical and human resources
Another way of investigating efficiency is to look at broad measures of resource capacity and also
utilization rates. For instance, one would predict that the countries that spend more (per capita, or as a
proportion of GDP) would also have higher absolute levels of physical resources such as hospital beds and
medical technology. For instance, comparing countries with social health insurance systems with those
funded through taxation, one can see a trend emerge. Social health insurance systems appear to be, on
average, more expensive that the tax-funded systems, and they also have higher population-adjusted
numbers of expensive diagnostic equipment (CT and MRI). In fact, as shown in Table 6.3, Austria has the
second highest level of CT scanners per capita, and highest level of MRIs.
Table 6.3 MRI and CT units per million population in selected European countries, 2003
CT scanners/ million MRI scanners/ million
population
population
Belgium (2002)
Austria
Luxembourg
Italy
Greece (2002)
Denmark
Germany (2002)
Sweden (1999)
Finland
Spain
Portugal
Czech Republic
Slovak Republic
France
Hungary
Poland
United Kingdom
(2001)
28.8
27.2
26.7
24
17.1
14.5
14.2
14.2
14
13
12.8
12.6
8.7
8.4
6.9
6.3
5.8
6.6
13.5
11.1
11.6
2.3
9.1
6
7.9
12.8
7.3
3.9
2.4
2
2.8
2.6
1
5.2
Source: OECD health data 2006
Turning to human resources, one can see quite significant variability across countries in the supply of
physicians and nurses (Figure 6.2). Higher density of physicians has been shown to be associated with
better health outcomes, and better responsiveness, in terms of lower waiting times.425
425
Steven Simoens and Jeremy Hurst, "The Supply of Physician Services in OECD Countries," (Paris:
Organization for economic co-operation and development, 2006).
139
Figure 6.2 Physician and nurse supply per 1000 population in Western Europe, 2003
Source: WHO Health for All 2005
Also there appears to be a weak positive association between physician density and health spending (as a
percent of GDP) across OECD countries.426 It is more likely, however, that spending would correlated with
both physician remuneration method (i.e. fee-for-service, versus salary and capitation methods) and the
number of practising physicians per population (Table 6.4).
426
Ibid.
140
Table 6.4 Relationship between physician density, remuneration and expenditure
Source: Simoens and Hurst 2006
Within the hospital sector, efficiency could be broadly ascertained by examining average length of stay and
occupancy rates. In the past few decades there has been a consistent trend towards shorter length of stays in
almost every OECD country (Figure 6.3).
Figure 6.3 Average length of inpatient stay in selected European countries
25
20
15
10
5
0
1980
1985
1990
1995
2000
2003
Austria
Czech Republic
Denmark
Finland
France
Germany
Hungary
Ireland
Italy
Poland
Portugal
Spain
Sweden
United Kingdom
2004
6.2.1 Hospital capacity in Austria
The Federation and the federal states already agreed on reducing the number of acute beds mid of the
eighties. This was made possible by shifting care to extramural levels of care as well as by a decline in the
average length of stay. The reduction is especially visible for hospitals funded by the federal health funds,
which provide a majority of the acute beds. Beds in hospitals not funded by the federal health funds are
often beds for long-term care which is why the reduction in length of stay was not so dominant.
Discrepancies are mostly due to changes in the legal status of the hospitals (hospitals are not any more part
141
of hospital statistics) or to the building and enlargement of rehabilitation centres. Beds per 100,000
inhabitants declined from 9.89 in 1991 to 7.73 in 2004.
The decline in beds between 1991 and 2004 notably affected the states of Vienna (-32%), Vorarlberg (29%) and Upper Austria (-16%).427
Figure 6.4 Beds in Austrian hospitals 1991-2004 (1991 = 100)
line= Austria total, diamond= hospitals funded by the federal health funds, circle=hospitals not funded by the federal
health funds
Number of beds 2004: hospitals funded by the federal health funds: 49,130 (77.7%), Hospitals not funded by the
federal health funds: 14,076 (22.3%).
In comparison to the European average Austria has a high density of hospital beds, especially for acute care.
Over the past 15 years a significant decline has taken place. However Austria’s number of acute beds
remains far above the European average. The Czech Republic, Hungary, Luxembourg and Slovakia have
similar values. In the figure below only those European countries are shown for which values for both years
are available.
427
BMGF (2006). Hospitals in figures accessed at www. bmgf.gv.at on 15/06/2006, own calculations
Source: BMGF Hospital Statistics (hospitals funded by the federal health funds), annual report (hospitals not
funded by the federal health funds), reports on diagnosis and services (hospitals funded by the federal health funds) –
average length of stay (all BMGF), Statistics Austria: Extrapolation of the population, yearly averages 1991–2004
(status: 23.05.2005)
428
142
Figure 6.5 Acute beds per 100,000 inhabitants
Acute beds per 100,000 inhabitants
Countries
EU
Sweden
Slovenia
Slovakia
Portugal
Luxembourg
Italy
Ireland
Hungary
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Belgium
Austria
0
200
400
600
800
1000
Beds per 100,000
1990
last available
Source: WHO Health for All, 2006.
6.2.2 Substitution policies in Austria
Generic substitution by pharmacists is not permitted in Austria, the views of the stakeholders (Pharmig,
Medical Chamber, social insurance, patient lawyer) regarding the introduction of an aut idem regulation 429
are mixed.430 Health insurance funds undertake a range of efforts to increase the share of generics
prescribed, partially employing financial incentives to motivate physicians to prescribe more generics. The
share of generics prescribed (of total prescriptions) at the different sickness funds varied between 9 and
15% (number of prescriptions), in terms of costs of prescribed medicines generics accounted for 6-10%. In
the segment in which substitution through generics is possible the share of prescribed generics amounted to
30-55% of all prescriptions and to 20-40% of total costs. More information on strategies used by the health
insurance funds to reduce expenditure on medicines can be found in the report by Mossialos, Ziniel,
Merkur, Walley und McGuire on “Public Policy and the Austrian Pharmaceutical Market: Options for
Reform”.431
With respect to substitution of personnel in the health care sector a tendency of patients to directly consult a
medical specialist instead of a general practitioner can be observed. Areas of responsibility of physicians
partially shift to other health care professionals, duties of general practitioners will be extended, they will
429
The physician does not prescribe a certain medication/drug but only the generic substance, doses and mode of
application. The pharmacists then chooses the cheapest from a group of medications which are comparable in terms of
quality
430
Mossialos E, et al. (2005). Public Policy and the Austrian Pharmaceutical Market: Options for Reform. London
School of Economics and Political Sciences, LSE Health and Social Care. London.
431
ibid
143
for instance be responsible for administrating and monitoring disease management programs. The provision
of services i.e the billing of services is usually based on the fact that the physician provides the service
personally. The extent to which nurses or medical assistants (e.g. dental assistants) perform medical tasks is
handled very differently, normally however responsibilities are separated very strictly.
A couple of studies have compared the cost of providing treatment in or outside of the hospital. Before
results are presented it is emphasised how complicated a comparison of service provision through a
physician in a surgery or through a hospital outpatient department is. With respect to interpretation of
results one should be well aware which parameters were chosen for the comparison in order to judge if the
comparison is reliable or valid.
In 2001 Laimböck compared treatment costs (per patient visit) of outpatient departments in hospitals (only
looking at general outpatient departments) with treatment costs of medical specialists in practices and
concluded that the general hypothesis of treatment being cheaper outside of the hospital cannot be
confirmed. Costs per visit of a general outpatient department are lower than fees of medical specialists with
a contract with social insurance. Comparing the cost of individual services in outpatient departments and in
practices of medical specialists shows a similar level of costs. When comparing two comparable institutions
the treatment costs are lower in the outpatient department. It was not possible to taken into consideration
that the illnesses of patients in outpatient departments are likely to be more severe than those of patients
consulting medical specialists in their practices.432
The results and the data used by Laimböck were discussed and criticised, arguing that they were partially
outdated or compared values which should not be compared with each other. Furthermore they could not be
extrapolated to the whole of Austria as they only represented a small region in the federal state of Tyrol.433
In 2001 the regional sickness fund of Vienna compared treatment costs in the Hanusch hospital434
(outpatient departments) with treatment costs of medical specialists in practices435. Overall treatment in
outpatient departments was slightly cheaper (by about 11%). Treatment was cheaper in the following
outpatient departments436: internal medicine, heart, gastro, diabetes, surgery, accident, rheuma,
otorhinolaryngology. Treatment in the following outpatient departments was calculated to be more
expensive than treatment by medical specialists in their practices: dermatology, children, ophthalmology,
urology and orthopaedics.
Hofmarcher, Riedel and Röhrling437 also analysed the question if treatment costs were higher in hospital or
outside the hospital and concluded that a potential for substitution between outpatient departments in
hospitals and practices of medical specialists does exist, however the scope of this potential is not clear.
Furthermore they urge that a simple comparison of average costs is not valid and that the aims of service
provision of each provider have to be taken into consideration.
The regional sickness fund of Vienna analysed the relationship between the number of physicians (density,
§ 2 contract physicians per 1,000 inhabitants in one district) and the number of hospital visits (inpatient
admissions per 1,000 inhabitants of one district) as well as the association between the density of contract
physicians and the number of visits to outpatient departments.438 Pazourek calculated correlation
432
Laimböck, M. (2001). ″Analysis and comparison of treatment costs in outpatient departments and practices of
medical specialists.″, received from Laimböck via email; Laimböck, M. (2000). Social health insurance between state,
monopoly and competition. Berenkamp
433
Hampel, R. (2001).″Please, respectable comparisons!″ Ärztezeitung 21, pp. 13-14
434
Integrated hospital of the regional sickness fund of Vienna
435
Using the study by Laimböck as a reference for calculation methods
436
First (considerably cheaper, about 62%), last (a little bit cheaper, about 8.9%).
437
Hofmarcher, M., Riedel, M., Röhrling, G. (2001).″ Focus: Doctor's Practice or Outpatient Department: One case is
not one case.". Health System Watch IV, supplement of the Austrian journal of social insurance Soziale Sicherheit, pp.
11-23.
438
Pazourek, J. (2001). Association between physician density, hospital visits and visits to outpatient departments–an
analysis of the regional sickness fund of Vienna. Presentation given in August 2001, Management Summary.
144
coefficients (Pearson) and used regression plots for visualisation. The hypothesis, that the higher the density
of (contract) physicians per district, the lower the number of hospital admissions in the district, could be
rejected, the hypothesis that the higher the density of contract physicians, the higher the number of hospital
visits was supported.
Regarding the association between physician density (contract physicians per 1,000 inhabitants) and the
number of visits to outpatient departments (per 1,000 inhabitants) the hypothesis “the higher the density of
contract physicians per federal state, the lower the number of visits to outpatient departments in the federal
state could be rejected. However the hypothesis “the higher the density of contract physicians the higher the
number of outpatient visits could be confirmed.
In the same presentation Pazourek showed that most patients accessed outpatient departments via the
following routes:439
-
Inpatients (47%)
-
Referred by physicians outside of the hospital (27%)
-
Final outpatient treatment (12%)
-
Came by themselves, emergency (6%)
-
Came by themselves, no emergency (5%)
-
Brought by ambulance (3%)
Based on the results of his analysis, Pazourek concluded that an increase in the number of contract
physicians would not result in a steering (substitution) effect but would increase the number of visits to
outpatient departments. A co-payment for patients when accessing outpatient care (introduced in 2001,
abolished in 2003440) would not steer consumption as patients rarely decide themselves to visit an outpatient
department but are usually referred during an inpatient stay or by a physician outside the hospital.
6.2.3 Physician career paths in Austria
After successful completion of studies of Human Medicine university graduates have various possibilities.
One is to complete post-doctorate training (Turnus), either in the form of a three year training to qualify as a
General Practitioner, or a six year training to qualify as a Specialist/Consultant (these are minimum time
periods). Training places are sites recognised by the Medical Chamber. Over the past years there has, in
part, been a significant shortage of training places in hospitals. Because it is often very difficult to get a
consultant training placement upon completion of their studies many of those graduates interested first
decide to enter the training to become a General Practitioner, during which they apply for Consultant
positions. Subsequent training for qualification as a specialist takes around 5 years, as parts of the previous
General Practitioner training may be counted as credit. A doctor who has completed his training for
Consultant is called an intern/assistant doctor (Assistenzarzt). During training he can also work as a ward
physician, this function can equally be performed by a General Practitioner.
Professional eligibility for General Practitioner or Consultant can only be obtained after compliance with
certain pre-requisites has been verified, e.g. evidence of having completed the minimum training period, a
fully completed positive report (Rasterzeugnisse), as well as, a positive examination result.441 With
completion of the examination the doctor receives the jus practicandi which, aside from the official right to
independent practice, is required for freelance activity, undertaking stand-in work, precautionary health care
examinations, counselling, certification/expert opinions etc. At this point in time the doctor has the option
439
OEBIG in Pazourek, J. (2001). Association between physician density, hospital visits and visits to outpatient
departments–an analysis of the regional sickness fund of Vienna. Presentation given in August 2001, Management
Summary.
440
Mossialos E, et al. (2005). Public Policy and the Austrian Pharmaceutical Market: Options for Reform. London
School of Economics and Political Sciences, LSE Health and Social Care. London.
441
Details on examinations for specialists see Chapter 6
145
of going into employment (e.g. in a hospital, nursing home, sanatorium, outpatient clinic), to be selfemployed (home doctor442, private practice, private doctor, contract doctor), or of joining a group practice, a
cooperative praxis, or long term substitution, etc.
After taking their exam very few General Practitioners (GPs) remain in hospitals. A GP, who continues to
work in the hospital, is called an assistant doctor (Sekundararzt). Most GPs work in their own individual
practices. Establishment of a practice is linked with numerous pre-conditions and brings with it many
obligations which are not covered in detail at this point.
If the qualified Consultant continues to work at a hospital then the next stage in the hierarchy is the position
of Oberarzt (senior physician/head of department), although actually the Oberarzt is a description of status
and not an official title according to the doctors law. The position of Oberarzt is awarded based on
professional qualification, length of service, and possibly upon the recommendation of the head of
department. The next step is the “first Oberarzt” or “first senior physician”, who is usually appointed by the
chief physician (Primararzt) and is chosen for this position based on length of service. The “first senior
physician” is at the same time the deputy for the chief physician. Technically the position of Chief
Physician is, after Consultant, the next step in the hospital hierarchy. The Chief Physician is responsible for
a whole specialist department.
In order to become Chief Physician it is not necessary to sit a special examination. The position is linked
with specific professional qualifications (Consultant in the specialisation of the department to be led),
professional experience as well as evidence of other required competencies. Criteria for the job
advertisement are specified by the employer.
Of course medical graduates can also follow other career paths (medical/non medical) and work amongst
other things in public health services, in research, in establishments of the social insurance funds, in the
pharmaceutical industry, consultancy, as occupational medical doctors, and as school doctors. With the
exception of the first (public services, see the following section) these areas are not gone covered in greater
detail in this report.
6.3 Provider payment methods
The methods used to pay health care providers create powerful incentives that affect provider behaviour and
the efficiency, equity and quality outcomes of health system financing. Specifically, these payment methods
can be used to influence the price and quantity of health care. In the health service, there are three basic
methods of physician payment: fee-for-service, salary and capitation. There are many variations of these
payment systems, but the basic principles remain.
Fee-for-service is an agreed upon value for a specific service which is to be provided. The incentive is to
provide the best service at a reasonable cost to maintain the confidence of patients. Fee-for-service payment
works well when there is an adequate supply of providers, minimal interference in the negotiation of prices,
and freedom to choose the provider. It fails when providers attempt to control supply and demand (cartels)
or when insurers set prices at a level too low for providers to survive (rent controls). Regulations can be
implemented to prevent these examples of potential failures.
Salary is the payment of a negotiated amount of money for a fixed period of time, within which providers
are commitment to providing services. The number of patients seen, services provided, and the cost of
services do not affect the payment. Legislation can be in place to cover overtime pay and holiday pay based
on time worked. However, salaries are still linked to services since the payment for salaries must come from
the payment for the service to the third party or through taxation in a public system.
442
A doctor who does not have an own practice or is employed by a hospital but practices medicine from his private
residence (e.g. compiling expert opinions, standing in for other doctors, etc.). He needs to register at the Medical
Chamber.
146
Capitation is the payment of a set amount of money to the provider to insure that services are provided to
the user in a given time period. The provider agrees to provide all agreed services and bares the risk that the
negotiated amount will cover costs and leave a profit. The user agrees to obtain the agreed services only
from the designated provider unless additional money is paid out. These different physician remuneration
methods have different inherent incentives (see Table 6.5).
Table 6.5 Doctor Payment Systems and incentive effects443
Payment
type
Definition
Fee-forservice
Salary
Payment for each
medical act
Payment per unit
of time input
(e.g. per month)
Payment per
patient for care
within a given
time period
(e.g. a year)
Capitation
Incentive
to
increase
activity
Incentive
to
decrease
activity
Yes
No
Incentive
to shift
patients’
costs to
others
No
Incentive
to target
the poor
Controls
cost of
doctors’
employment
Maybe*
No
No
Yes
Yes
No
Yes
No
Yes
Yes
No
Yes
*If fee-for-service payments for treating poor patients exceed those for treating middle classes
The established analyses of payment mechanisms focus on the balancing of risk aversion with moral
hazard.444,445 The combination of retrospective (i.e. fee-for-service) and prospective (i.e. capitation, salaries)
payment methods under the need to balance conflicting incentives falls within the scope of the economic
literature on principal-agent relationships as well as the literature on optimal contracts in the context of
multi-task agency relationships.446
There is inconclusive evidence on the link between targeted financial incentives and the behaviour of
individual doctors, particularly in relation to quality improvements. Methodological problems persist with
attributing complex behavioural changes to particular interventions, and with assessing the spillover effects
of interventions onto behaviours other than those incentivised.447 Other challenges with assessing the effects
of financial incentives on physician behaviour include a number of factors such as the observations that
beyond the economic rewards of financial incentives, doctors are motivated by other goals (e.g. improving
chronic disease management).448 Also, doctors may have a targeted income beyond which they are no
longer motivated by financial incentives (no linear relationship between incentives and impact).449 Despite
these challenges there are some important lessons regarding financial incentives: they are more effective if
they are owned by their target audience and aligned to professional values; they should be focused more on
technical aspects and less on indeterminate aspects of professional practice; and professional motivation is
443
A Maynard and K Bloor, "Do Those Who Pay the Piper Call the Tune?," Health Policy Matters 8 (2003).
K.M. Eisenhardt, "Agency Theory: An Assessment and Review," Academy of Management Review 14 ,, no. 4
(1989).
445
D Sappington, "Incentives in Principal-Agent Relationships," Journal of Economic Perspectives 5, no. 2 (1991).
446
J.C Robinson et al., "The Alignment and Blending of Payment Incentives within Physician Organizations," Health
Services Research 39, no. 5 (2004).
447
M Marshall and S Harrison, "It's About More Than Money: Financial Incentives and Internal Motivation," Quality
and Safety in Health Care 14, no. 1 (2005).
448
A Spooner, A Chapple, and M Roland, "What Makes British General Practitioners Take Part in a Quality
Improvement Scheme?," Journal of Health Services Research and Policy 6 (2001).
449
J Rizzo and D Blumenthal, "Is the Target Income Hypothesis an Economic Heresy?," Medical Care Research and
Review 53 (1996).
444
147
more likely to be damaged by overly bureaucratic schemes. Thus, it would be inappropriate to link financial
rewards to complex diagnostic processes or to the psychosocial aspects of care provision.
In Western European countries, the three methods discussed above are the main approaches for paying
providers. In the public sector most primary and outpatient care doctors are paid on a salaried or capitation
basis, or a combination of the two. Capitation payments are predominantly used in Italy, the Netherlands,
and the UK. Alternatively, fee-for-service payments prevail in some countries, namely Austria, Belgium,
France and Germany. This method of payment is also the norm for privately delivered primary and
outpatient care. Several studies have found supportive evidence for actual effects of payment method on
physician behaviour.15,450,451 Therefore, it has been proposed that a mixed payment scheme, which includes
elements of all three mechanisms helps to moderate these negative incentives.
In consideration of the incentives inherent in the main methods of physician payment, some alternative
models have been devised. These include performance-based reimbursement in Sweden and the GP contract
in the UK. In the United States, experimentation with physician payment methods that incentivise
physicians to expand the provision of preventive services, improve clinical outcomes and enhance patient
safety and satisfaction are collectively called “pay-for-performance” programs. These programs are based
on the premise that the structure of payment methods may not facilitate (or even prevent) the actions needed
to systematically improve quality of care.452
Explicitly stated quality standards can act as objectives to which health care providers commit. The
inclusion of metrics within a contract, by which standards can be measured, helps in analyzing adherence to
quality specifications. Quality specifications can be structure, process or outcome oriented thereby differing
in what they measure, but all enacted to meet the goal of quality provision. Structural mechanisms involve
making it compulsory for providers to build into contracts means by which quality levels can be assured.
Process mechanisms operate to monitor patient outcomes through specific protocols and guidelines, such as
the percentage of patients vaccinated, or guarantee a specified volume of services. Outcome targets are
similar to process goals in their use of guidelines except they are based on results of treatment rather than
actual treatment levels. However, a lack of information hinders purchasers’ understanding of the quality
level that they are paying for in some types of health services.
Incorporating a broad array of quality measures in an incentive program, appears to be an attempt to deal
with the “multi-tasking” problem, such that if providers face a number of tasks and resources are limited,
then effort will be allocated toward those tasks that are explicitly rewarded, taking resources away from
other activities. By choosing to attach financial rewards to a larger set of tasks, payers can elevate and
protect key priorities from these negative spill-over effects. However, the dimensions of care that will
receive the most attention will be those that are most easily measured and not necessarily those that are
most valued.
Hospital payment systems
Within the public hospital sector, salary payments are widespread although fee-for-service has been
customarily used in some countries with a move towards a case-based payment system according to
diagnosis related groups (DRGs). Most countries in Western Europe have moved to a performance-based
approach, using some combination of case-mix adjusted DRGs and/or global budgets. Within this general
framework, there is some diversity of approaches to payment for inpatient services, and many have
developed to meet cost-containment objectives.
450
C Chaix-Couturier et al., "Effects of Financial Incentives on Medical Practice: Results from a Systematic Review of
the Literature and Methodological Issues," International Journal for Quality in Health Care 12, no. 2 (2000).
451
T Gosden, F Forland, and I.S Kristiansen, Cochrane Review: Capitation, Salary, Fee-for-Service and Mixed System
of Payment: Effects on Behaviour of Primary Care Physicians., vol. The Cochrane Library, Issue 2. (Chichester, UK:
John Wiley & Sons, Ltd., 2006).
452
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. (Washington, DC:
The National Academies Press, 2001).
148
Case-based payment can be used for inpatient care, with hospitals being paid an inclusive flat sum for a
patient’s treatment according to a DRG. DRGs are used in the United States’ Medicare program for the
elderly and setting part or the whole of hospital budgets in Austria, Ireland, Finland, Portugal, Spain and
Sweden.453
Budgets can take different forms. ‘Hard’ budgets use penalties for over-spending and may also provide
reward for under-spending. If the budget is used to reimburse fee-for-service providers, the fees can be
automatically adjusted retrospectively to make sure that total expenditure remains within budget. The
rewards can involve retention by the agent of some or all of any surplus made. Alternatively, with target or
‘shadow’ budgets, a record is kept of the costs of the transactions undertaken, but no immediate penalties
are applied and overspending is automatically met. Budgets do not dictate specific practice patterns and
allow greater doctor autonomy than some other controls. They may also give the medical profession a
motivating rationale to develop, support and even implement clear clinical standards and other strategies to
achieve lower volumes. Doctors may have a strong incentive to monitor practice patterns for
appropriateness. Budgets can play an important role in health reforms that include decentralization of the
decision-making process in the health system and devolution of responsibilities on resource allocation to
local hospital managers.
Countries in Western Europe provide an interesting example of convergence towards a mixed payment
system, for funding hospital services. The majority of countries currently use some form of case-mix
system, original or an adaptation of the DRG system, often with a global budget cap. Each system has
adapted the specifics of the case-mix measure and/or the application to fit within the local funding
framework and to address the objectives prioritized within the local hospital environment.
There is no definitive best way of remunerating providers. The method chosen to pay providers depends on
the goals of policy-makers. There is greater potential success for mixed/blended payment systems with
performance management when activity is monitored. Capitation and salary systems create effective cost
control, but with the possibility of under-serving patients; however, if these systems are accompanied by
constrained evidence-based and cash limited systems of fee-for-service, they can increase activity and may
improve quality if accompanied by local micro-management.
Aligning providers’ financial incentives with quality goals may be a necessary precursor to the
improvement of health care purchasing. Quality-incentive programs should be viewed as part of a broader
strategy of promoting health care quality through measuring and reporting performance, providing technical
assistance and evidence-based guidelines, and increasingly, giving consumers incentives to select higherquality providers (where they have choice) and proactively manage their own health.
Payment of pharmacists
The role of pharmacists are becoming more clinical in addition to assisting in controlling pharmaceutical
expenditure when permitted to undergo generic and therapeutic substitution, and when there are incentives
to practice economical dispensing. One radically new role for pharmacists in the UK will be as prescribers,
responsible for dose adjustment and monitoring in a range of chronic conditions where a doctor has made
the diagnosis. Regulation of pharmacists differs across the EU Member States. Some different regulatory
practices include controlling community pharmacy ownership and location, setting allowable profit
margins, and influencing drug distribution patterns and product selection through different incentives and
remuneration methods.
The method of paying pharmacists impacts their product selection. Pharmacists receive a fixed fee per item
dispensed in Ireland, the Netherlands, Sweden and the UK. In the UK, there is also a fixed reimbursement
price on unbranded generics, therefore pharmacists have the incentive to dispense the cheapest suitable
453
G Carrin and P Hanvoravongchai, "Provider Payments and Patient Charges as Policy Tools for Cost-Containment:
How Successful Are They in High-Income Countries?," Human Resources for Health 1 (2003).
149
product and in doing so retain the difference between the purchase price and the reimbursement price.
Similar preferential margins to motivate dispensing choice exist in some other EU markets. In Denmark a
dispensing budget introduces a collective incentive to dispense economically. Pharmacists in Austria,
Belgium, Denmark, Germany, Greece, Italy and Portugal are paid regressive scaled margins or margins that
are a fixed percentage of a product’s price. Under this payment method, pharmacists have little incentive to
dispense cheaper products. Denmark (since 1991), Finland, France (since 2001) and Spain allow a
pharmacist to substitute a generic for a branded preparation, regardless of how the prescription was written.
6.3.1 Provider payment methods in Austria
The way health care providers are paid for their efforts can strongly influence their behaviour. Types of
reimbursement mechanisms are salary, capitation, fee-for service or blended systems. Each of these entails
different incentives for the provider, thus influencing his work. In general the payment of Austrian health
care providers is not linked to targets or quality outcomes, leaving room for potential productivity gains. In
the next sections the payment of physicians who signed a contract with social insurance, the reimbursement
of hospitals and the payment of hospitals doctors is described as well as potential impacts on their
behaviour.
Payment of physicians in ambulatory care – contract physicians of social insurance
Physicians who signed a contract with social health insurance are usually paid by a blended system, which
is based on fee-for service payment and supplemented by a capitated payment (per patient, for a certain time
span), also called basic reimbursement (Grundleistungsvergütung). Additional benefits (special services,
Sonderleistungen) are also reimbursed. Most health insurance funds pay their contract partners a basic
capitated fee for a quarter year (3 months), regardless of how many consultations occur within this time
span. Thus the risk related to the number of physician visits within a quarter is partially shifted to the
doctor. Many sickness funds provide payments per visit (in addition to the initial lump sum and mostly of a
limited amount). The height of the capitated payment varies amongst the sickness funds and may also
depend on the specialty of the doctor. Special insurance funds (Sonderversicherungsträger), SVA, BVA
and VAEB454 pay their contract partners (physicians) by fee-for service payment only, some regional
sickness funds have a very low basic reimbursement (Carinthia, Lower Austria)
Based on the fact that Austrian physicians are mostly reimbursed by fee-for service payments this would
lead to the assumption that they are incentivised to maximise the number of services they provide. In order
to counteract this, health insurance funds implement steering mechanisms in their reimbursement catalogues
and/or general contracts.
Steering instruments applied by most of the insurance funds when reimbursing providers are for instance
billing restrictions, capping of benefits provided and degressive payments (price-volume trade-off once a
certain volume of benefits is reached). The latter mechanism is used when new benefits are introduced or in
case a service is provided very frequently. Billing restrictions are used to ensure a certain quality of the
service provided, e.g. a physician is only allowed to bill a service if he provides evidence of having the
adequate training or equipment. They are also applied to restrict service provision to certain disease
indications, to limit the number of times a certain service is provided within a defined time period or to
prevent services being provided in combination with other services. In the case of caps/quotas services are
only reimbursed for a certain percentage of cases, e.g. 10%.
Reimbursement for preventive services is not linked to the fulfilment of defined targets, such as reaching a
certain number of people. The health check up is regulated in a separate general contract and reimbursed on
a fee-for service basis.
If the reimbursement of services is not linked to the fulfilment of quality targets there is a risk of health care
providers reducing the quality of services provided.
454
Self-employed, civil servants, Mining and Railway Industry
150
Reimbursement of inpatient care
About 40% of Austrian health care expenditure is for hospitals455. Hospitals are funded by social health
insurance, the Federation, the federal states, local governments (municipalities), hospital carriers, patients,
private health insurance and social welfare.
In comparison to the Federation and the federal states, who contribute fixed amounts of money and defined
percentages of the income generated by value added tax, social insurance456 pays a lump sum for public
hospitals according to § 447 para.1 ASVG. The lump sum covers all services in the areas of inpatient care,
part-inpatient care, day-clinical and outpatient care, including those services resulting from technological
advances provided by hospitals financed by the health funds in the federal states
(Landesgesundheitsfonds).457 Increases in the number of cases (e.g. dialysis) are also considered. This lump
sum represents about 42% of the total costs of hospitals financed by the health funds of the federal states
and is valorised according to the increase in the income generated through health insurance contribution. In
2005 social health insurance funds spent 3.419 billion Euros on hospital care representing about 34.7% or
the income raised by contributions458. Social insurance funds paid 3.384 billion Euros to the health funds in
the federal states. The federal states, the legal entities (hospital carriers) and the municipalities are liable for
any underfunding of the health funds.459 Considerable regional variations exist.
For-profit hospitals i.e. sanatoria which are not funded by the health funds in the federal states are funded
based on nationwide, performance-orientated principles. Health insurance funds allocate a yearly
prospective amount of 72.67 million Euros to the fund for the private hospitals (PrivatkrankenanstaltenFinanzierungsfonds, PRIKRAF) which is situated in the Chamber of Commerce and was set up in 2002.
The distribution of funds by the PRIKRAF is undertaken partially based on days and partially on
performance related measures. In addition to funds from social insurance for-profit hospitals receive a
major part of their income from private health insurance companies.
Funding of private hospitals which are neither funded by the health funds in the federal states nor by the
PRIKRAF fund (e.g. military hospitals) is regulated in individual contracts with social insurance. For the
Hanusch hospital (regional sickness fund of Vienna) and the accident hospitals special agreements exist.
On January 1, 1997 a performance orientated reimbursement system for hospitals, Leistungsorientierte
Krankenanstaltenfinanzierung , LKF, was introduced in hospitals funded by the federal health funds. This
reimbursement mechanism substituted the existing hospital reimbursement based on undifferentiated daily
payments. This step enabled the visualisation of the actual service provision. About half of daily concerns
are based on performance orientated funding460 and on countrywide standardized point values per diagnosis
related group (LKF core area).
This system is complemented by lump sum budgets. The value of each point is not the same in every
federal state, it depends on the funds available in the respective health fund of the federal state. Around half
of hospital services are reimbursed on the basis of a fee-for services payment by national budgets. This type
of payment entails the incentive of increasing the amount of services provided (maximising points) or of
engaging in DRG creep.461
455
456
457
Outpatient services provided in the course of the mother-child pass investigations and services explicitly excluded
by mutual consent of social insurance and the relevant federal states are not reimbursed
458
Hauptverband der österreichischen Sozialversicherungsträger (2006), Handbook of Austrian Social Insurance 2005.
Vienna.
459
460
Pazourek, J. (2005), ″Hospital funding since 1997.″ Soziale Sicherheit 1, pp. 11-16
461
Hofmarcher, M.M., Patterson, I., Riedel, M., (2002). ″Measuring Hospital Efficiency in Austria–A DEA approach,
Health Care Management Science 5, pp. 7-14
151
Reimbursement based on case related payments ought to, as a prospective reimbursement system, result in
an increase in efficiency by encouraging all groups engaged to be more aware of costs thus leading to a
reduction in costs.
The LKF system has increased transparency in inpatient care. Implicit standards are defined and due to the
case-based payment a relationship between diagnosis and services is established. The Austrian DRG system
is characterised by considerable flexibility, amongst other things taking account of medical advances as
well as long-term care institutions. Equally it is possible to continuously develop it further.462
The LKF system also includes negative incentives. It motivates health care institutions to admit more
patients, to maximise points (DRG creep), to engage in case-splitting and to admit certain ambulatory
patients to inpatient wards. Moreover there is an incentive to provide additional services.
Further “weaknesses” of the LKF system are the partial lack in depth of the case groups (considering the
severity of the disease) and that it is not always possible to distinguish between acute and chronic. There are
no incentives for the provision of preventive service. Fragmentation of the health care system is further
facilitated (missing interfaces, duplication of services, waiting times, etc.) In addition a stronger
competition takes place for expensive DRG groups.
Reimbursement of physicians in hospitals
Physicians in hospitals are paid by a salary which they receive from the hospital carrier. Usually the salary
is paid on a monthly basis and consists of three parts, the basic salary, payments for private patients and
payment for on-call work. The type of reimbursement and the amount not only vary amongst the federal
states but also depend on the hospital carrier. In some cases doctors working in hospitals are civil servants
for who own regulations apply463. The share of salary due to private payments (payments from patients in
private wards/beds) is not regulated in a uniform way. Normally these funds are distributed among the
doctors and other health care personnel by means of a distribution key. They sometimes represent a
considerable share of a physicians’ salary, especially for doctors higher up in the hierarchy (e.g. heads of
departments).
Physicians employed in hospitals are allowed to undertake part-time jobs, e.g. to open their own private
practice. Restrictions may be related to regulations of public services law.
Impact of the LKF System
When introducing the performance orientated payment system for inpatient care in Austria, thus
substituting the payment based on daily fees by performance orientated case based payments, the most
important aims were to contain costs and to increase efficiency for inpatient-care.464
Studies discussing the impact of the LKF system have, amongst others, been undertaken by Leonard,
Rauner, Schaffhauser-Linzatti and Yap465 (Impact of the reimbursement system on inpatient-admissions and
discharges in Austrian and Canadian hospitals466), by Sommersguter-Reichmann and Stepan467 (Analysis of
462
Pfeiffer, K.P. (2001). What are the effects of case payments on hospital funding? presentation given 6 November
2001, accessed at http://www.imib.med.tu-dresden.de/imib/apis/tagu2001/KarlPeterPfeiffer.pdf on 04/05/2006
Pfeiffer, K.P. (2004). Performance-orientated hospital funding in Austria– Temporary conclusions and future
perspectives. Presentation given in Seefeld.
463
Hofmarcher, M.M., Patterson, I., Riedel, M. (2002). ″Measuring Hospital Efficiency in Austria–A DEA approach.″
Health Care Management Science 5, pp. 7-14
464
ibid
465
Leonard, K.J., Rauner, M.S., Schaffhauser-Linzatti, M.M., Yap, R. (2003). ″The effect of funding policy on day of
the week admissions and discharges in hospitals: the cases of Austria and Canada″, Health Policy 63, pp. 239-257
466
Databasis in Austria: inpatient data for all patients in LKF funded hospitals (85% of all inpatient cases in 1998)
467
Sommersguter-Reichmann, M./Stepan, A., Evaluating the New Activity-Based Hospital Financing System in
Austria in: Dockner, E.J./Hartl, R.F./Luptacik, M./Sorger, G. Eds. (2000). Optimization, Dynamics and Economic
Analysis. Physica, pp. 49-63.
152
the impact of the LKF system on performance and costs) or by Hofmarcher, Lietz and Schnabl468 (DEA
Analysis of the input-orientated efficiency of emergency units between 1997 and 2000).
Hofmarcher, Lietz and Schnabl argue that the reduction in the increase in costs only had a short term effect.
The increase in costs for hospitals in 2001 amounted to 3.8%, being higher than GDP growth and yearly
inflation (1.6%).469
Sommersguter-Reichmann and Stepan show that the LKF System has led to point maximisation, especially
in non-profit hospitals. Hospitals aim to enlarge their share of the budget. A reduction in the length of stay
could not be clearly attributed to an early discharge of the patient or to a reduction of the excessive use of
resources. Possibly inpatients were shifted to outpatient departments for follow-up care as outpatient cases
have increased. Shifting of services, not only between inpatient wards and outpatient departments but also
between hospitals and free-lance doctors practising outside of the hospital were observed. Especially the
latter is problematic due to the fact that the two areas of health provision are based on different funding
streams.470
In the DEA analysis performed by Hofmarcher et al. nearly all hospitals analysed in 1997 were efficient
whilst only few hospitals were classified efficient in 1994-1996. The average efficiency score amounted to
90% in 1997 in comparison to 83% in 1996. The authors of the study assume that the increase in efficiency
is mostly based on an increase of the technical efficiency, not the productive efficiency.
As already mentioned before the introduction of the LKF system was followed by a decrease of the average
length of stay in hospitals. However the number of inpatient-admissions has gone up constantly, this being
partially rooted in the increase in day-clinic cases as well as case-splitting. Increases in costs were contained
by capping expenditures.
The Austrian association for health economics (Österreichische Gesellschaft für Gesundheitsökonomie,
ÖGGÖ) 471 undertook a survey in 2004 researching the impact of the LKF system. The implications of the
new system on costs, internal organization and planning, quality, services and other implications in
hospitals were analysed. 600 experts in the field of hospitals care and in the health system were questioned
out of which 110 replied, their answers were used for the evaluation.
Roughly half of the questioned experts stated that the LKF system had contained the increase in costs,
especially for the Federation and Social insurance (about 70% each), but also for hospitals (about 50%), the
federal states and private health insurance funds (about 43% and 46% respectively). Actually the share for
hospital funding of social insurance and the federation has increased more between 1996 and 2002 than the
share of the regional funding entities. 84.6% said that no savings could be achieved.
Experts stated that the LKF system has the following effects:
-
Extension of day clinics
Reduction of acute beds
Shifting of patients from ambulatory to inpatient care and vice versa
Creation of 5-day wards
468
Hofmarcher, M.M., Lietz, C., Schnabl, A. (2005). ″Inefficiency in Austrian inpatient care: identifying ailing
providers based on DEA results.″ Central European Journal of Operations Research, to be published
469
ibid
470
Sommersguter-Reichmann, M./Stepan, A., Evaluating the New Activity-Based Hospital Financing System in
Austria in: Dockner, E.J./Hartl, R.F./Luptacik, M./Sorger, G. Eds. (2000). Optimization, Dynamics and Economic
Analysis. Physica, pp. 49-63
471
Deszy, J., Holler, G., Spann, H., Schwarz, B. (2004). LKF funding, results of an expert survey by the Austrian
Association of Health Economics 2003/2004. Presentation
Deszy, J., Schwarz, B., Holler, G., Spann, H. (2004). ″Funding of the Austrian Health Care System.″
Gesundheitsoeconomica 2004, pp.5-79
153
With respect to multiple testing (duplication of diagnostic findings) 82% of the experts questioned believe
that these were reduced. Nearly 88% linked the decline in average length of stay to the LKF system. Almost
a quarter of the experts state that the LKF system has improved the quality of medical services, about 16%
that it has improved nursing services and about 40% that it has led to a better quality of organizational
services for patients (sum of the categories strongly improved and slightly improved). About 68% think that
changes in quality are neutral. Close to three quarters of the experts believe that the system has led to early
discharges and augmented re-admissions. Considering services as well as the data or costs, experts are of
the opinion that the system has improved transparency in hospitals.
With respect to shifting of services more than half of the experts state that shifts have taken place towards
long-term-care. 45% declare that services have been shifted from one hospital to another or to extramural
providers. Above 70% are neutral when asked to state if they think that the LKF System has improved
communication between the different sectors in health care. About the same share believes that the system
has not resulted in any reduced services for patients. Three quarters say that the LKF system may, in the
short term (up to 2 years) or in the medium term (5-6 years), result in a reduction of beds. Around 85% of
the experts questioned indicate that the LKF system does not encourage the referral of patients to the
economically most suitable level of care. About half believe that the LKF system changes the structure of
the health care system, roughly 85% that it distributes money.
In the course of the survey the questioned experts were asked to list problems which have either not been
solved or have been solved in an unsatisfactory way. The following examples were given: structural
problems, lack of steering and planning, missing incentives (to encourage more economic behaviour), lack
of quality assurance, problems related to interfaces. The following solutions were suggested: regional
budgets, equal funding for equal services, centralised administration of funds. With regard to steering and
planning, a stronger co-operation between intramural and extramural care ought to take place, furthermore
transparency should be increased and supply planned better. When asked about their opinion on the most
important targets of the health care agency, most of the experts quoted a fair reimbursement of services as
well as interface management.
Figure 6.6 Average length of stay in Austrian hospitals, 1995-2004
(without 0-day stays and long-term stays472) in hospitals funded by the federal health funds
Source: BMGF (2006). Hospitals in figures, accessed at www. bmgf.gv.at on 07/06/2006473
Since the introduction of the LKF system a continuous decline in the average length of stay in hospitals has
taken place. This is partially related to technological and medical advances, but also strongly influenced by
the reimbursement mechanism employed, which does not entail any incentives to keep the patient in
hospital longer than necessary.
472
Longer than 28 days
Hospital Statistics (hospitals funded by the federal health funds (Landesfgesundheitsfonds), annual report
(hospitals not funded by the federal health funds), reports on diagnosis and services (hospitals funded by the
federal health funds) – average length of stay (all BMGF), Statistics Austria: Extrapolation of the population,
yearly averages 1991–2004 (status: 23.05.2005)
473
154
Figure 6.7 Inpatient stays in Austrian 1991-2004 (1991 = 100)
Inpatient stays 2004: hospitals funded by the federal health funds: 2,334,444/ hospitals not funded by the federal health
funds: 253,542
Austria total, Hospitals funded by federal health funds (squares), hospitals not funded by federal hospital funds
(circles)
The number of inpatient stays has risen continuously since 1991, whereby the increase was stronger after
the introduction of the LKF system, especially in hospitals not funded by the federal health funds. The
collapse for hospitals not funded by the federal health funds in 1993/1994 originates in the fact that a
hospital in Carinthia changed its status from pertaining to the hospitals not funded by the federal health
funds to the hospitals funded by the federal health funds. The increase in 1-day cases has notably influenced
the rise in inpatient stays. Also the day-clinic cases, which until 1996 were partially billed as outpatient
cases and, since the introduction of the LKF system, have to be documented as inpatient stays.
6.4 Continuity of care
Patients are increasingly seen by a variety of health care professionals in a wide variety of organizations and
locations, raising concerns about fragmentation of care. On an international level, policy reports advocate a
concerted effort to enhance continuity of care.475,476 However, there remains a lack of consensus on the
definition of continuity and other related terms have been used, including continuum of care, coordination
of care, discharge planning, case management, integration of services and seamless care.477
In primary care, continuity is mainly viewed as the relationship between a single practitioner and a patient
that extends beyond specific episodes of illness or disease. Continuity implies a sense of affiliation between
patients and their practitioners (my doctor or my patient), often expressed in terms of an implicit contract of
loyalty by the patient and clinical responsibility by the provider.478 Explicit concern for continuity in
474
Data sources: Hospital Statistics (hospitals funded by the federal health funds), annual report (hospitals not
funded by the federal health funds), reports on diagnosis and services (hospitals funded by the federal health
funds) – average length of stay (all BMGF), Statistics Austria: Extrapolation of the population, yearly averages
1991–2004 (status: 23.05.2005)
475
World Health Organization, "The Ljubljana Charter on Reforming Health Care," (Geneva: World Health
Organization, 1996).
476
N Fulop and P Allen, "National Listening Exercise: Report of the Findings," (London: NHS Service Delivery and
Organization National Research and Development Program, 2000).
477
J.L Haggerty, R.J Reid, and G.K Freeman, "Continuity of Care: A Multidisciplinary Review," British Medical
Journal 327 (2003).
478
I.R McWhinney, "Continuity of Care in Family Practice. Part 2: Implications of Continuity," Journal of Family
Practice 2 (1975).
155
medical specialties has emerged since the late 1980s, reflecting the increased complexity of managing long
term diseases such as HIV and AIDS, diabetes, cardiovascular diseases, rheumatological conditions, and
cancer. Continuity is seen as the delivery of services by different providers in a coherent, logical and timely
fashion and is often referred to as a continuum of care. The specialty literature emphasises the content of
care protocols or management strategies, with relatively little attention to the processes required for
implementation.479
For continuity to exist, two distinguishing elements must be present - care of an individual patient and care
delivered over time. For the first element, care of an individual patient, the unit of measurement of
continuity is fundamentally the individual. Continuity is not an attribute of providers or organizations, but
rather how individual patients experience integration of services and coordination. The second element, care
over time, has been identified consistently as a longitudinal or chronological dimension of continuity.480
Continuity of care has many advantages, for instance: shorter consultations because of better prior
knowledge of the patient and their history by the doctor, and generally more rational clinical decisions.
Continuity of care is especially important for patients with co-morbidities or multi-morbidities. These
patients have more that one illness, each of which may impact on the course and management of the others.
The occurrence and degree of co-morbidity has been shown to increase with increasing age, lower level of
education, and lower public health insurance.481 Therefore, addressing patients with co-morbidity is an
important issue because it occurs disproportionately within populations that are socio-economically
disadvantaged and in the elderly, and especially in for population that are both.482,483
The small percentage of the population with co-morbidities often makes up a disproportionate amount of
the pharmaceutical consumption.484 From Austria, a study in Carinthia showed that 1.7% of patients
contributed to one-quarter of expenditure, while 7% of patients made up 50% of expenditure. Also, 7% of
patients contribute 26% of co-payments.485 These particularly expensive patients could be closely followed.
Targeting could be directed towards less than 7% of the patients as some of these expensive patients may be
in their final year of life, or may have received costly treatment following an accident.
With no specific designation to a GP, these patients may seek therapy from different doctors who may be
unaware of the other medicines they are taking and other conditions they may have. These patients may also
receive care in a hospital setting, where more expensive therapies may be used. They will then likely
request the same treatment when they return to a doctor of their choosing. Furthermore, a registry of such
patients could be kept to identify people who could potentially be expensive for the health care system.
Similar challenges exist in the treatment of patients with chronic conditions.
The benefits of continuity may also be seen in prescribing costs - for instance, the lower costs of dispensing
doctors who work in rural areas and who have greater continuity of care for their patients over urban
doctors is in part attributed to stable care arrangements. The lack of continuity of care is a particular issue in
urban areas where patients have wider choice of GP or of specialist. Patient choice is important; however, it
is necessary for each patient to have a coordinating doctor to follow up with treatments, particularly for
patients with multiple diseases.
479
H Campbell et al., "Integrated Care Pathways," British Medical Journal 316 (1998).
J Rogers and P Curtis, "The Concept and Measurement of Continuity in Primary Care," American Journal of Public
Health 70 (1980).
481
M van den Akker et al., "Multimorbidity in General Practice: Prevalence, Incidence, and Determinants of CoOccurring Chronic and Recurrent Diseases," Journal of Clinical Epidemiology 51 (1998).
482
A Menotti et al., "Prevalence of Morbidity and Multi-Morbidity in Elderly Male Populations and Their Impact on
10-Year All-Cause Mortality: The Fine Study (Finland, Italy, Netherlands, Elderly)," Journal of Clinical Epidemiology
45 (2001).
483
G Watt, "The Inverse Care Law Today," Lancet 360 (2002).
484
R Reid et al., "Conspicuous Consumption: Characterizing High Users of Physician Services in One Canadian
Province," Journal of Health Services Research and Policy 8, no. 4 (2003).
485
Selbstbehalteanalyse (2002) anhand der Versicherungsleistungen der KGKK (von Direktor Mag. Alfred Wurzer,
Mag. Roswitha Robinig, OE Revision, OE-L Josef Rodler, OE Organization).
480
156
6.4.1 Continuity of care in Austria
The Austrian health care system is characterised by a big number of actors, who are involved in funding
and/or providing health care services, the most important being Social Insurance, the federal states, the
Federation, the local governments and private providers. Professional representations such as the Medical
Chamber or the Chamber of Pharmacists have a very strong position in Austria. Responsibilities in funding
and service provision were described in Chapter 3 of the report.
Due to this fragmentation there is a considerable lack in continuity of care at all levels of the Austrian
health care system as well as a lack in communication between the different levels.
In Austria general practitioners only have very limited gatekeeping functions. Access to primary care
physicians and other ambulatory health care institutions is more or less free, leaving patients a great deal of
choice of providers. A referral note is only necessary for visiting a couple of medical specialities (e.g.
physical medicine) or for performing special tests/investigations. However at some sickness funds a patient
is only allowed to directly access a certain number of specialists per quarter (regulations vary at the
different funds). Patients are entitled to use out-patient departments of hospitals or integrated providers
(ambulatory clinics) of social insurance funds as first point of access when in need of care.
Continuity of care and co-operation between ambulatory providers hardly takes place though the
introduction of the e-card which was accompanied by an increased use of information technology incl.
computers and the future introduction of the electronic health record may encourage and facilitate
communication between providers.
The lack in communication and coordination does not only refer to physicians amongst each other but also
to the communication between the different health care professionals on the same level of care such as
psychotherapists, physiotherapists, speech therapists, etc.. They are obliged to fulfil certain standards in
terms of communication which however are not always met meaning that bilateral information (feedback) is
sometimes lacking.
Continuity of care between ambulatory and secondary care is hampered once again due to fragmentation of
funding and responsibility. Social insurance pays for a great share of inpatient care but does hardly have
any say in service provision. As social insurance mostly pays a lump sum payment for inpatient services
provided for their insured population, hospitals try to shift patients outside of the hospital in order to save
costs. Medicines (originators) are on occasion provided to hospitals free of charge by pharmaceutical
companies, making it difficult for the ambulatory physician being visited by the patient after discharge, to
explain why he has to change the medication given in hospital to a generic drug. Double testing and
treatment does occur however doctors in hospitals are in the mean time apparently more willing to accept
tests done by ambulatory providers and do not automatically decide to repeat them as soon as the patient
arrives in hospital.
Continuity of care following discharge of hospital, especially for patients who require more extensive care
such as chronically ill patients is subject to considerable regional variations, no standardized procedures
exist. Some health insurance funds employ so called “care coordinators” who are notified before the
patient’s discharge and help the patient to prepare for the time after his inpatient stay (giving information on
benefits of social health insurance, medication therapy, etc.).
Health care provision in long-term care and for social services is strongly fragmented, making it difficult for
people in need to get an overview over options available. Mostly private providers (social welfare
organizations) provide services which are difficult to compare amongst each other and are characterised by
regional variation.
Also the provision of other services in health care, such as emergency services involves multiple actors
making co-ordination extremely complicated.
157
Hospital funding exists in 9 different regional variations. In addition a number of physician contracts
(different sickness funds) exist; special arrangements apply to health care institutions.
Instruments encouraging integrated care are for instance planning instruments such as the Structural Plan
for Health Care (Österreichischer Strukturplan Gesundheit) incl. the plan for major equipment or the
Location Plan which is negotiated between each regional Medical Chamber and the Hauptverband.
Mechanisms to promote co-ordination and prevent shifting of resources are the agreement according to
article 15a of the Federal Constitutional Act, the co-ordination mechanism and sanctioning mechanism and
the recently introduced Reformpool. Other measures facilitating communication are improved information
technology infrastructure (e-card, electronic health record, etc.) and increased mobility of resources and
patients.
A range of projects to promote integrated care exist on various levels, either organised by the Federal
Ministry of Health and Women (PIK – patient-orientated integrated treatment (Patientenorientierte
Integrierte Krankenbetreuung486)), by social insurance funds (discharge co-ordinators, disease management
programs, development of treatment pathways) by the federal states or by others. The regional sickness
fund of Vienna has recently become the competence centre for integrated care, emphasising the need of
activities in this field.
486
For further information visit the project’s website at http://www.univie.ac.at/pik/
158
7. QUALITY OF CARE
There is little evidence available comparing quality of care across countries, due to difficulties in defining
and measuring quality, and collecting quality indicators in an accurate and systematic way. One survey on
perceived quality of care suggests that there is some variability in perceived quality of health care and social
services across the EU, with highest levels reported in Austria (Table 7.1).487
Table 7.1 Perceived quality of public services
Quality of health
service
Austria
8.1
Belgium
7.6
France
7.1
Germany
6.5
Hungary
5.3
Ireland
5.3
Italy
5.8
Poland
4.7
the Netherlands
6.7
United Kingdom
6.4
6.4
EU 15
5.0
Quality of social
service
7.6
7.1
6.4
6.7
4.8
6.1
5.7
4.0
6.7
5.8
6.2
4.5
Question 54: In general, how would you rate the quality of each of the public services in [country]? Please tell
me on a scale of one to 10, where one means very poor quality and 10 means very high quality – health services,
social services.
Source: Anderson 2004
7.1 Appropriateness of care
Appropriateness of care is a relatively new area of concern in health care, with only a small number of
initiatives, and even fewer that have been evaluated. This section outlines these initiatives, identifies the
role of pharmacies in achieving appropriate pharmaceutical care, raises the important of regulating medical
errors and highlights some of the concerns associated with dental care.
There are many strategies that are used in Europe to ensure appropriateness of medical care. These
strategies broadly consist of quality assurance, health technology assessment, systematic reviews, clinical
guidelines, and monitoring providers’ performance. The Cochrane Collaboration which is based in the UK
prepares and maintains systematic reviews of available medical evidence with which other European
countries can participate in.
Regulating prescribing patterns is another method used to ensure a suitable level of appropriateness of care.
Prescribing patterns differ significantly across countries. For instance, only 62.9% of consultations result in
prescriptions in the Netherlands, compared to 94.5% in Italy. Various approaches have been made to
monitor prescribing quality, such as the use of a Medical Appropriateness Index which assesses prescribing
suitability.488 In the UK, prescribing data are used to provide doctors with reliable and regular information
on their current prescribing in an attempt to encourage more effective and economical prescribing.
487
R. Anderson, "Health and Health Care," in Quality of Life in Europe. First European Quality of Life Survey 2003,
ed. European Foundation for the Improvement of Living and Working Conditions (Luxembourg: Office for Official
Publications of the European Communities, 2004).
488
E Mossialos, M Mrazek, and T Walley, "Regulating Pharmaceuticals in Europe: An Overview," in Regulating
Pharmaceuticals in Europe, ed. E Mossialos, M Mrazek, and T Walley (Maidenhead: Open University Press, 2004).
159
Clinical practice guidelines – specific criteria for how and when particular tests and treatments should be
used – may also reduce disparities in treatment across physicians as well as control spending.489 While it is
difficult to monitor and enforce these guidelines, financial incentives (or disincentives) coupled with
educational efforts may improve compliance. In France, there has been poor compliance with prescribing
guidelines for many reasons: the volume of guidelines, lack of information systems and limited capacity for
monitoring, and physicians concern that following the guidelines could negatively affect the quality of care
being delivered.490
The effectiveness of clinical guidelines is uncertain.491 While some studies demonstrate minimal effect of
clinical guidelines on physician prescribing behaviour492, others suggest that well-designed and consistently
implemented guidelines can help to deliver “best practice”.493 While most guidelines seek to improve
quality of care, others are designed with the explicit objective of cost-containment. The latter, however, are
unlikely to be acceptable because of ethical and legal implications.494 Also, if clinical guidelines are not
legislated, as in Finland, they may not be as successful in improving quality of care.
Variation in medical treatment creates a need for improved quality control. In response to wide
discrepancies in operative procedures across different hospitals in Belgium, a recent Advisory Commission
of experts highlighted the need for benchmarking and quality control. However, these proposals have been
met with considerable resistance from the providers. A National Guidelines Project was recently launched
in Italy, which outlines evidence-based guidelines in order to reduce medical practice variation for certain
conditions, however the specification of the conditions that are include have been left to the individual
regions. At present, there are no policies in Germany that provide guidance or attempt to control medical
errors, despite it being a widely recognized problem.
Pharmacies play a role in ensuring appropriateness of pharmaceutical care. Hospital pharmacies’ functions
have transformed since the 1970s. The role of hospital pharmacists has expanded to include working as
clinical pharmacists at the ward level along with their traditional responsibilities of drug preparation and
verification. Hospital pharmacies increasingly provide products to meet individual patient need, thus
necessitating increased collaboration between hospital pharmacists and prescribers, nurses, dieticians,
biochemists, and laboratory scientist. On an institutional level, hospital pharmacies must support the safe,
effective, and economic use of medicines in hospitals in accordance with government rules and budgetary
requirements. Thus, medical information and clinical pharmacy services are needed in the hospital to
service outpatient care. In addition, specialised databases and medicine information services based in
hospitals have been developed to facilitate drug treatment decision-making by clinicians.495
489
T Walley and E Mossialos, "Financial Incentives and Prescribing," in Regulating Pharmaceuticals in Europe, ed. E
Mossialos, M Mrazek, and T Walley (Maidenhead: Open University Press, 2004).
490
P Durieux et al., "From Clinical Recommendations to Mandatory Practice," International Journal of Technology
Assessment in Health Care 16, no. 4 (2000).
491
L. Gundersen, "The Effect of Clinical Practice Guidelines on Variations in Care," Annals of Internal Medicine 133
(2000).
492
I Hetlevik et al., "Implementing Clinical Guidelines in the Treatment of Diabetes Mellitus in General Practice,"
International Journal of Technology Assessment in Health Care 16 (2000).
493
F.B Garfield and J.M. Garfield, "Clinical Judgment and Clinical Practice Guidelines," International Journal of
Technology Assessment in Health Care 16, no. 4 (2000), M Perleth, E Jakubowski, and R. Busse, "What Is 'Best
Practice' in Health Care? State of the Art and Perspectives in Improving the Effectiveness and Efficiency of the
European Health Care Systems," Health Policy 56, no. 3 (2001), R Richman and D.R. Lancaster, "The Clinical
Guideline Process within a Managed Care Organization.," International Journal of Technology Assessment in Health
Care 16, no. 4 (2000).
494
A.O Carter et al., "Proceedings of the 1994 Canadian Clinical Practice Guidelines Network Workshop," Canadian
Medical Association Journal 153 (1995), T.S. Cheah, "The Impact of Clinical Guidelines and Clinical Pathways on
Medical Practice: Effectiveness and Medico-Legal Aspects," Annals of the Academy of Medicine, Singapore 27, no. 4
(1998).
495
N Taggiasco, B Sarrut, and C.G Doreau, "European Survey of Independent Drug Information Centres,," Annals of
Pharmacotherapy 26 (1992).
160
7.1.1 Quality of care in Austria
During the past years not only the notion of quality but also the awareness that more ought to be done for
this topic has received increasing attention in Austria.496 Developments are briefly discussed in the
following section. In the 1993 amendment of the Hospital Act for the first time country wide measures for
quality assurance were defined in the form of the mandatory establishment of commissions for quality
assurance in hospitals. Moreover patient rights and hospital hygienists were mentioned for the first time. In
the agreement according to article 15a of the Federal Constitutional Act, valid for 1997 to 2000, quality is
for the first time defined as a duty of the structural commission (Strukturkommission), in the agreement of
2001 to 2004 quality is incorporated into an own article and country wide quality projects are initiated by
the Federation.
The starting point for the Quality in Health Care Act, which came into effect on January 1 2005 were about
50 nation wide quality-related regulations as well as 20 projects of the resort on quality in terms of
structures, processes and outcomes.
The Quality in Health Care Act represents an embracing of all hitherto existing quality regulations which
are distributed across a range of laws. Provisions not only apply over the whole of Austria but span all
professions and sectors (coverage of all actors in the health system). The aim was to establish a nation wide
quality system which should have regard to the aspects of patient orientation, transparency, effectiveness
and efficiency as well as patient safety. The Quality in Health Care Act gives the Federal Minister of Health
the possibility to enact decrees related to various topics, amongst others on quality reporting, optimisation
of the use of antibiotics, assessment of patient satisfaction, patient safety, disease management/case
management programs, interface management497. Actual implementation of these is dependent on a range of
factors, among other things on the political willpower and courage of decision makers.
Quality is defined in the Quality in Health Care Act (Gesundheitsqualitätsgesetz), in § 2 para.2 as “Degree
of fulfilment of the attributes of patient-orientated, transparent and efficient provision of health care
services”. “At the centre of concern are, in this context, the optimisation of quality in terms of structures,
processes and outcomes”.498 “When providing the services patient safety has to be taken into
consideration”.499
Furthermore, in the elucidations of the law, quality is stated to be “ the relation between a (defined) ideal
state and the actual realisation of a service, being either a product, a service, a process or a system” 500 In the
Quality in Health Care Act addition definitions, e.g. structural quality, process quality and outcome quality
are provided in § 2. The Law envisages the implementation of a quality-strategy/ a quality system
for the whole of Austria
for all professions
for all sectors
by which quality requirements for the provision of health care services are dictated on a mandatory basis.
-
-
Quality reporting
In the course of the negotiations related to the article 15a of the Austrian Constitutional Act on the
restructuring of the health system and hospital funding, valid through 2001-2004, the Structural
Commission (Strukturkommission) was given the responsibility of initiating a country wide system of
quality reporting.501 A project, with the following aims, was started.502
496
Dr. Fronaschütz (Federal Ministry of Health and Women, BMGF). Interview 21 December 2005
Fronaschütz, U. (2005). Information Session 2: Quality in Health Care Act. Presentation given 17 January 2005
(Health Care Conference)
498
Quality in Health Care Act
499
Elucidations Quality in Health Care Act
500
Elucidations Quality in Health Care Act
501
Quality reporting in health care. Accessed at www.qbe.at on 12/07/2006
502
Quality reporting in health care. Accessed at www.qbe.at on 12/07/2006
497
161
-
-
Development of an Austrian system of quality reporting as well as setting up a quality report
entailing a comprehensive description of activities related to quality in the Austrian health care
system
The quality report should be flexible and subject to continuous further development
Definition of a country wide implementation strategy for the yearly quality reporting system.
Compulsory and systematic discussion and inclusion of all relevant actors, organizations and
carriers in the quality reporting process
Using the Austrian quality reporting as basis for comprehensive planning in the health care system
For the first time it was debated to establish a database for quality projects as well as a database for quality
related strategies in hospitals. Both were realized in the form of pilot projects. The results and the final
report on quality reporting and the pilot projects were handed over to the ministry but have, until now, not
been published.
Quality reporting is regulated in § 6 of the Quality in Health care Act (Gesundheitsqualitätsgesetz), see
Appendix 9.
The Austrian Social Insurance for Occupational risks (Allgemeine Unfallversicherungsanstalt, AUVA) has
been publishing a quality report on quality management in accident hospitals and rehabilitation centres
since 1996503. The report can be accessed and downloaded at/from the AUVA’s504 website. The quality
management system of the AUVA is based on the method of the PDCA (plan-do-check-act) cycle whereby
a detailed system of quality assurance was developed underlying continuous further development. During
the past years 40 mandatory quality standards were agreed on. The quality assurance system encompasses
continuing training and education of staff (in the fields of quality management, evidence based medicine
and project management), development of guidelines and clinical pathways, periodical evaluation of the
quality standards, patient safety and risk management, furthermore certification. In addition a range of
quality-related activities take place in order to make quality work more accessible for parties involved and
interested. The cooperative management (kollegiale Führung) demonstrates significant involvement in
quality work.
The Vienna association of hospitals (Wiener Krankenanstaltenverbund) also publishes a quality report. The
focus of their quality work is on the fields of patient- and staff orientation, process- and resource orientation
as well as organization505. In the report a range of initiatives, projects and activities of their quality work can
be found. For each hospital a list is made based on the following criteria: title of the
initiative/project/activity, contact person, duration, focus, aims and result.
Several hospitals publish quality reports, such as the hospitals of the Vinzenz-Group506, for instance the
Krankenhaus der barmherzigen Schwestern in Linz507 or in Ried508 or the state hospital
(Landeskrankenhaus) Stolzalpe.509 In addition to these there are health care institutions or individual
departments of health care institutions which have taken part in certifications or accreditation processes,
like as for example the state hospital Villach which is accredited by Joint Commission or numerous
laboratories which are certified according to ISO 9000ff.
503
Austrian Social Insurance for Occupational Risks, AUVA. Information provided on the telephone 13/07/2006
Austrian Social Insurance for Occupational Risks , accessed at www.auva.at
505
Quality
report
of
the
Vienna
association
of
hospitals
2003.
accessed
at
http://www.wienkav.at/_cache/Doku/big/KAV%20Qualitätsbericht%202003_5848.pdf on 12/07/2006
506
See Website of the hospitals of the Vinzenz group, accessed at www.vinzenzgruppe.at
507
Quality report 2003/2004. accessed at http://www.bhs.at/linz/index.asp?peco=&Seite=435&Lg=1&Cy=1&UID on
12/07/2006
508
Quality report (2005). accessed at
http://www.bhs.at/ried/redsyspix/download/Qualitaetsbericht%20final%20an%20KTQ.pdf on 12/07/2006
509
Quality report 2005. Accessed at http://www.lkh-stolzalpe.at/cms/dokumente/10011283_2248709/fc780f97/QMJahresbericht_2005_freigegebene%20Version.pdf on 12/07/2006
504
162
The hospitals of the federal state of Lower Austria (Landeskliniken) have decided to implement a uniform
system for quality management. Furthermore an assessment of the structure and the organization of quality
assurance in the individual state hospitals were performed.510
National programs to improve quality of care
In the course of the last agreement according to article 15a of the Federal Constitutional Act the Federal
Ministry of Health and Women supported and funded 5 major projects related to the topic of quality:511
1.
2.
3.
4.
5.
Quality reporting
Pat – Patient orientation in hospitals
MedTogether – Management of interfaces
Strategy for antibiotics
Optimisation of the use of blood
All of these projects have already been finished.
Within the framework of quality reporting the setup of a database for quality projects was initiated by the
BMGF. In the same context a pilot project on quality strategies in hospitals was performed. The results of
the pilot projects have been passed on to the ministry but have so far not been published.
Austrian Structure Plan for Health Care (Österreichischer Strukturplan Gesundheit, ÖSG)
The Austrian Structure Plan for health care replaced the formerly existing hospital plan and plan for major
equipment (Krankenanstalten- und Großgeräteplan) on January 1st 2006. The plan constitutes, according to
the agreement based on article 15a of the Federal Constitutional Act, a compulsory basis for the integrated
planning of the Austrian health care structure and is applicable to all sectors.
Mandatory quality standards for planning are an integrated part of the plan. At the moment these exist for
acute inpatient care. Those for non-acute inpatient care, for ambulatory care, rehabilitation and interfaces to
long-term care will be defined continuously and will become part of the ÖSG.
Social insurance quality projects512
Also in social insurance the topic of “quality“ has received increasing attention in the past. This is not only
visible in the definition of goals and priorities in the course of the Balanced Scorecard process but also in
the rising number of projects in this area. In 2003 and 2004 the project “Framework Quality Assurance”
was performed by the Hauptverband which was accompanied by an exhaustive collection of quality-related
regulations and norms as well as provisions in the Hauptverband and at the health insurance funds. In the
course of the definition of socalled Standard Products (Standardprodukte)513 of Social Insurance the project
“Quality in health care”, consisting of nine sub-projects, was started in 2004.514 Some of the sub-projects
have been completed in the mean time. Following the titles of all sub-projects:
-
Codesystem ambulatory care
Software support of the quality work in physician’ practices
Metamodel Quality
Implementation of a drug utilization review
Health care information systems for patients
Hospital organization of the future (concept of the competence centre Hanusch-Krankenhaus)
Austrian Drug Reimbursement
Knowledge Management Quality
510
Niederösterreichischer Landesrechnungshof St. Pölten (2005). Quality assurance in hospitals 2/2005 accessed at
http://www.noe.gv.at/service/politik/landtag/LandtagsvorlagenXVI/04/492/38B.pdf on 12/07/2006
511
512
Projects of or initiated by the Hauptverband
513
formerly known as „Innovation Projects“(products/solutions developed for use of all insurance funds)
514
Mag. Lichtenecker (Insurance fund of the Austrian Railway and Mining Industry, VAEB). New design and
new start. The projects were initiated step by step. Information provided via email 20/07/2006
163
The project “Metamodel Quality” braces the individual sub-projects and is supposed to display their quality
aspects in a total system view. The aim of the project was to develop an integrated quality model which
should be the basis for decisions on resources. It was orientated towards the WHO 21 Health for All Targets
(HfA21) for the European region. The Patient view is put at the centre, health economics is interpreted as
subject of quality management through which an integrated quality model is made possible. More detailed
information on the project (Executive summary) can be found in the Appendix 10.
Further projects of all health insurance funds include for instance the definition of minimum opening hours
for physician practices, optimising waiting times, securing barrier free access to physician practices,
improving the quality of the PAP-smears at gynecologists – QUOPAP (quality push PAP-smear), the
improvement of quality in the field of clinical, psychological diagnostics as well as the labeling of quality
regulations. The overall goal is to guarantee good quality for the insured and to put more weight on the role
of consumer protection.
Health insurance funds were, in the course of a survey performed in November 2005, asked to state the
quality projects of their fund. Responses were as follows (see Appendix 11 for details):
Completed projects: barrier free access for all contract partners, extension of minimum opening hours of
practices, implementation of treatment recommendations for hypertension (regional sickness fund of
Burgenland, BGKK), publications in the course of the pharmaceutical dialog (regional sickness fund of
Upper Austria, OOEGKK), DIALA Case Management (OOEGKK), PAP smear (regional sickness fund of
Carinthia, KGKK), standardized and anonymous enquiry- and authorization process for psychotherapy
(regional sickness fund of Salzburg, SGKK), treatment guidelines for social insurance institutions
(integrated providers) (SGKK, adopted from the OOEGKK), quality- and environment management system
following the regulations of DIN EN ISO 9902 and DIN EN ISO 14001 (ISO-certification) in integrated
health care institutions (regional sickness fund of Vorarlberg, VGKK).
Projects in process: improving the quality of prescribing, increased prescribing of generics, efficiency
project/ DEA to ensure treatment quality (regional sickness fund of Vienna, WGKK), AMI (myocardial
infarction), EPOETIN for anemia (BGKK), Disease Management, Diabetes consultation, treatment at home
(regional sickness fund of Styria, STGKK), IVSOOE (stroke project) (OOEGKK), improvement of the
quality of PAP-smears (OOEGKK), physical medicine (SGKK), quality assurance for expert opinion
related to long term care (Austrian Social Insurance Authority for Business, SVA).
Continuous projects/activities: enforcing the inclusion of quality standards in the reimbursement list/fee
structure (training, equipment, documentation, etc.).
Planned projects: Participation in the OEBIG515 Project “implementation of a quality assured
mammography screening program in Austria (OOEGKK), development of standards for digital imaging and
electronic archiving in radiology (regional sickness fund of Lower Austria, NOEGKK). In addition
increased activities related to the development of guidelines and clinical pathways should be undertaken.
Nationwide funds (BVA, SVA, VAEB) take part in some of the projects initiated by the regional sickness
funds.
DEA project of the regional sickness fund of Vienna516
The aim of the project performed in 2005 was to ensure the efficiency and quality of medical treatment.
Efficiency of physicians in practices was calculated by means of the instrument of Data Envelopment
Analysis (DEA). Inputs were fees, expenses for pharmaceuticals and referral-costs. Data from the first
quarter in 2004 were used for the measurement of efficiency. Potential for improvement was assessed in
such a way that physicians with an efficiency score of less than 73% were stated to be inefficient. These
physicians were attended personally by explaining them how the score was calculated and from which
inputs it results. The focus of the conversations held by doctors was: laboratories, radiology (MRT, CT
515
516
Austrian Federal Institute for Health Care (ÖBIG)
Dr. Eger (Regional sickness fund of Vienna, WGKK). Interview 26 January 2006
164
examinations), pharmaceuticals. The project was completed on December 31st, in total 200 GPs and
specialists were analysed. In the future contact to contract partners should be enforced to ensure
sustainability, the number of physicians will be raised. The project should become part of the standard
procedures in the regional sickness fund of Vienna. For further details on the project, see Appendix 12.
Quality of care and physicians
Activities related to quality on the level of physicians are on the one hand defined by legislation (e.g.
documentation, training, quality assurance for physicians in ambulatory care) and on the other hand based
on activities of the medical associations (for the various medical specialties), the professional organizations
(Austrian Medical Chamber and the Chambers in the federal states, Austrian Chamber of Dentists) or other
institutions (e.g. hospitals). Examples are for instance in terms of legislation the evaluation of primary care
physicians in their practices according to § 118a Physician Act (devolved to the ÖQMed Association), in
terms of the medical associations the development of guidelines and quality indicators and in terms of the
professional organizations the provision of continuing professional education of physicians (devolved to the
Austrian Academy of Physicians), the development of a guideline for quality assurance and the organization
of quality circles.
Further projects for quality assurance are the ANISS project (Austrian Nosocomial Infection Surveillance
System – a HELICS pilot project), the QIP project (Quality Indicator Project), a project which originates in
the United States whereby hospitals engage in a benchmarking process, based on self assessed indicators. In
Austria about 35-40 hospitals take part in this project, mainly situated in Upper Austria (the national coordination office is funded by the BMGF and is placed in Linz, contact: Ms. Reli Mechtler). Beyond the
above mentioned projects there is a project to improve palliative care, in which the focus is put on the
training of parties involved. In the context of the project a curriculum for care is developed, that for doctors
is currently being produced.
A project on hospital hygiene which is currently being revised i.e. newly designed it PROHYG. In a first
step (performed the first time in 2002) indicators were collected and guidelines developed (PROHYG
guidelines) which were subsequently tested. Now the situation should be evaluated and the guidelines
updated.517
A disease related project is the founding of a network for stroke as well as the setting-up of a stroke register
for joint documentation of the stroke units in Austria. The aim is to exchange experiences and develop
standards.518
An overview over a couple of quality projects (accessible to the public) can be found on the website of the
forumQ. (Information centre for quality management in health care at the Karl Landsteiner Institute for
hospital organization) at www.forumQ.at.
Quality projects for preventive services and for services in the field of health promotion are performed by
the Healthy Austria Fund (Fonds Gesundes Österreich) .519 Examples are for instance the projects health
promoting hospitals, health promoting schools.520
Targets to improve quality
The responsibility for the development of national quality standards, applicable to all professions and
sectors was transferred to the Federal Institute for Quality in Health Care. This is about to be founded and
should be joined together with the Health Care Austria Plc. (Gesundheit Österreich GmbH).
517
Dr. Arrouas (Federal Ministry of Health and Women, BMGF). Interview 13 January 2006
Lang, W., Lalouschek, W. (2002). ″A network against stroke, report on the second Vienna stroke day - on the
occasion of the world stroke day. Journal für Neurologie, Neurochirurgie und Psychiatrie 3 (2), pp. 48-52
519
Which will be merged with the Austrian Institute for Quality in Health Care and the Austrian Federal Institute
for Health Care to become the Health Care Austria Plc.
520
Dr. Geyer (Federal Ministry of Health and Women, BMGF). Interview 29 December 2005
518
165
In addition, as already mentioned, a range of legal provisions on quality assurance exist, amongst others in
the Physician Act, in the Medicine products Act or in the General Social Insurance Act.
The majority of health insurance funds states that they have defined quality targets solely for the provision
of medical services- The following targets were quoted when responding to the survey among the health
insurance funds, performed in November 2005 (for details see Appendix 13).
Quality targets in the fee structure: proof of training for certain equipment, proof of training/education,
period for keeping medical records, own targets in laboratory medicine, provisions for the laboratory
catalogue 2005, -for the pathology catalogue 2005.
Targets in the General contract: disability free access for new contract partners, quality indicators for
allergy ambulatories, for contract institutes for physical medicine (spas) and quality standards in new
contracts.
Other targets: Durability of fillings from dentists, care for MS patients: checking on the scope of diagnostics
before diagnosis by the medical officer at the sickness fund for all processes of care: orientation following
procedure instructions in dental ambulatory clinics, periodical and successful participation in interlaboratory comparisons.
National monitoring of quality programs
The Quality in Health Care Act (Gesundheitsqualitätsgesetz, GQG) created the legal basis to dictate quality
standards to all health care institutions and to assess their compliance with them521. The GQG became
effective on January 1, 2005. In the law the establishment of a federal institute for quality in health care is
envisaged which will amongst other duties be responsible for developing incentive mechanisms and
external controls. The actual implementation of the law (in form of ordinances) will still take a while.
Also before the creation of the above mentioned law measures to ensure and assess the quality of care
provided existed. In the area of inpatient care, for instance the Austrian hospital and major equipment plan
existed until December 31, 2005 and was replaced by the Austrian Structural Plan for health care thereafter.
The regulations of the structural plan like for example the quality standards related to the structure of health
care institutions (for staffing, infrastructural requirements, medically or scientifically stipulated minimum
frequencies) are mandatory. Individual structural plans were developed in all federal states.
Legal provisions related to quality assessment are amongst others in the Hospital Act (Krankenanstalten
und Kuranstalten Gesetz), in the Medical Devices Act (Medizinproduktegesetz) and in the General Social
Insurance Act (Allgemeines Sozialversicherungsgesetz). Beyond these there are international provisions for
quality assurance which have to be followed.522 Sanitary supervision of health care institutions is part of the
responsibility of public health physicians.
Federal Institute for Quality in Health Care
According to § 9 para.1 of the Quality in Health Care Act a Federal Institute for Quality in Health Care will
be established. It will support the Federal Minister of Health and Women in conducting and realising his/her
assigned duties. The institute has the following responsibilities, taking into consideration a country-wide
approach spanning all sectors and professions as well as the principles of patient orientation, transparency,
effectiveness and efficiency. Furthermore international standards (see also Appendix 14):
1.
„Cooperation in the development of general guidelines and principles
a) for the definition of standards in the fields of quality in terms of structures, processes and
outcomes
b) for documentation related to quality reporting and for quality reporting itself
c) for motivating- and incentive mechanisms
521
Fronaschütz, U. (2005). Information Session 2: Quality in Health Care Act. Presentation given 17 January 2005
(Health Care Conference) “
522
166
d) for control according to § 8 para.1
2. Inspection-, recommendation- and development of quality standards which can be enacted by the
Federal Minister of Health and Women (federal rules for quality (Bundesqualitätsrichtlinien) or
recommended as guide for orientation (federal guidelines, Bundesleitlinie).
3. Development of a yearly quality report
4. Execution of i.e. cooperation in posing motivation- and incentive mechanisms
5. Enforcement of i.e. cooperation in the supervision of the compliance with provisions of this law as
well as with decrees enacted in the course of this law or any other specifications.
6. Support of the Federal Minister of Health and Women in coordinating country wide measures for
quality in order to ensure national and international comparability of health care services“
The institute does not yet exist, it is about to be established. On April 20, 2006 the Council of Ministers
decided on the merging of the Healthy Austria Fund (Fonds Gesundes Österreich), the Austrian Federal
Institute for Health Care (Österreichischen Bundesinstitutes für Gesundheitswesen, ÖBIG) to the
“Healthcare Austria Plc.” (Gesundheit Austria GmbH). The Federal Institute for Quality in Health Care will
also be integrated into the company. The decision of parliament was heavily criticized by the opposition.
The future “Health Care Austria Plc” will be owned to 100% by the Federation.
The 1993 amendment to the Hospital Act dictated the establishment of commissions for quality assurance in
hospitals. In the context of quality reporting a pilot project was initiated in which a database collecting
quality strategies of hospitals was set up. The results of this pilot project are in the ministry and have not yet
been published.
Quality control in ambulatory care takes place by means of voluntary as well as, only recently introduced,
mandatory measures.
Voluntary measures are for instance processes of certification (ISO), -of accreditation (EFQM, Joint
Commission), quality circles and peer reviews.
With the fifth amendment of the Physician Act a compulsory quality control was introduced. It is organised
as a self-assessment whereby physicians assess the quality of their practices by answering a questionnaire
(60 questions). The quality indicators in the questionnaire were defined by the physicians in co-operation
with a scientific board of experts. For the time being it only includes criteria belonging to the dimensions of
structure or process quality. The responses are checked for plausibility, in addition random inspections of
practices take place. By 2008 about 15,000 practices will be evaluated, which are then re-assessed every
two to three years523. Evaluations started mid April 2006:524
The responsibility for the quality assessment, according to § 118a Physician Act, lies with the Quality
assurance association ÖQMed which was founded especially for this reason and is owned to 100% by the
Physicians.525 Not only is it the association’s duty to come up with quality indicators but also to administer
a quality register as well as performing quality controls. Quality defects are to be corrected within a certain
time span, otherwise the physician takes the risk receiving a disciplinary complaint with the Chamber of
Physicians. Health insurance funds are entitled to take a look at the evaluation results of their contract
partners.526
523
HÖ (2005). ″ Quality in physician practices.″ Medical Tribune 18, accessed at http://www.medicaltribune.at/dynasite.cfm?dssid=4170&dsmid=63806&dspaid=484448 on November 18th 2005
524
Austrian Medical Chamber (2006). PK „Quality assurance in Austrian physician practices“, dated 15 March
2006, accessed at: http://www.aek.or.at/cache/000000000020060315112322.xml/PK-Unterlage%202006-0315.pdf, on 11/04/2006
525
Wirtschaftsblatt 9.11.05. Health care – argument about quality control in practices escalates – Ministry urges
for solution, physicians do not want to be controlled.
526
Czypionka, T., Riedel, M., Röhrling, G. (2006). ″Europe in motion: Quality of care in physicians’ practices.″
Health System Watch I, supplement of the journal of Austrian social insurance, Soziale Sicherheit
167
In addition to the before mentioned compulsory standards there are non-binding quality standards in form of
guidelines which are for instance developed by the respective medical associations or social insurance.
Furthermore recommendations, issued by the Ministry of Health and Women (Strategy for the use of
antibiotics, ProHyg guidelines).
Monitoring of quality projects is effected by use of the strategic instrument Balanced Scorecard and other
mechanisms for project management.
In addition measures for quality control in integrated health care institutions exists as well as for contract
partners. Controls of contract partners are usually ex-post controls to check compliance with quality
provisions in the fee structure as well as reactions to patient complaints.
In the course of the health insurance fund survey performed in November 2005 nearly all sickness funds
replied that they perform quality controls not only for their integrated health care institutions but also for
their contract physicians. Examples for quality controls in integrated health care institutions are
commissions for quality assurance, operating approvals, ISO certifications and external quality assessments.
Examples for quality controls of contract physicians are: proof of participation in quality circles,
participation in interlaboratory comparisons, examination of training and equipment requirements, patient
surveys and appraisals.
Detailed responses of the health insurance funds, see Appendix 15.
A considerable problem is the fact that social insurance only disposes of few possibilities to actually
measure the quality of the services provided, another that it does not have appropriate instruments to
sanction, only in the case of fraud, severe treatment errors or the suspicion of abuse.
7.2 Patient safety and medical errors
Medical errors present a significant, although largely preventable barrier to high quality health care. Thus,
policy makers, medical professional and patients are conferring an increasing amount of attention to the
occurrence of and risks attached to medical errors. Medical errors result in 44,000-98,000 unnecessary
deaths and over one million injuries per year in the US 527 and about 18,000 unnecessary deaths per year in
Australia in addition to 50,000 patients becoming disabled528. A follow on study from Wilson et al.’s work
on quality in Australian health care found that of any potential cause, human error accounted for the most
adverse events (81.8%). This result highlights the need for systems to be put in place that limit the contact
patients have with the unavoidable occurrence of human errors.
In the US, fatalities from prescription errors were found to have increased by 243 per cent from 1993 to
1998, outpacing almost any other cause of death, and also progressing faster than the increase in
prescriptions.529 Also errors in prescribing medications appeared to be the most common mistake made
among family physicians.530 Another study in an American teaching hospital reports finding four errors per
1,000 medication orders, 70 per cent of which had the potential to be seriously harmful.531 Preventable
adverse reactions to drugs are claimed to be the single leading cause of hospitalisation in the US, where 2
per cent to 7 per cent of hospitalised patients have avoidable adverse drug events and consequently have
527
American Hospital Association, "Hospital Statistics," (Chicago: 1999).
R.M. Wilson et al., "The Quality in Australian Health Care Study," Medical Journal of Australia 163 (1995).
529
D.P. Phillips and C.C. Bredder, "Morbidity and Mortality from Medical Errors: An Increasingly Serious Public
Health Problem," Annual Review of Public Health 23 (2002).
530
S.M Dovey et al., "Types of Medical Errors Commonly Reported by Family Physicians.," American Family
Physician 67, no. 4 (2003).
531
Timothy S. Lesar, L. Briceland, and D.S. Stein, "Factors Related to Errors in Medication Prescribing," Journal
of the American Medical Association 277, no. 4 (1997).
528
168
hospitals stays 8 to 12 days longer than they should.532 Studies done in the UK have shown similar results,
with one report of a 49 per cent error rate in the administration of intravenous drugs.533 Medical errors have
been attributed to a number of causes: administrative and investigation failures, simple ignorance, lapses in
treatment delivery, miscommunication, complications in payment systems, among many others.534 Others
suggest that medical errors arise from poor design of health care delivery processes as opposed to technical
incompetence among health care professionals.535
Patients who face multiple interventions and have more serious conditions causing them to remain in
hospital longer are more likely to suffer consequences resulting from a medical error. Otherwise, all
patients regardless of sex, age and level of comorbidities face medical error risks.536 Without robust
information systems to track medical error occurrences and difficulties in documenting their occurrence
such as universal underreporting, assessing the actual size of medical errors as a problem remains difficult..
Not only do adverse events represent a concern for patient safety but also to health care system finances as
they lead to greater medical complications or even patient deaths. A Harvard study of adverse drug events
found that such events led to an increase length of stay by 2.2 days while preventable adverse drug events
led to an increase of 4.6 days.537 Bates el al. also found that adverse drug events cost a 700 bed teaching
hospital over GBP 3.5million per year. In addition, errors lead to intangible costs such as diminished trust
in health systems, medical professionals and individual hospitals and physical and psychological effects of
prolonged hospital stays and/or disability levels.538
The first systematic research on medical errors throughout Europe was released in January 2006 with a
Eurobarometer survey assessing citizens’ perceptions of medical errors throughout the European Union
(EU)539. This fills in some of the gaps in the medical errors literature as the majority of work on the topic
comes from the US and to a lesser extent Australia. The Eurobarometer survey included all EU-25 states as
well as the accession (Bulgaria and Romania) and candidate countries (Croatia and Turkey). Findings
illustrate a wide variety across Europe in risk perceptions associated with and experiences pertaining to
medical errors. This survey found that 78% of EU citizens found medical errors to be an important problem
in their country, however country-level data found wide differences ranging from 97% in Italy to 48% in
Finland. 63% of Austrians saw medical errors as an important problem in their country currently, putting it
below the EU-25 average. However, when asked if they are worried about suffering a serious medical
error, Austrians were the least worried in the EU-25 apart from Swedes and Dutch respondents with 76%
expressing no concerns. Women, age and lower education levels tend to be associated with a higher
likelihood of perceiving medical errors as an important problem. Clearly, those who have actually
experienced a medical error or who have had a family member in such a situation tend to be more likely to
view the problem as important and to be more prone to worrying about suffering a medical error.
Austrians expressed particular assurance regarding quality in hospital care in responses collected as part of
the Eurobarometer survey. As the figure demonstrates below, Austrians appear to be confident about
experiences in hospitals relative to the rest of the EU-25.
532
L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System,
Committee on Quality of Health Care in America (Washington, D.C.: National Academy Press, 2000).
533
K Taxis and N. Barber, "Ethnographic Study of Incidence and Severity of Intravenous Drug Errors," British
Medical Journal 326 (2003).
534
S.M Dovey et al., "A Preliminary Taxonomy of Medical Errors in Family Practice.," Quality and Safety in
Health Care 11, no. 3 (2002).
535
Kohn, Corrigan, and Donaldson, eds., To Err Is Human: Building a Safer Health System.
536
S.N. Weingart et al., "Epidemiology of Medical Error," British Medical Journal 320 (2000).
537
D.W. Bates et al., "The Costs of Adverse Drug Events in Hospitalized Patients," Journal of the American
Medicine Association 277 (1997).
538
Kohn, Corrigan, and Donaldson, eds., To Err Is Human: Building a Safer Health System.
539
European Commission, Eurobarometer Medical Errors (2006 [cited 26 June 2006]); available from
http://ec.europa.eu/health/ph_publication/eurobarometers_en.htm.
169
Figure 7.1 Percentage of hospital patients concerned about serious medical errors.
Greece*
75%
60%
Poland
UK
49%
Slovenia
49%
47%
EU-25
Hungary
42%
Germany
42%
40%
France
37%
Netherlands
33%
Denmark
30%
Czech Republic
Austria
Sweden
24%
20%
*Country with highest percentage of respondents stating ‘worried’ to ‘How worried should hospital patients be about
serious medical errors?’ Alternative responses are ‘not worried’ and don’t know’
Source: Eurobarometer Medical Errors Survey January 2006
Part of the explanation for findings regarding perceptions of the likelihood of medical error could be any
relevant personal experiences regarding errors or the lack thereof. Austrians have had very low rates of
personal experiences (respondent or family suffering medical error) with adverse events either in a local
hospital or as a result of medicine prescribed by a doctor. Figures 7.4 and 7.5 illustrate Austria’s position
leading all of the EU-25 on these two questions.
170
Figure 7.2 Percentage of respondents reporting a family member having suffered a medical error
from a prescribed medicine
Austria
7%
Germany
7%
Hungary
9%
Netherlands
9%
EU-25
11%
France
11%
Slovenia
11%
UK
11%
14%
Czech Republic
15%
Italy
16%
Poland
21%
Denmark
23%
Latvia*
* Country with highest percentage of respondents stating ‘yes’
o ‘Have
t
you or a family member suffered a serious
medical error from a medicine that was prescribed by a doctor?’
of the EU-25, accession countries (Bulgaria,
Romania) and candidates countries (Croatia and Turkey)
Figure 7.3 Percentage of respondents reporting a family member having suffered a medical error in a
local hospital
Austria
11%
Germany
12%
Hungary
12%
Netherlands
17%
Slovenia
17%
EU-25
18%
Italy
18%
UK
18%
Czech Republic
19%
France
19%
Poland
Denmark
Latvia*
28%
29%
32%
* Country with highest percentage of respondents stating ‘yes’ t o ‘Have you or a family suffered a serous medical error in
a local hospital?’ of the EU
-25, accession countries (Bulgaria, Romania) and candidates countries (Croatia and
Turkey)
Source:Eurobarometer Medical Errors Survey January 2006
171
These responses demonstrate that hospital incidents occur more often than medicine-related errors. Using
the questions regarding perceptions of the likelihood of a medical error occurring, this data can be used to
shed some light on what appears to drive risk perceptions formulation. About 20% of individuals who saw
medical errors as important had personally experienced a medical error in hospital whereas only 8% of
those who expressed indifference towards the topic had personally experienced an error.
When looking at trust levels for individual professional groups, most Europeans have confidence that their
doctor, medical staff and dentist will not commit at an error while treating them. Respondents were most
confident in their dentist with the EU-25 average being 74%. While Austria is above average for all three
professional categories, there is still room for growth in the trust attached to medical professionals across
Europe. Figure 7.6 shows the varying degrees of confidence amongst the EU-25 for doctors and other
medical professionals. Finnish citizens (responses not depicted on the graph) have the highest level of
confidence in both categories (as well as with dentists).
In sum, this new Eurobarometer survey demonstrates that medical errors are perceived by Europeans as a
problem and citizens are well aware of their occurrence as 78% have read or heard about them. While the
majority of respondents express confidence in health professionals, a sizeable sample does not. Although
patients believe the health system holds responsibility for avoiding medical errors, this survey shows how
Europeans do see the patient as having a role in decreasing his likelihood of becoming a medical error
statistic.
Figure 7.4 Confidence that doctors and medical staff would not make a medical error to harm them
Medical Staff
Doctors
France
86%
Austria
84%
UK
Hungary
77%
77%
76%
73%
Netherlands
72%
EU-25
69%
Italy
68%
72%
68%
61%
65%
61%
Slovenia
Greece*
74%
63%
Germany
Poland
82%
79%
Czech Republic
Latvia
86%
59%
36%
34%
25%
38%
36%
24%
* Country with lowest percentage of the population expressing co nfidence in both doctors and medical staff
in the EU-25, accession countries (Bulgaria, Romania) and candidates countries (Croatia and Turkey)
Current debate on the topic focuses on thinking about systems to avoid the occurrence of medical errors.
Efforts now concentrate on promoting a culture of patient safety by encouraging teamwork and
communication about adverse events.540 Quick response and the recognition of early warning signs also
play key roles in preventing the potential long-term negative impacts of medical errors. The surgical
oncology and general surgery intensive-care units at Johns Hopkins Hospital implemented a safety scheme
that had staff follow eight steps to reduce patient safety concerns. This program resulted in a one-day
540
D. McCarthy and D. Blumenthal, "Committed to Safety: Ten Case Studies on Reducing Harm to Patients,"
(New York: Commonwealth Fund, 2006).
172
decrease in average patient length-of-stay and 43 less catheter-related infections annually saving eight lives.
This success demonstrates how creating cultures of safety in the workplace and improving teamwork across
hospital staff can save both lives and money. The Missouri Baptist Medical Center in St. Louis, Missouri
initiated a rapid response system to early signs of declining patient health to avoid acute crises. This system
has resulted in a 15% reduction in cardiac arrests for the 489-bed hospital and a 3.95% decline in the
hospital’s mortality rate.541
In the United Kingdom, the National Patient Safety Agency was established in 2001 with the aim to
improve patient safety by reducing the risk of harm through medical errors through the promotion of a
culture of learning from adverse events. This followed the publication of a Department of Health report –
An Organization with a Memory – highlighting the human and financial costs of medical errors. The
Agency operates an annual national system of reporting adverse events. Data are held anonymously and
disseminated across the country in order to look retrospectively at incidents to determine what happened,
how, and why. The Agency also offers resources such as learning tools for NHS staff to help raise
awareness of patient safety issues.
Similar organizations exist in Canada – the Canadian Patient Safety Institute – set up in 2003; and Australia
– the Australian Patient Safety Foundation.
Patient safety can be improved through various efforts. Education is one way – through formal pre-and
postgraduate training, and in experiential learning including continuing professional development (CPD).
Modern professional training courses in patient safety ought to demonstrate a culture of safety, one which:
acknowledges and learns from error; encourages all to improve quality and safety; and is supportive of all
personnel to protect patient safety, regardless of rank.542
Rules and regulations can also be used to improve patient safety, for example through evidence based
practice (EBP). Some countries, for instance the United Kingdom through the National Institute of Health
and Clinical Excellence (NICE), are increasingly incorporating EBP into their guidelines. Also on an
international level, a World Alliance for Patient Safety was formed in 2002 which passed a resolution
urging the World Health Organization to develop global clinical norms and standards. However it is
important to highlight that even when guidelines or protocols are available, health care professionals have
been shown to deviate from them; therefore it is crucial that rules in health care that are designed to
influence behaviour must be understood and accepted by those expected to use them.543
7.2.1 Patient safety in Austria
Patient safety is defined as “the avoidance, prevention and amelioration of adverse outcomes or injuries
stemming from the processes of health care”. Events include “errors”, “deviations” and “accidents”. Safety
emerges from the interaction of the components of the system, it does not reside in a person, device or
department. Improving safety depends on learning how safety emerges from the interactions of the
components. Patient safety is a subset of healthcare quality”.544
Austria does not have an own national agency to ensure patient safety. In the course of the health care
reform 2005 the Federal Ministry of Health and Women put a special emphasis on the topic of patient
safety. The Quality in health care Act defines patient safety in § 2 (4) as “measures to prevent adverse
541
Ibid.
Amanda Howe, "Patient Safety: Eductation, Training and Professional Development," in Patient Safety: Research
into Practice, ed. K Walshe and R Boaden (Berkshire: Open University Press, 2006).
543
T Claridge, D Parker, and G Cook, "Pathways to Patient Safety: The Use of Rules and Guidelines in Health Care,"
in Patient Safety: Research into Practice, ed. K Walshe and R Boaden (Berkshire: Open University Press, 2006).
544
Cooper, J.B., Sorensen, A.V., Anderson, S.M., Zipperer, L.A., Blum, L.N., Blim, J.F. (2001). Current research on
Patient Safety in the United States. Final Report. Health Systems Research. Inc. Subcontract # 290-95-2000. National
Patient Safety Foundation. In Holzer, E., Thomeczek, C., Hauke, E., Conen, D., Hochreutener, M.A. (2005). Patient
Safety- guide for handling risks in the health care sector. Facultas. Vienna, pp. 171
542
173
outcomes (actions, omissions, other incidents), which may harm the patient”. Beginning in the Nineties
national projects on quality were initiated and quality assurance became very important. A great number of
projects was brought to life, some of them placing a special focus on patient safety: handling adverse events
in patient care – “error culture and error management”, optimising the use of antibiotics, prevention and
monitoring of medication errors based on the Med-Safe Model, ANISS project to document and monitor
nosocomial infections, quality reporting, definition of quality criteria related to structures within the
framework of the Austrian Structural Plan for health.
Due to the Quality in health care Act the Federal Minister of Health was given the authority to enact a range
of ordinances, amongst these also in the field of patient safety. It will be interesting to see as to which
extent she makes use of her competence. The future federal institute for quality in health care will most
likely also be involved in patient safety.
Information systems for patient safety were i.e. are built up in the course of the above mentioned projects
(e.g. in the quality reporting project, for the monitoring of adverse effects of medicines, for the Med-Safe
project, for the haemovigilance register, databases for complaints in hospitals, etc.).
National legislation for medical negligence545
In case of damages resulting from medical treatment or omission, two avenues of approach may be chosen.
One is the judicial approach and the other is the extrajudicial approach.546
In order to receive compensation, the damaged patient can appeal to the civil courts. Before a lawyer
institutes a procedure of civil law he often presses charges against the physician and effects an expert
opinion which may be relevant for possible further procedures according to civil law. Patient lawyers are
not entitled to appeal to courts of justice.
In the course of an extrajudicial proceeding the patient lawyer, who aims to receive a compensation
payment, can choose the option of appealing to the liability insurance of the hospital carrier or of the
treating physician. Partially also professional bodies (for doctors, dentists) have established arbitration
boards to handle extrajudicial settlements. These are either located at the regional Medical Chambers or are
run in co-operation with the federal government or federal hospitals. An extrajudicial settlement has
advantages for patients, courts, health care providers and consumer protection organizations.
Liability may be based in misconduct of the physician such as a treatment error or a lack of counselling. In
general it is important to distinguish between liability based on penal law or on civil law.
The consequence of penal misconduct can, under certain circumstances, be a penal process and possibly
even a penal conviction. The legal basis of penal liability is the book of penal law. Offences according to
penal law are involuntary manslaughter according to § 81, bodily injury caused by negligence according to
§ 88 or arbitrary treatment according to § 110. Civil liability obliges the physician to provide compensation
for his misconduct. Compensation can be linked to a contract (treatment contract with the physician or the
hospital whereby the hospital carrier is liable for the physician as assistant according to § 1313a ABGB547)
or to an offence (not based on a contractual relationship but based in conducting treatment). Both claims
can be made at the same time. Premises which the patient has to fulfil in order to receive compensation for
experienced harm/damage (financial or non-financial) are, according to the ABGB damage (§§ 1293, 132527 ABGB), causality, fault (§ 1299 ABGB, benchmark for diligence of the physician § 49 Doctors’ law)
and illegality (§ 1295). The physician can guard himself against civil liability by signing up for liability
545
Vienna Medical Chamber. Liability. accessed at http://www.aekwien.at/665.html on 19/03/2006
Riegler, A.. (2002). Main features of the physician liability in civil law with respect to treatment errors considering
the current legal situation. In Meggeneder, O., Hengl, W. Eds. The informed patient. Linz
546
Zimmer, D. (2002). Extrajudicial conflict settlement in the relationship physician-patient. In Meggeneder, O.,
Hengl, W. Eds. The informed patient. Linz
547
ABGB= Allgemeines Bürgerliches Gesetzbuch = General Civil Law Book
174
insurance for physicians; this is not possible for penal liability. Issues related to limitation of actions are
regulated in § 1489 of the ABGB.
It is evident that patient safety is a topic of increasing importance in the ordinance on quality assurance
(ordinance of the Austrian Medical Chamber on the quality assurance of medical treatment provided by
ambulatory physicians in their practices and in group-practices – QS-VO 2006 according to § 118c Doctors’
law 1998 BGBl 169/98 idF BGBl I Nr. 179/2004) in which § 8 “criteria for quality related to processes for
physicians in their practices”, as part of standard Z6 “Adverse events/patient safety”, the following is stated:
“Adverse events are discussed with all (potentially) involved co-workers. The aim is to find the reason for
the event. Measures are implemented to avoid a recurring of the event. The patient affected by the adverse
event will, after consultation of the liability insurance of the physician, according to § 58a para.2 Doctors’
Law, be informed demonstrably by him/her about the event”.
Reporting of medical errors, access to information about the quality of services
Austria has so far not defined a national concept for the reporting of medical errors. For some sub-areas
systems and structures have already been established a couple of years ago (legal obligation to report
adverse effects of medicines, establishment of a haemovigilance register). From the viewpoint of the
Federal Ministry of Health and Women the Project “ Handling errors” (in the realm of the project “patient
safety in Austrian hospitals”) represents the first comprehensive discussion of the topic.548 The aim was to
find out how errors are dealt with in Austria. Initially the current level of knowledge was assessed; in a
second step four hospitals were chosen which were observed more closely. The institute for palliative care
and organizational ethics at the University of Klagenfurt was consigned to undertake this research. Various
hypotheses were generated and studied.
A description of the existing error culture was provided as well as a definition of requirements to establish a
modern error culture. Critical factors for success were listed and following partial stages were planned, for
instance the necessity of creating awareness and of social interaction with the topic, the execution of a
qualitative sampling survey as well as the development of a training program “error culture” including
relevant basic conditions (implementation of local and national reporting systems, execution of standardized
surveys to be able to make comparisons, establishment of a competence centre for error culture and error
management. Another project of the Ministry is the project to prevent and monitor medication errors based
on the Med-Safe Model.
Other organizations are also dealing with the topic of reporting/publication of medical errors: The Austrian
association of general practitioners (Österreichische Gesellschaft für Allgemeinmedizin, ÖGAM)
recommends physicians to take part in the German project “Every error counts” .549 The Hauptverband
(Main Association of the Austrian Social insurance institutions) suggested the introduction of an
anonymous error reporting system in 2005.550 The Austrian Medical Chamber was in principle not opposed
to such as system however it was only prepared to engage in negotiations beginning in 2006.551 The Vienna
Hospital Association (Wiener Krankenanstaltenverbund) started an area wide introduction of a complaint
management for all urban hospitals and geriatric centres. The General hospital in Linz has introduced a
548
Dinges, S. (2005). About establishing a new error culture for handling errors in inpatient care. In E. Holzer, E.,
Thomeczek, C., Hauke, E., Conen, D., Hochreutener, M.A. (2005). Patient Safety- guide for handling risks in the
health care sector. Facultas. Vienna.
549
Website of the German initiative www.jeder-fehler-zaehlt.de, an Austria-specific-assessment is planned
550
Endel, G. (2004). Patient safety and medical errors. accessed at
http://www.sozialversicherung.at/mediaDB/77461.PDF on 20/03/2006
551
Austrian Medical Chamber. Error reporting system: Doctors prepared to talks after 2006. accessed at
http://www.aerztekammer.at/index.php?id=000000000020050511145949&aid=xhtml&id=0000000000200505111459
49&type=module&noedit=true on 19/0372006
Martin, K. (2005). ″Patient lawyer following confrontation course.″ Ärztemagazin 21 accessed at
http://www.medical-tribune.at/dynasite.cfm?dssid=4169&dsmid=64407&dspaid=492072 on 19/03/2006
175
database for complaints. The Vienna hospital association has furthermore recently introduced an error
management system whereby errors and near misses may be filled into an internet platform anonymously
without having to fear sanctions. The federal hospital in Feldkirch has already some time ago started a new
IT system which is called CIRS (Critical Incident reporting system).552
Apart from institutional approaches/projects, numerous individual initiatives related to patient safety are
exercised by people such as Prof. Pateisky (AKH Vienna553) – gynaecology, or Prof. Koller (Medical
University of Vienna) – nosocomial infections.
Information and/or data on medical errors is most likely available in quite a few health care institutions (e.g.
hospitals), social insurance carriers or at the Ministry, it is however not made available to the public.
Medical errors are unfortunately communicated to patients mostly in the context of single events, whereby
the importance of factual reporting takes a back seat. Institutions such as patient lawyers report in a reliable
way. In Austria 499 people received compensation which amounted to €4,610,826.00554 in total. From the
451 cases which were referred to the patient compensation fund, 99 have been decided favourably.555
Based on § 27a para.5 of the Federal law on hospitals and spas556 a patient compensation fund557 was
established.558 The fund aims to complement the existing compensation law and to optimise it. The fund is
used in cases in which a legal claim does not face chances of success. It is funded solely by patients who
pay a sum of €0.73 per day spent in hospital.559 The regulation is heavily criticised for the fact that patients
have to pay for their own compensation. In 2004 country-wide 451 patients claimed compensation, 78%
were assessed favourably. In total payments in the range of €3,418,234.21 were made.560
The department for Evidence Based Medicine at the Hauptverband estimates that, based on international
publications, 245,000 incidences and 2,900-6,800 iatrogenic deaths occur in Austrian hospitals.561 Even if
these figures represent, according to the author, a worst case estimate, they should however draw attention
to the topic and justify additional initiatives related to quality management.
Until recently the legal- as well as the structural framework for the establishment of a standardized error
reporting system did not exist. Equally there was no error culture or awareness for a discussion of the topic.
Any other information related to quality is available to patients only in a limited way.
Patients receive information on health care services from a range of different sources (Internet, brochures,
television and recommendations of family/friends/acquaintances). In addition they are informed by
physicians and other health care professionals about existing treatment options and are referred to other
health care institutions (medical specialists, laboratories, hospitals, etc.) in the course of treatment.
Information for patients is mostly restricted to aspects of quality related to structures (range of services
available), on rare occasions it is possible for the patient to estimate the outcome or the risk (e.g. risk of an
operation in a chosen hospital).
552
Poznansiki, U. (2006). ″Error management: how to deactivate bombs.″ Clinicum 5, accessed at
http://www.medizin-medien.info/dynasite.cfm?dssid=4171&dsmid=74036&dspaid=575495
553
AKH= Allgemeines Krankenhaus=General Hospital
554
Paid by liability insurance (77%), by the arbitration board at the Medical Chamber (15%), the arbitration board of
the federal state (2%), and the hardship-fund (Härtefonds) (6%)
555
ARGE PA (Working group of patient lawyers) (2004). Austria Report 2004. Presentation by Martin Kräftner
(Office of the patient lawyer of Lower Austria)
556
BGBl 5/2001
557
Enacting legislation of the respective federal laws
558
Patient Lawyer of Lower Austria (2004). Patient compensation fund, Activity report. St. Pölten.
559
A maximum of 28 days per year
560
ARGE PA, Working group of patient lawyers (2004). Austria Report 2004. Presentation by Martin Kräftner (Office
Patient lawyer Lower Austria)
561
Endel, G. (2004). Patient safety and medical errors. accessed at
http://www.sozialversicherung.at/mediaDB/77461.PDF on 20/03/2006
176
Information such as mortality statistics are available for the hospital area (via the LKF system), the data is
handled very carefully, an exchange only takes place amongst the health care providers, for instance via the
DIAG database of the Ministry. Access to this system is handled in a very restrictive way. For ambulatory
care (physicians) little data exists, possibly at some of the associations of medical specialties. This data is
also not published.562
Patient safety is stated as one of the core principles in the newly established quality law of 2005, giving the
topic more significance. The Quality in Health Care Act announces for the patient that he will have access
to transparent information on health care related aspects in the future. During the elaboration of the law
experiences from other countries were taken into consideration.563
The demand of the patient lawyers for a new patient right to increase transparency of quality related data
has been met. Increased transparency should be ensured by means of a periodic quality reporting system
which is currently being established. § 6 (3) of the Quality in health care Act states “The Federal Minister
of Health and Women has to, with respect to improving transparency, report the intensity of active
participation of actors in the Austrian quality system, to the interested public in a suitable way. Furthermore
he has to ensure that appropriate feedback systems to those responsible for quality reporting are developed”.
The results as well as the final report on the first Austrian quality report have been given to the Ministry but
not been published yet. At the same time the Ministry is setting up a website for patient safety. The further
development of the topic of transparency in health care with respect to quality information will depend
strongly on the political courage of the decision makers.
In Austria various institutions representing patient interests i.e. enforcing patient rights exist which patients
can approach when in need of information or equally in the case of complaints or legal cases.
Safety of the blood supply564
In Austria the safety of blood and blood products is regulated by a number of laws. Legal foundations are
the Blood Safety Law (Blutsicherheitsgesetz -1999 - BSG BGBl I 1999/44 i. d. F. BGBl I 1999/119))
together with the associated Blood Donation Regulation (Blutspendeverordnung BSV BGBl II 1999/100)),
the Pharmaceutical Law (Arzneimittelgesetz §§ 75, 75a, 75b)) including the corresponding regulations, in
particular, the Pharmaceutical Plant Regulations (Arzneimittelbetriebsordnung) 2005 and the regulations
pertaining to medication produced from human blood, the Federal Law for Hospitals and Clinics
(Bundesgesetz über Krankenanstalten und Kuranstalten), as well as, at a European level, the “haemovigilance565-guidelines“ – Guideline 2005/61/EG, which were agreed upon on 30th September 2005. Beyond
that there are minimum standards for blood depots566 (published by the Ministry of Social Security and
Generations (BMSG) in June 2002), as well as, recommendations on haemovigilance in the Guide to the
preparation, use and quality assurance of blood components of the Council of Europe (Chapter 30).
By request of the BMSG an Austrian haemo-vigilance register was set up in the Austrian Institute for
Health Care (ÖBIG) in January 2003. ÖBIG has a central position for the notification of undesirable effects
of medication in connection with the transfusion of blood and blood products. The aim of haemo-vigilance
is quality assurance and quality improvement, as well as, the minimisation of risks and dangers in the
562
ibid
564
Dr. Johann Kurz (Federal Ministry of Health and Women, BMGF). Telephone interview September 2005
Austrian Federal Institute for Health Care (ÖBIG) (2005). Haemovigilance in Austria. Commissioned by the BMGF.
Vienna.
BMGF (2004). Healthcare report Austria.Vienna
For further information see www.bmgf.at und www.ris.bka.gv.at
565
Haemovigilance describes the compilation and processing of undesired effects of blood and blood products, as well
as, a monitoring system, which documents the transfusion chain from donor to patient.
566
The recording procedure in the hospital is regulated through these (who reports what, when, to whom, and how
often)
563
177
aforementioned areas. The reporting system is supervised by ÖBIG and the affiliated Contamination
Information Centre (Vergiftungsinformationszentrale, VIZ).
7.2.2 Patient rights in Austria
Patient rights are rooted in numerous laws, amongst others, in the General Civil Law Book (Allgemeinen
Bürgerlichen Gesetzbuch) (§§ 1295, 1325, 1167, 1489 ABGB), in the Penal Law Book (Strafgesetzbuch)
(§§ 88, 90, 95, 110, 184 StGB), in the Law for Hospitals and Clinics (Krankenanstalten und Kuranstalten
Gesetz) (§§ 5a KAG, further details in the executive legislation of the federal states) in the Doctor’s Law
(Ärztegesetz) (§§ 48, 49, 51, 54) as well as the laws of various health professions, in the General Social
Insurance Law (Allgemeines Sozialversicherungsgesetz) as well as its special laws (Sondergesetzen), in the
Pharmaceutal Law (Arzneimittelgesetz), in the Medical Product Law (Medizinproduktegesetz), in the
Hospitalisation Act (Unterbringungsgesetz), in the Law for Reproductive Medicine
(Fortpflanzungsmedizingesetz), in the Aids Law (Aidsgesetz) and in the Genetic Technology Law
(Gentechnikgesetz).
Patient charta
For the first time, in 1993, in a comprehensive amendment to the Hospital Law, a paragraph with the
heading Patient Rights was included (§ 5 KAG). Points particularly worth mentioning are the right to
treatment, self-determination, clarification and information, the right to look at their medical records,
protection of privacy, and the right to a dignified death. Because of severe fragmentation a consolidation of
the legal policies in this area was called for.
A concise and, for lay persons, easy to understand, summary of the most important patient rights was issued
in 1999 within the framework of a contract between the federation and the nine federal states in accordance
with Art. 15a B-VG (BGBl I 1999/195), Agreement for the assurance of Patient Rights, Patient charta
(Vereinbarung zur Sicherstellung der Patientenrechte, Patientencharta). The first federal state to sign the
agreement was Carinthia.
Contents of the patient charter are ensuring personal rights and human dignity, ban on discrimination based
on types of illnesses, the right to treatment and care (equal access, proper implementation), respect for
dignity and integrity, self-determination and information and the right to documentation. Moreover there are
special terms for children, directives on the representation of patient interests as well as the enforcement of
claim for damages.
The creation of the patient charter has brought with it numerous consequential actions/activities, which have
led or will lead to further improvement of patient rights. In the meantime the patient charter has been signed
by all federal states and is therefore valid country-wide.
Advance directive
Every citizen in Austria is entitled to set up an advance directive and to thereby proclaim their will i.e.
decide on what will happen with him in case he is severely ill and not able to comprehend, to take decisions
or to communicate. By means of an advance directive the patient can reject certain medical treatment, the
area of responsibility does however not cover any measures of nursing. There are no formal requirements,
but a universal form for advance directives was developed as well as various brochures and guidebooks567
(e.g. of the hospice umbrella organization568 or of the Patient lawyer in Lower Austria569)
567
In co-operation of the BMGF, the Ministry of Justics, the umbrella organization for hospice care in Austria,
patient lawyers, the Medical Chamber and other institutions.
568
Hospice care in Austria. Information on advance directives. accessed at http://www.hospiz.at/
569
Patient Lawyer of Lower Austria (2002). Advance directive – Patient guide. St. Pölten. Accessed at
http://www.patientenanwalt.com/pdf/1_Ratgeber_Patientenverfuegung.pdf on 10/09/2006
178
The legal basis is primarily the Advance Directive Act, which came into existence on June 1 2006;
furthermore the Patient Charta, the Hospital Act or the Penal Law Book. The new federal law regulates the
preconditions for the development of a living will, its consequences and possible contents.570
Institutions for patients (information, complaints)
In Austria there are diverse institutions which represent patient rights or enforce patient rights, and to which
the patient can turn for information, or in cases of complaints or disputes. Here the independent, directivefree, autonomous institutions of patient lawyers (also known as patient representatives), which since the
90ies have been established in every federal state by the federal state legislator play an important role. Their
geographical limits extend over the whole federal state (jurisdiction dependent on the place where the
incident took place and not the place of residence of the patient), the area of competence varies from region
to region (all are responsible for hospitals, some for nursing homes and/or doctors in their own practices).
In some federal states the patient lawyer is also a lawyer for areas related to nursing (e.g. in Lower Austria),
in other federal states these two areas of responsibility are separated. In Vienna, for instance, the merging of
the two institutions is currently discussed.
The help of patient lawyers can be called upon free of charge. Their duties cover advisory services,
clarification and information, mediating in conflicts/disputes, as well as, assistance with out of court claims
following treatment errors. Public relations work is of great importance. Since mid 2001 the supervision of
the patient compensation fund571 falls into the area of responsibility of the patient lawyers. Patient lawyers
have merged to a single consortium (ARGE PA) in order to represent patient interests at a national level and
to coordinate the activities of individual patient lawyers. Representatives of patient lawyers are members of
numerous bodies at national and regional level.
Besides the patient lawyers there are other places which represent the interests of patients, such as the
Chamber of Labour (Arbeiterkammer) (for insured and their dependents, also in the field of social
insurance), who offer an advisory service for their members as well as represent them in court. In some
social insurance funds ombudsmen/women were appointed, whose area of responsibility include legal
issues relating to social insurance. Following the directives in § 11e of the Hospital Law
(Krankenanstaltengesetz), some hospitals have appointed ombudsmen for their patients, who are at the
patient’s disposal for information, suggestions, or complaints. Arbitration boards and public attorney set up
by some chambers of doctors should also be mentioned. In part patient lawyers and arbitration boards work
very closely together.
In addition more than 1,600 self help groups572 make an invaluable contribution in supporting patients’
concerns.
Since the year 2004 patients can also turn to the non-profit patient-initiative in health care
(PatientInnenInititiative im Gesundheitswesen, PinG), which helps patients with urgent problems, offers
juridical advice and counselling for other areas not within the remit of patient lawyers. Furthermore they
provide assistance in dealing with private issues and activities as well as supporting individuals by giving
them comprehensive information about various new developments and drawbacks in the health care
sector.573
570
Bachinger, G. (2006). Helping patients, the new Advance Directive Act in Austria. Patient lawyer of Lower
Austria. August 2006. accessed at
http://www.patientenanwalt.com/pdf/0608_Letter_Bachinger_Das_neue_Patientenverfuegungs-Gesetz.pdf on
10/09/2006
571
Not a refund, rather a supplementation and optimisation of liability as set out in civil law. Legal basis § 27a
Abs. 5 and 6 of the Federal Law for Hospitals and Spas (BGBl. I Nr. 90/2002) as well as regional specifications
(up to 2003).
572
Self-help-groups, accessed at www.selbsthilfe.at
573
No author (2006).Self-help-groups: Advice and help. DA, Die Apotheke June, pp.20
179
Use of these services: patient lawyers574
Table 7.2 Legal cases of patient lawyers (Austria total)
Hospitals
Nursing homes
Physician practices
Social insurance
Others
Total complaints
2003
3374
163
609
201
926
5273
2004
3677
288
618
169
1003
5755
Source: ARGE PA (Working group of patient lawyers) (2004). Austria Report 2004. Presentation by Martin Kräftner
In 2004, in hospitals, most legal cases were registered in the departments of surgery, accident surgery,
internal medicine and gynaecology.
Figure 7.5 Distribution of cases in hospital departments in Austria, 2004
Distribution of cases in hospital departments - Austria 2004
Surgery; 790
Others; 856
Neurosurgery,
Anaesthesiology/
Intensive care; 71
Ophtalmology; 67
Ortolaryngology;
252
Gynaecology; 342
Neurology; 144
Internal Medicine;
369
Urology; 69
Pediatrics; 103
Accident Surgery;
609
Orthopedics; 252
Psychiatry; 73
For doctors in their own practices most legal cases concerned the following specialist areas: dentistry,
general medicine, orthopaedics, and gynaecology.
574
ARGE PA (Working group of patient lawyers) (2004). Austria Report 2004. Presentation by Martin Kräftner
(Office of the patient lawyer of Lower Austria)
180
Figure 7.6 Distribution of cases among doctors in surgeries in Austria
Distribution of cases amongst doctors in surgeries
Austria 2004 without Tyrol
General
Practitioners; 92
Others; 86
Gynaecologists; 47
Doctors of Internal
Medicine; 21
Pediatricians; 5
Dentists; 196
Orthopaedic
Surgeons; 62
Ophtalmologists; 28
Emergency
services,
Ambulance; 40
Dermatologists; 27
Radiologists; 14
Ombudswomen of the regional sickness fund of Vienna
The Ombuds-Office of the regional sickness fund in Vienna is staffed with two persons, with the
Ombudswomen Gertraude Jung and her co-worker Ms. Heidi Exl. In 2005 2,845 contacts were registered,
adding about 960 not yet registered contacts. In total this results in an increase of about 16% compared to
2004 whereby increases in email contacts were particularly strong (+60%).
Figure 7.7 Legal cases of the ombudswomen of the Vienna sickness fund, 2005
2004 - 2737 Fälle (+ ca. 960 nicht erfasste) = 3697
2005 - 2845 Fälle (+ ca. 1440 nicht erfasste) = 4285
1800
1600
1400
1200
telefonisch
1000
schriftlich
800
persönlich
600
per E-Mail
400
nicht erfasste
200
0
1756
245 359 377
2004
960
1683
250 312 600 1440
2005
Fälle = cases, telefonisch= on the telephone, schriftlich = in writing, persönlich=in person, per E-Mail = via E-mail,
nicht erfasste= not registered
Source: Vienna sickness fund, report of the ombuds-office for the year 2005, received 19/0672006 (via email)
181
Cases of the Ombuds-Office were categorised according to the relevant organizational entities at the
regional sickness fund of Vienna. From the figure below it can be inferred that most of the cases are related
to the medical field, then to the district offices, treatment economics and contributions. Changes to the
previous year are all below 3%.
Figure 7.8 Legal cases of the ombudswomen of the Vienna sickness fund, 2005 related departments
betroffene Organisationseinheiten
30%
Ärztl.Dion/Med.Dienst
25%
Bezirksstellen
Behandlungsökonomie
20%
Beitragsbereich
Leistungsabteilung
15%
Eigene Einrichtungen
10%
Dion
sonstige Abt.
externe
30% 18% 13% 12% 11% 4%
5%
2%
2%
8%
0%
Ärztl. Dion/Med. Dienst= medical management, Bezirksstellen=district offices, Behandlungsökonomie=treatment
economics, Beitragsbereich= constibutions, Leistungsabteilung=benefits department, Eigene Einrichtungen=
integrated institutions, Dion= management, sonstige Abteilungen= other departments, externe= external
Source: Vienna sickness fund, report of the ombuds-office for the year 2005, received 19/0672006 (via email)
The Ombuds-Office was able to provide help to 31% of the contacts, 61% of enquiries were answered by
providing information, for 6% of the enquiries it was not possible to help the person who referred to the
Ombuds-Office. In 2005 27% of all enquiries were undertaken by pensioners, 24% by representatives of the
active working population, 15% by insured with another sickness fund, 11% by unemployed, 10% by
dependants, 6% by persons without health insurance coverage, 3% by voluntary insured and persons
receiving maternity benefits as well as 1% by of employers. In comparison to the previous year there are
hardly any deviations.
A detailed table of the cases during the past 8 years can be found in the Appendix 16.
7.3 Patient choice
Individuals can exercise choice at various decision points within a health system. Regarding insurance,
individuals may be able to choose to have insurance or not, choose between public or private insurance, or
between individual insurance funds. Choice of provider may relate to the first contact provider, general
practitioner, specialist, hospital, or of a doctor in the hospital. Finally, patients may have some degree of
choice of treatment, for instance they may have the option to refuse treatment, type of treatment, time of
treatment, and the setting.575
However, there are many possible constraints to choice; therefore it is rare for choices to be completely
‘free’. Explicit constraints may arise from restricting choice to: specific groups of people, such as high
income earners; a limited range of options, such as providers within a geographical area; a particular point
in time; and those who are willing to pay an extra fee.576 Implicit constraints to choice may relate to
575
576
S Thomson and A Dixon, "Choices in Health Care: The European Experience," Euro Observer 2004.
Ibid.
182
contextual factors such as: individual’s knowledge and information; health system capacity; proximity to
services; ability to pay; cultural or institutional norms; institutional responses to particular incentives such
as risk selection by competing insurance funds.
Generally social health insurance systems offer a greater level of choice of provider to the population than
tax-based health systems. In Austria patients are offered unlimited choice of general practitioner,
ambulatory specialist, hospital and nursing home.
The only country in Western Europe that offers individuals a choice of public or private insurance coverage
is Germany. In Austria individuals do not have choice of their insurance fund – this is determined on the
basis of occupation and/or region of residence.
Figure 7.9 Perceived choice of GP/doctor in Austria vs. European average, 2004
100%
86%
90%
80%
72%
70%
60%
ESS-average
50%
Austria
40%
28%
30%
20%
14%
10%
0%
Enough choice
Not enough choice
Source: European Social Survey 2004577
Data from the European Social Survey from 2004 ask questions about perceived choice of physician. Far
more respondents in Austria reported adequate choice of doctor than the average across all countries
surveyed (Figure 7.11). Disaggregating the countries highlights that individuals are most satisfied in terms
of patient choice in Belgium, Switzerland, France and Germany, and least in Greece, Iceland, Portugal and
Ukraine (Figure 7.12). It is important to highlight the difficulties in comparing perceptions and opinions
across countries; differing cultures, religion, history, and socio-economic context may significantly
influence (and bias) the responses in surveys.
Recent reforms have taken place in Belgium, Germany and the Netherlands which involved increasing
consumer choice of sickness fund and/or increasing the funds’ financial responsibility in order to improve
efficiency.578
The reforms of 1992 in the Netherlands allowed people to enrol in any sickness fund they wished regardless
of their geographical location.579 However, the effects of this reform were limited by the small price
differentials between competing funds, which may not outweigh the transaction costs of switching. In order
to improve efficiency, Dutch sickness funds were permitted to contract selectively with physicians and
577
The European Social Survey includes 24 countries: Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France,
Germany, Greece, Hungary, Iceland, Ireland, Luxembourg, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain,
Sweden, Switzerland, United Kingdom, Ukraine.
578
W Van de Ven et al., "Risk Adjustment and Risk Selection on the Sickness Fund Insurance Market in Five
European Countries," Health Policy 65 (2003).
579
F.T Schut, S Gress, and J. Wasem, "Consumer Price Sensitivity and Social Health Insurer Choice in Germany and
the Netherlands," International Journal of Health Care Finance and Economics 3, no. 2 (2003).
183
other health care professionals in any geographic area.580 However, their freedom to negotiate contracts was
limited by rigidly defined entitlements in the health insurance legislation and government price regulation.
In Germany, freedom of choice of sickness fund was granted in 1996. Since then, fund switching has
become quite common, and the evidence suggests that funds are competing on the basis of price.581
However, funds are not permitted to selectively contract, or choose the most efficient providers and
hospitals for preferred cooperation, therefore impeding any efficiency gains and leaving risk-selection as the
most effective tool to maintain competitiveness. While many believe the lack of selective contracting is the
main obstacle to achieving competition and enhanced efficiency, others contend that high transaction costs
and lack of managerial experience in the medical profession are more important.582
In order to ensure fairness, risk-adjusted premium subsidies were implemented alongside reforms
introducing choice of insurance fund. The factors that the risk-adjustment mechanisms were based on,
however, were inaccurate predictors of future health care needs. More specifically, the risk-adjustment
scheme in Germany only accounted for crude indicators such as income, age, reception of disability
insurance and entitlement for sickness allowance. Therefore, despite these attempts to preserve solidarity,
the sickness funds were left with financial incentives to select profitable consumers. This selection not only
undermines the equity goals, but also those of efficiency. Recent reforms in Germany sought to remedy this
problem of risk selection, including compensating sickness funds that have high cost members, in addition
to introducing managed care (Disease Management Programs) which provides incentives for sickness funds
to insure people with chronic illness.
The experiences in these three countries highlight the need for an appropriate, improved risk adjustment
model. More specifically, health-based risk adjustment mechanisms may help prevent selection, for
example by adjusting for prior year expenditures, prior utilization, self-reported health information and
mortality. Examples of these methods can be found in the US 583 and in the introduction of Pharmacy Costs
Groups in the Netherlands584, which reduces the incentives for risk selection.
580
F.T Schut and E van Doorslaer, "Towards a Reinforced Agency Role of Health Insurers in Belgium and the
Netherlands," Health Policy 48, no. 1 (1999).
581
Schut, Gress, and Wasem, "Consumer Price Sensitivity and Social Health Insurer Choice in Germany and the
Netherlands."
582
P. Riemer-Hommel, "The Changing Nature of Contracts in German Health Care," Social Science and Medicine 55
(2002).
583
L.M. Greenwald, "Medicare Risk Adjusted Payments: From Research to Implementation," Health Care
Financing Review 21, no. 3 (2000), G.C Pope, R.P Ellis, and A.S Ash, "Principal Inpatient Diagnostic Cost Group
Model for Medicare Risk Adjustment," Health Care Financing Review 21, no. 3 (2000).
584
L.M Lamers, "Pharmacy Cost Groups: A Risk-Adjuster for Capitation Payments," Medical Care 34, no. 6
(1999).
184
Figure 7.10 Perceived choice of GP/doctor in European countries
Belgium
95%
Switzerland
95%
France
91%
Germany
91%
Luxembourg
88%
Denmark
86%
Ireland
86%
Austria
86%
Slovenia
80%
Slovakia
79%
Norway
78%
76%
United Kingdom
74%
Czech
ESS-average
72%
70%
Netherlands
Hungary
68%
67%
Poland
Finland
64%
Sweden
63%
Estonia
62%
Spain
61%
55%
Greece
Iceland
46%
41%
Portugal
Ukraine
19%
0%
20%
40%
60%
80%
100%
120%
7.3.1 Choice in the Austrian health system
Choice of insurer
Austria has a system of statutory social insurance. The insurance is a legal requirement and is linked with
the commencement of gainful employment liable for compulsory insurance. Coverage usually begins
immediately, without a waiting period, and usually in the form of comprehensive coverage (including all
branches of social insurance – health, accident, and pension insurance). The insured person can, with very
few exceptions, neither opt out of insurance nor select the insurance fund, since this is also legally
regulated. Affiliation is, on the one hand, associated with the type of employment and on the other hand
regional criteria (location of the workplace, location of residence). There is no competition between the
insurance funds. This means that selection according to risk is not possible.
185
The legal foundations of the Austrian social insurance may be found in the following federal laws and their
numerous amendments:
* General Social Insurance Law (Allgemeines Sozialversicherungsgesetz, ASVG) – for employees,
apprentices, employee peers etc.
* Civil Service – Sickness and Accident Insurance Law (Beamten-Kranken- und Unfallversicherungsgesetz,
B-KUVG) – sickness and/or accident insurance for persons employed in the public sector and similar,
governed by public law are, on the basis of this employment status, entitled to special retirement terms.
* Commercial Social Insurance Law (Gewerbliches Sozialversicherungsgesetz, GSVG) – for self-employed
persons in the commercial sector.
* Federal law regarding social insurance for freelance, self employed persons (Bundesgesetz über die
Sozialversicherung freiberuflich selbständig Erwerbstätiger, FSVG) – for doctors, pharmacists and
patent lawyers
* Social Insurance Law for Farmers (Bauern-Sozialversicherungsgesetz, BSVG) – for self-employed
persons in farming and forestry
In addition to the above stated laws contractual agreements such as collective and individual contracts play
a very important role in Austrian social insurance.
Choice within the social health insurance system
Options are very limited in the Austrian social insurance system. Since affiliation to a particular insurance
fund is governed by law, a change to an alternative fund occurs in only a few cases e.g. when particular
insurance requirements are no longer met, a change of job, becoming unemployed585 or when, as far as
personal circumstances allow, a private insurance is opted for to replace the compulsory insurance. Those
insured with the Austrian Social Insurance Authority for Business (Sozialversicherungsanstalt der
Gewerblichen Wirtschaft, SVA) have the most options available.
In 2000 freelance members of chambers were given the opportunity to opt out of the compulsory social
insurance (health and/or pension insurance) (§ 5 GSVG). At the end of the 3rd quarter 2005 freelancers
constituted about 8.6% of all those insured.586 Pre-requisite for this was an application from the appropriate
trade association. They had to provide evidence of an equivalent health insurance coverage, whether it be a
compulsory insurance in accordance with GSVG (§ 14ab), or a private collective or individual insurance (or
further insurance) in accordance with ASVG.587 Only doctors are not required to choose one of the three
above mentioned options, but rather they receive commensurate protection via the health care facility
arranged by their representative agency. The occupational groups of doctors, pharmacists, lawyers, trustees,
veterinarians, notaries, patent lawyers, and civil engineers have all applied for exemption from the GSVG
health insurance, lawyers and civil engineers have also applied to opt out of pension insurance588. The
options vary depending on whether the insured person carries out only freelance work or whether he also
has another form of employment. Despite opting out, as already suggested, certain circumstances may still
require a compulsory health insurance in accordance with § 14b GSVG. By the end of the 3rd quarter 2005,
2,319 people (approx. 6.4% of freelancers) opted for an insurance in accordance with § 14ab.589
Up to 2002, from the 4th year of self employment and as long as their income was above a certain limit
(limit of allowance in kind), insured persons had the opportunity to claim benefits as those entitled to cash
benefits (upgrade) this means they receive medical attendance, medication, dental treatment and dental
585
Recipients of health care benefits resulting from entitlement through unemployment insurance are, based on their
place of residence, insured with the regional sickness fund
586
Austrian Social Insurance Authority for Business (SVA), statistics, received on 02/01/06 (via email)
587
588
Austrian Social Insurance Authority for Business (2005), Social Insurance Authority for Business, Introductory
information (Erstinformation). Vienna.
589
Dr. Richter (Austrian Social Insurance Authority for Business), information given 16 March 2006
186
prostheses as cash benefits (make the claim as if they are private patients).590 They receive a statutory
amount as reimbursement. All other benefits (institutional care, curative care, etc.) are received as
allowance in kind. Insured persons below this limit are entitled to allowance in kind. The 26th amendment of
the GSVG (from 1.01.02) brought with it additional possibilities for those entitled to allowance in kind or
cash benefits in order to better fit the insurance protection to individual needs (see § 85a GSVG). Those
entitled to cash benefits could, for the first time, change, upon application, in part/or completely to an
allowance in kind entitlement. Those entitled to allowance in kind could, against payment of an additional
contribution (of varying amounts) acquire cash benefit entitlement591. At the end of 2002 there were 1,585
upgrades amongst those still actively working and 4,498 amongst pensioners (insured persons who opted
voluntarily for a total entitlement to cash benefits).592
Table 7.3 Options for self-employed after 2002
ACTIVE
PENSIONERS
normal AIK
half CB 60,76**
half CB 2,00
full CB 75,94**
normal CB
normal AIK
half CB 60,76**
full CB 75,94**
31.12.2002* 31.12.2003 23.02.2004 31.12.2004
253,850
1,362
1,693
2,151
4,435
5,575
5,925
1,585
1,556
1,463
1,517
19,913
103,668
1,058
1,105
1,275
4,498
3,58
3,534
3,434
11.08.2005
3,229
6,333
1,713
1,42
3,367
Actively working incl. working pensioners
*) Final status upgrade
**) Value 2004
Source: Austrian Social Insurance Authority for Business, received 16/03/2006
Categories:
- Normal AIK: normal allowance in kind
- Active half cash benefit (CB): Persons entitled to allowance in kind, who have opted for a cash
benefit entitlement in hospital (2006 €64.02 per month)
- Active half cash benefit for €2.00: Persons entitled to cash benefits, who have opted change back to
allowance in kind for their medical attendance – retain their entitlement to cash benefits only for
the hospital
- Active full cash benefits: those who have opted for total entitlement to cash benefits (2006 €80.02)
– this option is only possible for those entitled to allowance in kind
Newly self-employed persons whose yearly income is not yet fixed and who are uncertain as to whether
they will exceed certain insurance limits can submit an option for health and accident insurance (Opting-In).
Exemption from the pension insurance however remains in place593. This insurance can be terminated by
means of deregistration. This option was chosen by 5,168 people (about 14% of freelancers) by the end of
the 3rd quarter 2005.594
Insured persons covered by a legally governed multiple insurance (several activities are carried out which
are subject to compulsory insurance) are, primarily, able to choose which insurance fund they will use for
which benefit. On July1, 2004 36,285 persons i.e. 1.2% of the employed had two or more occupations.595
Otherwise the service responsibility will comply with legal requirements. The insured person can however,
590
Certain advantages such as: authorization by a senior physician not required, compliance to RÖV, Directive on
economic prescribing (Richtlinie über die ökonomische Verschreibweise) not required
591
Neumann, T. (2002), ″New options in the health insurance for businesses/ self-employed.″ Soziale Sicherheit
10, pp. 423-426
592
Dr. Richter (Austrian Social Insurance Authority for Business), 16 March 2006 (via email)
593
Austrian Social Insurance Authority for Business, accessed at http://esv-sva.sozvers.at on 10/03/2006
594
Dr. Richter (Austrian Social Insurance Authority for Business). 16 March 2006 (via email)
595
Haydn, R. (2005), ″Multiple insurance in Austrian Social insurance, individual-related statistics 2004.″ Soziale
Sicherheit 2, pp. 74-82.
187
upon application, call on the services of another health insurance fund with whom he is insured. Some
insured persons who in accordance with §5 GSVG have the opportunity of opting out still choose an
insurance in accordance with the GSVG because then a multiple insurance with its many advantages
becomes applicable.
People without insurance cover have the opportunity of insuring themselves voluntarily. Voluntary
insurance requires a formal application and can be secured for single or multiple branches of social
insurance.
In a survey conducted by the Austrian Association for Health Economics (Österreichische Gesellschaft für
Gesundheitsökonomie, ÖGGÖ) in 2004, analysing the impact of the LKF System (Austrian DRG system for
hospital funding), 600 experts from hospitals and other areas related to health care were asked if the insured
population should have the option of choosing between the individual sickness funds and what impact this
choice might have. Statutory health insurance should nevertheless be maintained. About 53% of the 110
experts who filled out the questionnaire favoured the option of choice to increase competition, roughly 55%
considered it positive because it would lead to an increase in services for the insured and around 70%
argued that it would result in a better personal assistance of the insured.
Choice of private health insurance
The role of private health insurance in Austria is not very dominant, mainly due to the comprehensive
coverage by legally defined statutory health insurance. Reaching 2.4%596 of total health care expenditure the
share of private health insurance is fairly low. It is primarily used to pay for better accommodation in
private wards of hospitals, for free choice of doctors (only in private hospitals) and for reducing waiting
times. Nevertheless private health insurance funds about 7%597 of the expenditure of public hospitals. In
ambulatory care (doctors in surgeries) private health insurance is not of major significance.
The market is dominated by few (8) market participants who are joined together in the Association of
Insurance Companies (Verband der Versicherungsunternehmen, VVO) and have a total of 1,344 million
Euro in premium revenues. UNIQA held a share of nearly 50% in 2004, Wiener Städtische of about 20%,
Merkur and Generali each a little bit more or less than 13%. The remaining private health insurers each
occupy shares of less than 3%. The largest items in terms of expenditure are payments for hospitals, dental
care and physician services.598
The option of signing up for a substitutive private health insurance is only open to a small group of
individuals, those who opted out of statutory social health insurance based on § 5 GSVG. Furthermore
persons not covered through either compulsory or voluntary social health insurance.
Choice of provider: physician
The Austrian social insurance allows the insured person free choice of which doctor they visit. They can
visit freelance doctors having a contract with one or several sickness funds, doctors in contract group
practices, doctors in facilities provided by health insurance funds (ambulatory clinics), doctors in contract
establishments (e.g. hospital outpatient departments) or private doctors (who do not have a contract with a
sickness fund), doctors in private group practices, or doctors in private facilities across the whole of
Austria.599 Freedom of choice can be exercised more readily in more highly populated areas than in rural
areas primarily because the concentration of health care on offer is higher.600 Although the geographic
distribution of contract doctors should, according to § 135 Abs. (2) ASVG, ensure that, as a rule, the choice
of at least two doctors or group practices, which may be reached in reasonable time, may be called upon for
treatment.
596
597
ibid
598
Association of (private) Insurance Companies (2005). Yearly report 2005, accessed at www.vvo.at, on 27/04/2006
599
Web portal of Austrian Social Insurance, accessed at www.sozialversicherung.at
600
188
A restriction in the free choice of doctor is, according to OGH judgement, admissible in cases where the
health insurance fund wants to restrict examinations with large scale equipment e.g. magnetic resonance
examinations, to be carried out in specific contract facilities.601
Some sickness funds only allow the insured to directly visit one general practitioner and one specialist
physician during a single billing period (as a rule 3 months), further specialist visits are possible by referral
through the GP. This regulation varies among the health insurance funds, some even allow unlimited direct
access to medical specialists (e.g. regional sickness fund in Tyrol, beginning January 2006). A change of
contract doctor is only allowed after declaration of reasons for the change and with the approval of the
health insurance fund. Furthermore the insured person is not permitted to consult several contract doctors in
the same branch for the same condition at the cost of the health insurance.602 In certain cases, following an
application, an exception can be made. When enlisting services at the expense of social insurance, the
insured person is obliged to present his e-card as proof of entitlement.
Choice of provider: hospital
Basically the insured person is permitted to personally select the hospital at which he will receive inpatient
treatment. Restrictions may arise because of reimbursement of transportation costs to the hospital, as
generally, in case intramural care, in accordance with § 144 ASVG, is required the patient will be admitted
to the nearest, federally funded hospital, having the necessary treatment facilities. The patient’s wishes (also
with regards admission to a non-public (PRIKRAF603 financed) hospital, having signed a contract with the
health insurance fund) are however taken into consideration as far as possible.604 The package of care605 as
well as the share of costs606 to be borne by the patient can vary depending on the health insurance fund. In
case of maternity and also for insured demonstrating a certain social level of need no cost sharing applies.
In addition most of the patients have to pay a daily charge for inpatient care based on the Hospital Act.
For elective interventions the consulting physician issues a referral/an admission notice. The patient can
notify the doctor of special wishes, although (at least in the case of patients without supplementary private
health insurance) the choice of hospital in which the patient is to be treated is ultimately dependant on the
number of free beds. The referring physician can clarify with the hospital as to whether there is a free bed
for his patient (this is considered a special service of the physician for his patient). The need for inpatient
care is verified by the hospital upon admission of the patient.
In theory a free choice of doctor is also possible in the private ward. This is however not legally stipulated.
Private insurances use this in part to attract clients. In this case also, attempts are made to comply with the
patient’s wishes as far as is possible. Free choice of doctor in the hospital is generally not advised since this
would be difficult to arrange from an organizational point of view. This may be considered in some areas
and may offer some advantages. Patients in the general ward of Austrian hospitals are not entitled to choose
their personal physician.
In so-called Belegspitäler, hospitals in which a doctor is permitted to supervise and treat his patient without
being directly employed by that hospital, the patient is entitled to bring with him/her a trusted doctor to
carry out the treatment or operation. The doctor pays a part of his fees to the hospital in exchange for the
use of premises, apparatus und equipment.607
601
603
PRIKRAF= Privatkrankenanstalten Finanzierungsfonds (Fund to finance the private hospitals)
604
General Social Security Act (Allgemeines Sozialversicherungsgesetz, ASVG)
605
Hospitalisation in the private ward for insured according to the B-KUVG and the GSVG (those entitled to cash
benefits)
606
No cost sharing following social insurance legislation on the general ward for insured according to the B-KUVG
and the GSVG, cost sharing for insured according to the ASVG and the BSVG.
607
Hofmarcher and Rack 2006
602
189
Impacts of patient choice on equity and efficiency
Due to the system of statutory social insurance most of the population has no choice of insurance fund. A
consequence of this is that risk selection is very restricted if at all possible, resulting in more solidarity in
the health system. Some insured of the Austrian Social Insurance Authority for Business
(Sozialversicherungsanstalt der gewerblichen Wirtschaft), namely free lance workers associated to a
Chamber, based on § 5 GSVG) as well as voluntary insured persons have restricted options of choice. For
the first group (e.g. doctors, vets, tax accountants) choice most likely applies to insured with a comparably
higher income (potentially higher contributions) and a lower risk (assuming that higher education is
correlated with a lower health risk), meaning that an exclusion from the insured population is, even if the
group only represents 10% of the insured, not necessarily an advantage for the insurer. Persons choosing to
take out voluntary insurance are people who do not meet criteria for statutory insurance, who are not
covered as dependants and often have a lower income. Persons not covered by statutory social insurance,
relying totally on private health insurance are not covered in this report.
Insured pay social insurance contributions based on their income not on their risk. Contributions are
progressive up to a certain income limit, at which they change to be regressive (high income earners pay a
smaller proportion of their income for social insurance than low income earners). Social insurance is
characterised by a re-distribution between the insured population, re-distributing between healthy and sick,
between generations, between high-income earners and low-income earners, between insured without
dependants and insured with dependants and partially also between men and women.
Direct access to care is granted to insured by means of provision of benefits in kind. Some insured have
changed their status voluntarily, paying for services in cash like private patients and applying for a refund
afterwards.
Health insurance funds display variations not only in connection with their benefits package but also with
their tariffs. These are influenced by a range of factors, amongst others by legal or contractual provisions,
by the negotiation power of the insurance fund and also by the financial situation of the fund. It should be
considered if the fund is a regional fund or a national fund as the starting point at tariff negotiations is quite
different.
No information can be given on whether health care providers treat patients of different sickness funds in
other ways or if risk selection takes place (motivated by differences in tariffs). In order to answer this
question an empirical analysis ought to be performed.
Regarding treatment in hospitals some insured persons are put at an advantage because the benefits package
of their sickness fund includes treatment in the private ward (e.g. all insured according to the B-KUVG,
certain groups of insured according to the GSVG – those utilising benefits in cash).
User charges or exemptions may vary among insurance funds. However general exemptions from user
charges exist like for instance for persons who are in need of social protection (based on a directive by the
Hauptverband), for persons suffering from notifiable communicable diseases (by law) or for insured
incurring high costs due to certain illnesses (by claim). This means that insured may be required to pay
different user charges depending on the sickness fund they are registered with.
Variations in the care of insured i.e. regarding the choice of health care providers and treatment may also be
related to regional circumstances. Theoretically the insured can freely choose the doctor he consults,
practically the density of physicians is considerably lower in rural areas than it is in urban areas. As a
consequence the residence of the insured i.e. the place from which he accesses the health care provider can
influence the type and scope of care provided. It should be noted however that not only the number of
contract physicians, but also their availability (opening hours, working hours) have to be taken into
consideration when assessing the extent of care provided. Access to emergency care in Austria is in line
with international standards, for other types of care insured in rural areas may have to be prepared to travel
longer distances.
190
In addition to regional circumstances the socioeconomic status of individuals as well as their nationality
(e.g. migrants), their religion or their physical or mental condition (disability) influences their care.
A further aspect influencing the choice of health care provider is the information status of the insured i.e. a
lack of information/knowledge results in the fact that the insured may consume either not the appropriate
care or no care at all. Insured who are courageous enough to ask for information, who organise themselves
in self-help-groups or who possess the means to facilitate information search (e.g. Internet) are put at an
advantage.
7.4 Satisfaction with health care
Another ‘output’ that could be examined is patient and public satisfaction. Data from a Eurobarometer
survey and the European Social Survey both asked respondents a series of questions, of which some
touched upon satisfaction with the health system. The results are discussed below.
The European Social Survey provides a level of satisfaction ranked from 0 (least satisfied) to 8 (most
satisfied). Austria ranks 5th out of the 25 EU member states, and considerably higher than the EU average
(Figure 7.13).
From the Eurobarometer survey, we can see that Austrians are especially satisfied with aspects of life where
other Europeans are rather dissatisfied; that is, with law and order and the health care system. While 23.4%
of Europeans are happy with law and order, 74.2% of Austrians are happy with it, and while 32.6% of EU
citizens are happy with the health care system, 68.1% of Austrians are satisfied with their health care
system. 42-52% of EU citizens are dissatisfied with these two aspects, but only 8-12% of Austrian citizens
complain about these points.
The education system and public transport garner a 55-57% satisfaction rate in Austria, and 14.4% and
19.8% dissatisfaction respectively. These satisfaction levels are also considerably higher than EU averages.
Satisfaction and dissatisfaction levels with life in general are much closer to European averages with 85.1%
of respondents in Austria saying that they are satisfied and 5.2% that they are dissatisfied.
When people were asked what they consider to be 'the two most important issues facing [their country] at
the moment' and were given a choice between 15 options (including an ‘open’ answer), 'crime' figured as
the number one concern among Europeans (Figure 7.14). An average of 40.1% of EU citizens thought it
was one of the two most important issues in their country, while ‘crime’ registered more support in
Belgium, France, Ireland, Italy, Luxembourg, the Netherlands and the UK than any other answer.
In second place, 'unemployment' was considered to be one of the two most important issues by roughly 1 in
3 Europeans (EU 15=35.9%), obtaining more support than any other issue in Germany, Greece, Spain,
Austria and Finland. In third place, an average of 18.9% of EU citizens thought that the 'health care system'
was one of the two most important issues, gathering more support than any other response in Sweden
(52.1%), Portugal (38%) and Denmark (32.0%), and obtaining the second largest degree of support in the
Netherlands (51.2%), the UK (40.2%), Ireland (38.9%) and Finland (38.8%). In Greece respondents
indicated the 'health care system' as their third most important issue, with 26%. Conversely, the 'health care
system' was ranked considerably lower in Italy (5th position), in Germany and Luxembourg (6th), Austria
(7th), Belgium (9th), and France and Spain (11th place).
191
Figure 7.11 Overall satisfaction with the health system (scale of 1-10)
Belgium
Luxembourg
Finland
Iceland
Austria
Denmark
Switzerland
France
Spain
Norway
Slovakia
Netherlands
United Kingdom
Czech
EU Average
Sweden
Slovenia
Greece
Germany
Estonia
Ireland
Portugal
Hungary
Poland
Ukraine
0
1
2
3
4
5
6
7
8
192
Figure 7.12 Opinion on most important issue facing the country at the moment (15 options)
Austria
7th
Belgium
9th
Immigration
3rd
Denmark
Finland
2nd
France
Greece
11th
3rd
Germany
6th
Italy
Netherlands
5th
2nd
Spain
Sweden
Te rrorism
11th
Education
UK
1st
2nd
EU 15
3rd
0
10
20
30
40
%
health care system
50
unemployment
60
70
crime
Source: Eurobarometer survey 2002
Figure 7.13 Views on how the health system is run
15
EU
U
K
ed
en
Sw
Sp
ai
n
s
N
et
h
er
la
nd
Ita
ly
G
re
ec
e
an
y
er
m
G
Fr
an
ce
Fi
nl
an
d
ar
k
en
m
D
el
gi
um
B
A
us
tr
ia
%
100
90
80
70
60
50
40
30
20
10
0
Agree 1996
Agree 2002
Disagree 1996
Disagree 2002
Note: ‘Agree’: runs quite well / only minor changes; ‘Disagree’: only fundamental changes / needs to be rebuilt
completely
As seen in Figure 7.15, the majority of Austrians believe the health system runs quite well, although there
was a slight decline from 1996 to 2002 (from about 72% to 68%). Only one country had a higher proportion
of individuals agreeing with the statement – Finland. That same survey questioned the individuals about the
extent to which doctors spent adequate time with them in general, and regarding preventive health and
lifestyles; which is indicative of perceived quality of physician care.
193
When asked whether they agree or not that 'doctors do not spend enough time with you when you go to
them', respondents receive the opportunity to express how contented they are with the quality of the service
which is given by their doctor (one of the most basic and ordinary health care services). The question
targets a specific and common service, and is therefore very different from questions about satisfaction with
the health care system as a whole.
In general, Europeans agree that doctors do not spend enough time with them, as one in two EU citizens is
of this opinion608, while one in three respondents disagrees.609 Dissatisfaction with the time doctors spend
with patients is highest in Finland, Greece and Portugal, where around 60-65% of respondents agreed, while
Greece had the highest percentage of ‘strongly agree’ answers (36.1%).
Yet, citizens were more satisfied in the Netherlands, France and Sweden, as 35-40% of the public disagreed
that doctors spend too little time with patients, while Denmark is the only country where an absolute
majority (61.4%) disagreed that doctors do not spend enough time and the majority of respondents ‘strongly
disagreed’ (34.7%).
Another specific aspect of the doctor-patient relationship is dealt with when citizens are asked whether they
agree or not that 'doctors do not spend enough time with you discussing preventive action and healthier
lifestyle when you go to them' (Figure 7.16). A doctor’s role is not solely to cure illnesses and prescribe
medicines, but also to give advice and information on healthier choices, and this question focuses on
whether doctors are perceived to perform this role well enough. Taking the average across the fifteen
countries, one in two respondents were dissatisfied610 with the amount of time doctors spend discussing
prevention etc, while only one in four Europeans thought doctors spend enough time.611
Above 60% of citizens in Greece, Finland and Portugal agreed and were thus the most dissatisfied, with
Greece being the only country where a majority of respondents, 40.7%, declared to ‘strongly agree’ that
doctors spend too little time. On the other hand, around 30% of the Dutch, Austrian, Swedish and French
respondents were satisfied with the time doctors spend on preventive information, while 46.6% of Danes
were contented. Denmark is also the country with the highest rate of ‘strongly disagree’ at 22.9% (EU
15=8.6%).
Figure 7.14 “Doctors do not spend enough time discussing prevention and lifestyle choices”
80
70
60
50
%40
30
20
10
15
EU
K
U
ed
en
Sw
Sp
ai
n
s
er
la
nd
et
h
N
G
Ita
ly
an
y
er
m
re
ec
e
G
Fr
an
ce
Fi
nl
an
d
ar
k
en
m
D
el
gi
um
B
A
us
tr
ia
0
Agree 2002
9, 11
Disagree 2002
Percentage of those who ‘strongly agree’ plus the percentage of those who ‘tend to agree’.
Percentage of those who ‘tend to disagree’ plus the percentage of those who ‘strongly disagree’.
609, 12
194
7.4.1 Patient satisfaction in Austria
When European Social Survey data are disaggregated to the regions in Austria, it appears there is very little
variation within the countries (Figure 7.17). On the whole, health care is viewed as quite satisfactory.
Figure 7.15 Satisfaction with health care in Austria – regional variation
Vorarlberg
Steiermark
Burgenland
Wien
Average
Oberösterreich
Tirol
Kärnten
Niederösterreich
Salzburg
0
1
2
3
4
5
6
7
8
9
10
The sample of 2256 Austrians aged above 15, who participated in the second round of the European Social
Survey were included in a further analysis to investigate the factors significantly associated with
satisfaction levels. A question asking people “what they think overall about the health services in Austria
nowadays?” that measured satisfaction with health services on an 11-point scale (from extremely bad to
extremely good) was the dependent variable.
Explanatory variables included in the analysis are socio-demographic factors such as age (as a continuous
variable), gender and legal marital status (married or not). Region consisted of the 9 states of Austria;
Burgenland, Carinthia (Kärnten), Lower Austria (Niederösterreich), Upper Austria (Oberösterreich),
Salzburg, Styria (Steiermark), Tyrol (Tirol), Vorarlberg and Vienna (Wien). Following the International
Standard Classification of Occupation ISCO-88 occupation variable includes 9 categories: 1) legislators,
senior officials, manager 2) professionals 3) technicians 4) clerks 5) service workers, shop and sales
workers 6) skilled agricultural and fishery growers 7) craft workers 8) plant/machine operators and 9)
elementary occupation. Subjective general health was reported on 5-point scale from very good to very bad,
while income was reported on a subjective way asking people to report whether on the present household
income they a) live comfortable, b) they cope, c) they find it difficult or d) they find it very difficult.
Political preferences were measured by asking respondents which political party they voted in the last
elections. Answers included: Social Democratic Party (SPÖ-socialists), Austrian People’s Party (ÖVPconservative), Freedom Party (FPÖ-conservative), Greens (Grüne-ecological), Liberals Forum (LIFliberal).612
612
Linear regression was run including the above explanatory variables in the model to predict satisfaction with health
care. Preliminary analysis conducted on predictor variables to check for violations of the major assumptions of
regression. Data has been weighted using:
195
Additional explanatory variables included a variable indicating whether the respondent had visited a
doctor/GP/special the last 12 months (yes, no) and whether s/he feels s/he has enough choice regarding
GP/specialist (yes, no). Finally, satisfaction with economic situation and trust in the legal system were both
ranked on a 11-point scale and treated as a score.
Table 7.4 shows regression coefficients from the regression analysis (including the political party voted).
Model 1 (including political party voted) explains 35% (F(35,855) = 10.84, p = 0.00) of the variance in
satisfaction with health services among Austrians.
Table 7.4 Factors associated with satisfaction level in Austria
Variable*
Coefficient P
Age
Gender
Marital status
Feeling about income (base: living comfortable)
coping
difficult
very difficult
Region (base: Burgenland)
Carinthia
Lower Austria
Upper Austria
Salzburg
Styria
Tyrol
Vorarlberg
Vienna
Occupation (base: legislators, managers)
professionals
technicians
clerks
service workers
agricultural/fisher growers
craft workers
plant/machine operators
elementary occupation
Subjective general health (base: very good)
good
fair
bad
very bad
Consulted doctor last 12 months
Choice of doctor
0.013899
0.4327261
-0.3913699
0.013
0.012
0.018
-0.0659459
-0.635174
-0.0301027
0.683
0.036
0.966
-0.3791211
-0.4774587
-0.0680586
-1.264527
0.13379
0.2861942
0.313508
-0.0916177
0.364
0.113
0.844
0.004
0.686
0.42
0.416
0.779
0.0585152
-0.0418146
0.3112445
0.4093949
0.9167602
0.2756642
1.058077
0.1473994
0.855
0.909
0.337
0.262
0.089
0.469
0.021
0.7
-0.2398292
-0.507054
-1.131249
-0.8218153
-0.0767942
0.1139296
0.144
0.048
0.053
0.547
0.77
0.594
(1) Design weight, which corrects for differences in probability selection (i.e. makes the sample more representative of
the “true” sample of individuals aged 15+ in the country)
(2) Post-stratification weight, to adjust the sample data to conform more to the population’s parameters (in this case
age and sex).
196
Party voted last election (base: SPÖ)
ÖVP
FPÖ
Grüne
LIF
Other
Satisfaction with state of economy
Trust in legal system
_cons
0.5672335
0.5965118
0.000305
2.624297
2.201892
0.3186713
0.2015817
2.826877
0.004
0.053
0.999
0.042
0.00
0.00
0.00
0.00
* Dummy variables were as follows:
Gender: 0=female, 1=male
Marital Status: 0=not married, 1=married
Consulted doctor last 12 months: 0=no, 1=yes
(enough) choice re GP/doctor: 0=no 1=yes
Note: Multicollinearity was not considered a concern since the strongest correlation between the independent variables
was 0.36. Multicollinearity was also checked after the regression was run checking the variance inflation factors of the
independent variables. The results confirmed that education and the variable indicating whether the respondent was
hampered in daily life by any chronic illness were problematic and therefore were excluded from the final model.
As shown in the above table, age and sex are both significant predictors of satisfaction with health services
and so does marital status. Males and older people are more satisfied than females and younger people
respectively (B=0.013, p<0.05; B=0.43, p<0.05), while being married is associated with lower rates of
satisfaction (B=-0.39, p<0.05). Moreover, Austrians who find it difficult to cope on their present household
income are significantly less satisfied with health services than those who live comfortably with their
income (B=-0.64, p<0.05). Residents of Carinthia, Lower Austria, Upper Austria, Salzburg and Vienna
seem less satisfied with heath services than those living in Burgenland (the reference region), but only
Salzburg was significant at a 0.05 level. Plant and machine operators are the only occupation showing
significant association with satisfaction (B=1.06, p<0.05) rating the services higher than the reference
occupation, i.e. legislators, senior officials and managers.
Self-reported health was also associated with satisfaction with health services. Unhealthier people rated the
services lower than those reporting very good health condition, although this was significant only for those
with fair health condition (B=-0.50, p<0.05). This is quite interesting given that unhealthier people are the
ones using the health services more. However there was not enough evidence to support that access to
health care (i.e. whether they have visited a doctor/GP/specialist at least once during the last 12 months)
was significantly associated with satisfaction (although the regression coefficient has a negative sign).
Political preferences were shown to be a very strong predictor of satisfaction with health services. In
comparison to those who voted the Social Democratic Party of Austria (SPÖ), Austrian who voted People’s
Party (ÖVP), the Liberal Forum (LIF) or reported voting another smaller party (other) rated the health
services in the country higher (B = 0.57, p < 0.05; B = 2.62, p < 0.05; B = 2.20, p < 0.05, for ÖVP, LIF and
other, respectively).
Finally, satisfaction with the state of economy in the country as well as trust in the legal system were
significant predictors of satisfaction with health services. Greater satisfaction with the state of economy
(B=0.32, p<0.05) and increased trust in legal system (B=0.20, p<0.05) was associated with increased
satisfaction with health services.
Table 7.5 shows the regressions coefficients of the analysis including all the above explanatory variables
used in the previous model but the party voted in the last elections. As shown in table 7.5, age, marital
status and occupation are not significant anymore, while changes are observed in the region as well. On the
197
other hand, health becomes stronger predictor, while the rest variables behave more or less similarly to the
previous model.
Table 7.5 Factors associated with satisfaction (not including political preference)
Variable*
Coefficient P
Age
Gender
Marital status
Feeling about income (base: living comfortable)
coping
difficult
very difficult
Region (base: Burgenland)
Carinthia
Lower Austria
Upper Austria
Salzburg
Styria
Tyrol
Vorarlberg
Vienna
Occupation (base: legislators, managers)
professionals
technicians
clerks
service workers
agricultural/fisher growers
craft workers
plant/machine operators
elementary occupation
Subjective general health (base: very good)
good
fair
bad
very bad
Consulted doctor last 12 months
Choice of doctor
Satisfaction with state of economy
Trust in legel system
_cons
0.0005429
0.3164862
-0.0733594
0.914
0.037
0.617
-0.085595
-0.5598244
-0.4584403
0.538
0.049
0.361
-0.0646398
-0.5924469
-0.1410001
-0.8446284
-0.0304646
-0.2685841
0.0071787
0.1430778
0.878
0.042
0.645
0.025
0.919
0.483
0.986
0.618
-0.3427133
-0.5569301
-0.4580064
-0.3097293
0.2588705
-0.1529969
-0.0199814
-0.0116312
0.237
0.092
0.132
0.33
0.589
0.631
0.955
0.974
-0.3376941
-0.1828786
-0.904571
-1.081605
-0.1166853
-0.2968684
0.3543473
0.1491528
4.882311
0.026
0.384
0.041
0.179
0.614
0.112
0.00
0.00
0.00
* Dummy variables was as follows:
Gender: 0=female, 1=male
Marital Status: 0=not married, 1=married
Consulted doctor last 12 months: 0=no, 1=yes
(enough) choice re GP/doctor: 0=no 1=yes
198
Note: Model 1 accounts for 35 percent (F(35,855) = 10.84, p = 0.00) of the variance in satisfaction with
health services among individuals aged above 15 in Austria, while model 2 (excluding the political
preferences) accounts for 25% (F(30,1657). This means the first model explains our dependent variable
much better than the second.
Satisfaction with the benefits package
In the 1992 and 2002 Eurobarometer surveys, individuals across Europe were asked whether they felt the
benefits packages should be reduced a ‘basic package’. While more individuals disagreed than agreed in
most countries, there was a far wider discrepancy in some countries such as Sweden, Spain and the United
Kingdom than other countries including Austria (Figure 7.18). Also, the extent to which individuals expect
governments to fund all medical devices and technologies differs across countries (Figure 7.19); with more
people agreeing in the tax-funded systems of Denmark, Finland, Sweden, and the United Kingdom than the
rest.
Figure 7.16 The provision of care should be restricted to a basic package, 1992 and 2002
Agree 1996
Agree 2002
Disagree 1996
15
EU
UK
Sp
ai
n
Sw
ed
en
Lu
Ne
x
th
er
la
nd
s
Po
rt
ug
al
y
Ita
l
Au
str
ia
Be
lg
iu
m
De
nm
ar
k
Fi
nl
an
d
Fr
an
ce
G
re
ec
e
G
er
m
an
y
Ir
ela
nd
90
80
70
60
50
%
40
30
20
10
0
Disagree 2
199
Figure 7.17 “It is impossible for any government/public/private health insurance scheme to pay for all
new medical treatments and technology”
70
60
50
40
%
30
20
10
15
EU
K
U
ed
en
Sw
Sp
ai
n
s
er
la
nd
Ita
ly
N
et
h
an
y
G
er
m
re
ec
e
G
Fr
an
ce
Fi
nl
an
d
ar
k
en
m
D
el
gi
um
B
A
us
tr
ia
0
Agree 2002
Disagree 2002
7.5 Inter-generational solidarity: caring for older people
It is interesting to compare the extent to which individuals believe family or the state should be paying for
long-term care services for older people; an area also covered in the Eurobarometer survey. In terms of
caring responsibilities, on average, a great majority of Europeans (85.9%) do not live with someone ill/
handicapped/ elderly whom they take care of and approximately the same percentage of EU citizens do not
provide help to someone ill/ handicapped/ elderly not living with them. When asked who they think 'should
mainly pay for taking care of elderly parents?' and were presented with four options – ‘the elderly parents
themselves’, ‘their children’, ‘the national government or social insurance’ or ‘regional/ local government’
– the majority of Europeans (57.7%) answered that it should be the responsibility of the national
government.
In 14 countries this was the favoured option, receiving the highest levels of support in the Netherlands
(74.4%), Finland (72.8%) and Greece (68.5%) (and East Germany – 75.5%), and the least support in
Denmark, Spain and Ireland, where less than 50% of the public thought it was the national government’s
responsibility. It should be noted, however, that the relatively low support in Denmark is compensated by
the fact that 41.5% of Danes think the regional/ local government should pay for elderly care. This makes
Denmark the country where the ‘public option’ is the most favoured, as 89.4% of the population believes
that it is the national or local authorities’ responsibility to finance care for the elderly.
The big exception to this trend is Austria, where only 25% of citizens thought that the national government/
social insurance should pay for the elderly while nearly 40% considered that ‘their children’ should pay.
Other countries where the option of children paying for their elderly parents’ care received considerable
support was Spain (32.4%) and Portugal (27.7%), in contrast to Denmark, Finland and the Netherlands
where less than 5% of the population favoured this option (EU 15=14.2%).
On average, 11.9% of Europeans thought ‘the elderly parents themselves’ should pay for the care they need.
This option was particularly favoured in Germany (22.7%), Luxembourg (18.4%) and Austria (16.7%), but
was very unpopular in Portugal, Sweden, Italy and Greece where only 5-6% of citizens believed that the
elderly themselves should pay. Attitudes towards the ‘regional/ local option’ varied significantly as 41.5%
of Danes and 26.9% of Italians supported it, but no-one in Sweden (0%) and only 1-2% in Germany and
Portugal approved of it (EU 15=10.7%).
200
8. CONTRIBUTION OF THE HEALTH SYSTEM TO HEALTH IMPROVEMENT
8.1 Trends in life expectancy in Europe
As seen in the below figures, continual improvements in life expectancy are seen since 1975 in many
European countries, namely in Western Europe (Figures 8.1 and 8.2).
Disability-adjusted life expectancy is an estimate of the number of years a person will live in full health.
This indicator was used in the World Health Report 2000 as the summary indicator of the level of
population health status because it contains information about both mortality and morbidity. The prevalence
of disability is required for its calculation, however, which could lead to comparability problems, since
various countries use different definitions of disability.
Figure 8.1 Life expectancy at birth in selected EU countries (males)
80
78
76
74
72
70
68
66
64
62
60
58
1975
AT
ES
1980
FR
SE
1985
1990
HU
UK
IT
EU15
1995
LV
EU10
2000
PL
SK
Figure 8.2 Life expectancy at birth in selected EU countries (females)
86
84
82
80
78
76
74
72
70
68
66
64
1975
AT
ES
1980
FR
SE
1985
1990
HU
UK
IT
EU15
1995
LV
EU10
2000
PL
SK
Source: WHO health for all data 2006
201
Table 8.1 Estimates of life expectancy and healthy life expectancy (HALE) in Europe, 2002 or most
recent year (ranked by women)
Healthy life expectancy
Country
Spain
Sweden
France
Italy
Germany
Luxembourg
Austria
Finland
Belgium
Greece
Netherlands
Malta
Slovenia
United Kingdom
Portugal
Ireland
Denmark
Czech Republic
Slovakia
Estonia
Cyprus
Poland
Hungary
Lithuania
Latvia
Bulgaria
Romania
Turkey
EU average
EU-15 average
NMS average
Women
75.3
74.8
74.7
74.7
74
73.7
73.5
73.5
73.3
72.9
72.6
72.3
72.3
72.1
71.7
71.5
71.1
70.9
69.4
69
68.5
68.5
68.2
67.7
67.5
66.8
65.2
62.8
71.75
73.29
69.43
Life expectancy
Men
69.9
71.9
69.3
70.7
69.6
69.3
69.3
68.7
68.9
69.1
69.7
69.7
66.6
69.1
66.7
68.1
68.6
65.9
63
59.2
66.7
63.1
61.5
58.9
58
62.5
61
61.2
66.86
69.26
63.26
Country
Spain
Italy
France
Sweden
Finland
Austria
Germany
Cyprus
Greece
Luxembourg
Netherlands
Malta
Belgium
United Kingdom
Portugal
Slovenia
Ireland
Denmark
Poland
Czech Republic
Lithuania
Slovakia
Estonia
Hungary
Bulgaria
Latvia
Romania
Turkey
EU average
EU-15 average
NMS average
Women
83.36
83.22
83.17
82.26
82.05
81.59
81.59
81.5
81.33
81.15
81.08
80.78
80.76
80.71
80.7
80.35
79.92
79.46
78.91
78.65
77.9
77.84
77.22
76.75
75.98
75.97
75.1
72.2
79.69
81.49
78.59
Men
76.41
77.11
75.64
77.85
75.25
76.03
75.69
77.25
76.57
74.94
76.36
76.33
74.23
76.08
73.82
72.6
74.56
75.05
70.53
72.09
66.51
69.91
66.18
68.39
68.97
65.73
67.71
67.9
73.06
75.706
70.55
Source: WHO health for all data 2006
While the advantage with indicators of healthy life expectancy and disability-adjusted (or disability-free)
life expectancy is that they can be obtained for many countries and therefore compared613, they have an
important weakness. HALE and DALE provide policy makers with little indication of the underlying
factors that may be influencing health attainment in the country. These factors may include housing,
education, transport and economic development, or the health system.
613
It should be noted, however, that adjusting life expectancy for levels of health involves a process of estimation, and
in many countries, even life expectancy itself is estimated because of limited or absent data on mortality.
202
8.2 Avoidable mortality
Additionally, the use of DALYs as a measure health outcome has received considerable criticism, largely
due to assumptions made in their calculations.614 In light of the controversy surrounding the use of
disability-adjusted life expectancy, alternative methods of measuring health improvement have been
suggested. These have the advantage of determining the extent to which the health system is contributing to
health improvement, therefore serving as a tool to measure health system performance.
Several approaches have been developed in attempts to quantify the contribution of the health system to
health improvement. The most widely used to date makes use of readily available mortality data and makes
assumptions about certain causes of death that should not occur in the presence of timely and effective
medical intervention. This method has given rise to the development of numerous terms including
“avoidable mortality” and “mortality amenable to health care”.
Avoidable mortality as a concept was first developed by Rutstein and colleagues as a measure of quality of
care in the 1970s.615 Since then this concept has been commented on, reviewed by and developed by several
authors, most importantly, Holland, Charlton, Mackenbach and Westerling.616 More recently, Nolte and
McKee updated the previous analysis using data from the 1980s and 1990s.617
Analyses of avoidable mortality are essentially based on a list of selected disease groups that are considered
to be effectively treatable or preventable by health care services. This work has focused on differentiating
the causes that are responsive to medical intervention through secondary prevention and treatment
(‘treatable conditions’), and those responsive to interventions that are usually outside the direct control of
the health services through inter-sectoral health policies (‘preventable’ conditions).618
614
For instance, in order to calculate the years of life lost to disease, age at death of people with disease was compared
to a standard life expectancy as opposed to the actual life expectancy of the population group that is being studied A
Williams, "Calculating the Global Burden of Disease: Time for a Strategic Re-Appraisal," Health Economics 8
(1999).. This practice causes significant distortions to international comparisons. Furthermore, an arbitrary gender gap
was used to make the DALY calculations, which may underestimate the burden of disease of women relative to men.
The method of calculating quality of life has also been widely criticized, mainly due to the use of ‘expert opinion’ and
the practice of forced consistency of quality of life scores T Arnesen and E Nord, "The Value of Daly Life: Problems
with Ethics and Validity of Disability Adjusted Life Years," BMJ 319, no. 7222 (1999).. Also, the use of age weights
to account for the different social value of people at different ages is another ethical issue that has been widely argued.
615
D.D. Rutstein et al., "Measuring the Quality of Medical Care," New England Journal of Medicine 294 (1976).
616
J.R. Charlton et al., "Geographical Variation in Mortality from Conditions Amenable to Medical Intervention in
England and Wales," Lancet i, no. 691-6 (1983), W.W Holland, ed., European Community Atlas of 'Avoidable Death',
Commission of the European Communities Health Services Research Series No.3 (Oxford: Oxford University Press,
1988), W.W Holland, ed., European Community Atlas of 'Avoidable Death', 2nd ed., vol. 1, Commission of the
European Communities Health Services Research Series No.6 (Oxford: Oxford University Press, 1991), W.W
Holland, ed., European Community Atlas of 'Avoidable Death', 2nd ed., vol. II, Commission of the European
Communities Health Services Research Series No.9 (Oxford: Oxford University Press, 1993), W.W Holland, ed.,
European Community Atlas of 'Avoidable Death' 1985-89 (Oxford: Oxford University Press, 1997), W.W Holland and
E Breeze, "The Performance of Health Services" (paper presented at the The Political Economy of Health and
Welfare: the twenty-second annual symposium of the Eugenics Society, London, 1985), W.W Holland et al., "Heaven
Can Wait," Journal of Public Health Medicine 16 (1994), J.P Mackenbach, M.H Bouvier-Colle, and E. Jougla,
""Avoidable" Mortality and Health Services: A Review of Aggregate Data Studies," Journal of Epidemiology and
Community Health 44 (1990), R. Westerling, ""Avoidable" Causes of Death in Sweden 1974-85," Quality Assurance
in Health Care 4 (1992).
617
E Nolte and M McKee, Does Healthcare Save Lives? Avoidable Mortality Revisited (London: The Nuffield
Trust, 2004).
618
There are over 30 conditions considered treatable, some examples are: cancer of the colon, skin, cervix, testis and
breast; diabetes mellitus; epilepsy; pneumonia; appendicitis; thyroid disease; measles. Three conditions are considered
preventable: deaths from lung cancer, motor vehicle and traffic accidents and cirrhosis of the liver. It is important to
note that over time the conditions that are considered treatable may change, therefore it is difficult to draw conclusions
about time trends. However cross-country comparisons are not subject to the same methodological limitation, since at
one point in time, the same standards in terms of quality of health care should apply to all countries.
203
Improved access to timely and effective health care has a significant impact on health, in particular through
reductions in infant mortality and in deaths among the middle aged and older people. Studies indicate that
improvements in life expectancy can be attributed largely to improvements in mortality from amenable
conditions, particularly during the 1980s619. These improvements in most countries resulted from falling
infant mortality. However, falling mortality among the middle-aged was the main driver of improved
amenable mortality in Denmark, the Netherlands, the UK, France (men) and Sweden (women). In the
1990s, while amenable mortality remained an important contributor to improvements in life expectancy in
southern Europe (especially Portugal and Greece), its contribution to improvement in health in other
countries was less significant, although still accounted for 20% of the total improvement among women.
A recent comprehensive study of avoidable mortality in Europe uses data extracted from the World Health
Organization (WHO) mortality files for the period 1990-2002.620 Levels and trends in avoidable mortality
are examined by calculating age-standardized death rates with direct standardization to the European
standard population. This analysis is restricted to the larger countries of the EU, thus excluding Malta and
Luxembourg, and also limited to those with sufficient data for the time period, thus excluding Cyprus,
Turkey, Belgium, Slovakia, Denmark and Greece.
Treatable mortality
As shown in Figure 33, treatable mortality was highest in central and eastern European countries
(particularly Romania, Bulgaria and Hungary) in both 1990/91 and 2000/02. Portugal is the only EU 15
country to display similarly high levels. Levels were lowest in France (women) and Sweden (men). All
countries, except Romania (men), experienced declines in treatable mortality during the 1990s, particularly
Portugal, Austria and Finland as well as new EU member states (in Czech Republic, rates declined by
around one-third).
Figure 8.3 Age-standardized death rates of treatable mortality in 18 European countries, 1990/91 and
2000/02
Treatable Mortality: Men
Treatable Mortality: Women
Romania
Bulgaria
Hungary
Latvia
Estonia
Czech Republic
Poland
Portugal
Lithuania
Slovenia
Austria
Finland
Ireland
Germany
UK
Italy
Spain
France
Netherlands
Sweden
1990/91
2000/01/02
0
50
100
150
200
250
Deaths/ 100 000 population
Romania
Bulgaria
Hungary
Latvia
Estonia
Czech Republic
Poland
Lithuania
Portugal
Slovenia
UK
Ireland
Austria
Germany
Finland
Italy
Netherlands
Spain
Sweden
France
1990/01
2000/01/02
0
50
100
150
200
250
Deaths/ 100 000
Source: Nolte and McKee 2004
619
Nolte and McKee, Does Healthcare Save Lives? Avoidable Mortality Revisited.
C. Newey et al., "Avoidable Mortality in the Enlarged European Union," (Paris: Institut des Sciences de la Santé,
2003).
620
204
Preventable mortality
Preventable mortality estimates combine three major causes: deaths from lung cancer, motor vehicle and
traffic accidents and cirrhosis of the liver. There is a substantial gap between rates of preventable mortality
for men and women in all countries, with death rates among men at least twice those of women (Figure
8.4). This gender gap in preventable mortality is most pronounced in the new Member States of central and
Eastern Europe, which also show the highest absolute values, especially for Hungarian men. This gap
reflects the much greater exposure to risks such as drinking and smoking among men. For women, death
rates were again highest in Hungary, followed at some distance by Slovenia and Romania, as well as the
United Kingdom.
Unlike the situation with treatable causes, throughout the 1990s men have consistently seen declines in
preventable mortality whilst women have not. The declines among men were most prominent in Italy,
Austria, Portugal, Finland, the United Kingdom Czech Republic and Slovenia. Preventable mortality among
women declined in some countries, particularly those in the Mediterranean region, and increased in Sweden
and the Netherlands and all new member states (except Slovenia) and Romania. By 2000/2002, levels of
preventable mortality among women were lowest in Spain and Portugal, as well as Bulgaria.
Figure 8.4 Age-standardized death rates of preventable mortality in 18 European countries, 1990/91
and 2000/02
Preventable Mortality: Women
Preventable Mortality: Men
Hungary
Slovenia
Latvia
Estonia
Czech
Poland
Lithuania
Romania
Italy
Austria
Portugal
Spain
France
Germany
Bulgaria
Netherlands
Finland
UK
Ireland
Sweden
Hungary
Slovenia
Romania
UK
Austria
Ireland
Portugal
Germany
Czech
Italy
Poland
France
Estonia
Latvia
Lithuania
Sweden
Netherla
Spain
Finland
Bulgaria
1990/01
2000/01/02
0
50
100
150
200
250
Deaths/ 100 000
1990/91
2000/01/02
0
20
40
60
Deaths/ 100 000
Source: Nolte and McKee 2004
In Austria, improvements in avoidable mortality made significant positive contributions to the overall
increase in life expectancy in the 1980s, accounting for 40-44% of the increase in mean and women. About
one-fifth of the improvement resulted from a decline in infant mortality, and another 13-16% due to
declining adult (40+) mortality. In the 1990s, avoidable mortality changes made a smaller contributions to
life expectancy than in the 1980s, especially among men. Unlike the 1980s, much of the improvement in
life expectancy can be attributed to falling mortality among the middle-aged. However among women,
avoidable deaths still accounted for almost 40% of the increase in life expectancy.
What causes premature deaths?
The overall trends in avoidable mortality obscure important differences in specific categories of causes of
deaths. Therefore, what are the causes of premature deaths? This section examines three of the main causes
205
of treatable deaths: infant mortality, cerebrovascular disease, and testicular cancer; and the three main
causes of preventable deaths: tobacco smoking, road traffic accidents, and alcohol consumption.
Infant mortality reflects deficiencies in the health system, in particular prenatal and natal care, as well as
broader determinants such as living conditions. Infant mortality has decreased in the EU-15 in the last 25-30
years because of improvements in these two areas. Likewise, infant and child mortality rates have been
falling since the 1980s, and accelerated in the 1990s, in all the new Members States and in particular in the
three Baltic countries and Poland. The reduction in infant mortality in the central European countries almost
immediately following transition explains the improvement in treatable mortality observed in these
countries. However the countries with less improvement in treatable mortality over the 1990s experienced
increases in infant mortality, which were short-lived in some (Estonia, Lithuania) and sustained in others
(Latvia, Bulgaria).
Many countries in Europe also experienced declines in mortality from cerebrovascular disease throughout
the 1990s, which again were immediate in some (Czech Republic, Slovakia, Slovenia, Hungarian women)
while temporarily increasing in others, particularly the Baltic states of Estonia and Latvia, as well as
Bulgaria and Romania. Hypertension is a strong risk factor for cerebrovascular disease, and its control was
shown to be particularly poor in Eastern Europe.621 However, this is now changing, with recent
improvements in cerebrovascular disease mortality possibly reflecting a combination of better access to
pharmaceuticals and hypertensive treatment along with improvements in specialized health care.
Despite evidence of greater awareness and significant declines in the prevalence of hypertension in the new
Member States622, it is noted that the treatment of hypertension is still largely inadequate, with low
proportions of blood pressure control reported in a number of countries, including Latvia and Poland.623
Indeed, levels of premature mortality from cerebrovascular disease in the new Member States and
Candidate Countries are still substantially higher than in the EU15. Tobacco smoking, diet (salt intake), and
alcohol, are additional important risk factors for cerebrovascular disease.
Death from testicular cancer is a clear indication of shortcomings in the health system, since it is a type of
cancer that can be treated effectively. Romania and Bulgaria, whose levels of mortality from treatable
conditions were the highest, were also the only countries to have recorded an increase in mortality from
testicular cancer among men over the last 30 years, at a time when substantial improvements had occurred
in the rest of Europe due in part to improved diagnosis.624
Tobacco smoking is the single most important risk factor of lung cancer; and lung cancer is the single most
preventable disease. Tobacco smoking is also a significant risk factor for other common diseases such as
coronary heart disease. Traditionally smoking has been very common among men throughout Europe, and
less so amongst women. As a consequence, a gender gap in death rates from lung cancer has emerged.
Female smoking patterns have however been changing with smoking rates increasing625, especially among
the young in major cities.626 This change is reflected in the increases in preventable mortality seen for
countries such as Hungary, Romania and Slovenia, and Sweden and the Netherlands627, where lung cancer
621
D. Ryglewicz et al., "Stroke Mortality Rates in Poland Did Not Decline between 1984 and 1992," Stroke 28 (1998).
R. Cifkova et al., "Trends in Blood Pressure Levels, Prevalence, Awareness, Treatment, and Control of
Hypertension in the Czech Population from 1985 to 2000/01," J Hypertens 22 (2004).
623
V. Dzerve, N. Britcina, and J. Pakhomova, "Prevalence and Control of Hypertension in Latvia," J Hum Hypertens
18 (2004), S.L. Rywik et al., "Poland and U.S. Collaborative Study on Cardiovascular Epidemiology in the
Community: Prevalence, Awareness, Treatment, and Control of Hypertension in the Pol-Monica Project and the U.S.
Atherosclerosis Risk in Communities Study," Ann Epidemiol 8 (1998).
622
624
F. Levi et al., "Western and Eastern European Trends in Testicular Cancer Mortality," Lancet 357
(2001).
625
F. Levi et al., "Trends in Mortality from Major Cancers in the European Union, Including Acceding Countries, in
2004," Cancer 101, no. 12 (2004), J.E. Tyczynski et al., "Lung Cancer Mortality Patterns in Selected Central, Eastern
and Southern European Countries," Int J Cancer 109 (2004).
626
B. Forey et al., International Smoking Statistics. Second Edition (Oxford: Oxford University Press, 2002).
627
Among women the Netherlands has the highest prevalence of smoking (almost 30%) next to Greece in the EU15.
206
rates for women have risen over the last decade, to a large extent, reflecting the increasing death toll among
a generation of women who began smoking in the 1960s. It has been predicted that this increase in smoking
will surpass trends already seen in several countries in Western Europe.628
However, as seen in Poland, the negative impact of transition on tobacco consumption does not have to be
definitive. The Polish government was the first in the region to enact comprehensive tobacco control
legislation and, since 1995, has developed a set of tobacco control policies that were more comprehensive
than those in force in the EU15.629 Smoking rates are now declining in this country with health indicators
improving as a result. In 1996 54% of Polish men smoked, but by 2003 this had fallen to 39%.630 It is
anticipated that the gender gap in preventable mortality, as defined here, will continue to narrow in the
foreseeable future, reflecting the changing patterns in smoking.
The consistent decline in mortality from traffic accidents during the 1990s has contributed greatly to the
declines in preventable mortality seen for men, particularly in the Mediterranean countries. It has also had a
major influence on rates of preventable mortality for women, outweighing the effects of increasing rates of
lung cancer and liver cirrhosis for women in countries such as Finland.
Liver cirrhosis, a condition that is strongly related to alcohol consumption631, also appears to be a growing
concern for a number of countries, particularly Romania, the Baltic states, Ireland and United Kingdom,
where rates have considerably increased for both men and women. National statistics data from England
and Wales show the increase in alcohol-related deaths since 1980. WHO Regional Office for Europe
recently grouped countries into levels of alcohol consumed. High consuming countries632 were found to be:
Czech Republic, France, Germany, Ireland, Lithuania, Luxembourg, Portugal, Slovenia and Spain, and
Denmark, Greece, Hungary, and Latvia.633
Avoidable mortality vs. DALYs
As shown in the figure below, the ranking for 19 countries based on disability-adjusted life expectancy (as
calculated by the WHO) is significantly different from the ranking with amenable mortality. In using
avoidable mortality to create the ranking, significant losses in rank are seen in Greece (7 to 12) and the UK
(10 to 18), while gains are seen in Denmark (17-10), Finland (13 to 8), Germany (14-6) and Norway (11 to
2).
628
P. Brennan and I. Bray, "Recent Trends and Future Directions for Lung Cancer Mortality in Europe," Br J Cancer
87 (2002).
629
A.B. Gilmore et al., "Free Trade Versus the Protection of Public Health: The Examples of Aclohol and Tobacco.,"
in Health Policy and European Union Enlargement, ed. M. McKee, L. MacLehose, and E. Nolte (Buckingham: Open
University Press, 2004).
630
European Commission, "Tobacco or Health in the European Union: Past, Present and Future," (Brussels: European
Commission, DG Health and Consumer Protection, 2004).
631
G. Corrao et al., "A Meta-Analysis of Alcohol Consumption and the Risk of 15 Diseases," Prev Med 38, no. 5
(2004).
632
More than 10 litres per person per year
633
N. Rehn, R Room, and G Edwards, "Alcohol in the European Region – Consumption, Harm and Policies,"
(Copenhagen: World Health Organization Regional Office for Europe, 2001).
207
Figure 8.5 Comparison of rankings based on disability adjusted life expectancy (1999) and
standardized death rates (per 100,000; ages 0-74) from mortality amenable to health care (1988)
Source: Nolte and McKee, 2003
8.3 Trends in chronic diseases in Europe
In Europe, obesity rates range between 9.5 and 27% among men and reach 35% among women634 (Figure
8.6). Central and Eastern European countries have experienced a dramatic increase in obesity rates in the
last decade.635 In Hungary, the obesity rate has doubled since 1989. Four-fifths of Latvian women and
Czech men have a body mass index greater than 25, therefore are classified as overweight. Compared to the
EU average, the prevalence of obesity, particularly among women, is significantly higher in Greece, Malta
and Cyprus. An important cause of obesity has been the arrival of fast food and the decrease in physical
activity in these countries where the traditional diet is based on meat, fat and non-vegetables.
Tobacco smoking is the single most important risk factor of lung cancer; and lung cancer is the single most
preventable disease. Tobacco use continues to be the largest single cause of death and disease in the EU
killing over 650,000 people every year. Beyond the direct effects to the user, tobacco smoke is a serious
environmental health hazard; current estimates indicate that approximately 100,000 non-smoking
Europeans die each year due to second-hand smoke. If current smoking patterns continue, it will likely
cause nearly 10 million deaths each year by 2020.636 In addition to the public health impacts, the EU bears a
substantial economic burden due to smoking. Conservative estimates project the costs of tobacco use to
range between €98-130 billion a year or 1.04-1.39% of the Gross Domestic Product (GDP) for 2000.
Tobacco smoking is also a significant risk factor for other common diseases such as coronary heart disease.
Traditionally smoking has been very common among men throughout Europe, and less so amongst women.
As a consequence, a gender gap in death rates from lung cancer has emerged. Female smoking patterns
634
It is important to highlight the difficulties in drawing comparisons across countries in obesity, due to potential differences in
measurement and lack of standardized methodology.
635
D.A. Spritzer, "Obesity Epidemic Migrates East," Canadian Medical Association Journal 171, no. 10 (2004).
C Murray and A.D Lopez, eds., The Global Burden of Disease: A Comprehensive Assessment of Mortality and
Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020 (Cambridge, US: Harvard School
of Public Health Care, 1996).
636
208
have however been changing with smoking rates increasing637, especially among the young in major
cities.638 This change is reflected in the increases in preventable mortality seen for countries such as
Hungary, Romania and Slovenia, and Sweden and the Netherlands639, where lung cancer rates for women
have risen over the last decade, to a large extent, reflecting the increasing death toll among a generation of
women who began smoking in the 1960s. It has been predicted that this increase in smoking will surpass
trends already seen in several countries in Western Europe.640
Smoking rates are incredibly high in the countries of CEE.641 For example, the prevalence of smoking
among the Turkish, Hungarian, Latvian and Bulgarian male and female population is over 65% (See Figure
8.7). In Malta, tobacco consumption was 68% higher than the EU average in 1999.642 Since 2000,
expenditure on tobacco, alcohol and other narcotics has been reduced in Malta but has continued to increase
in Cyprus. While the policy response to tobacco was initially weak, more recently several countries,
particularly Poland, Hungary and the Baltic States, have enacted tobacco programs that are stronger than in
many EU countries.643
Figure 8.6 Obesity prevalence in Europe
40
Male, BMI >30
Female, BMI >30
Prevalence obesity
35
30
25
20
15
10
5
0
IT Nl FR DK SE PL BE SI LU AT EE ES IE LV LT SK FI HU UK DE CY PT CZ MT EL
Source: International Obesity Task Force, 2005
Although the vast majority of tobacco-related death and disability occurs in middle-aged and older adults,
smoking behaviour is most commonly established in childhood and adolescence. In fact, the vast majority
of smokers begin using tobacco products well in advance of 18 years old.644 Young smokers may acquire
the habit and become addicted prior to adulthood, rendering it difficult to quit and increasing the risk for
tobacco-related health problems later in life. It has been estimated that unless current trends change, 30 to
40% of the approximately 2.3 billion children and teenagers worldwide will become smokers in early adult
637
Levi et al., "Trends in Mortality from Major Cancers in the European Union, Including Acceding Countries, in
2004.", Tyczynski et al., "Lung Cancer Mortality Patterns in Selected Central, Eastern and Southern European
Countries."
638
Forey et al., International Smoking Statistics. Second Edition.
639
Among women the Netherlands has the highest prevalence of smoking (almost 30%) next to Greece in the EU15.
640
Brennan and Bray, "Recent Trends and Future Directions for Lung Cancer Mortality in Europe."
641
I. Pudule et al., "Patterns of Smoking in the Baltic Republics," Journal of Epidemiology and Community Health 53
(1999).
642
World Health Organization Regional Office for Europe, "Health for All Database," (Copenhagen: WHO Regional
Office for Europe,, 2005).
643
K. Fagerstrom et al., "The Anti-Smoking Climate in Eu Countries and Poland," Lung Cancer 32 (2001).
644
US Department of Health and Human Services, "Preventing Tobacco Use among Young People: A Report of the
Surgeon General," (Atlanta, Georgia: Public Health Service, Centers for Disease Control and Prevention, Office on
Smoking and Health, 1994).
209
life and beyond.645 Pierce and Gilpin found that half of all new male adolescent smokers will smoke for at
least 16 years, while females continue the habit for 20 years.646
Figure 8.7 Regular daily smokers in the adult population (age 15+), 2003
LV
TR
EL
EE
BG
LT
SK
H
PL
ES
DE
NL
PT
R
CZ
IT
DK
BE
FR
MT
AT
CY
IE
SI
UK
FI
SE
Female
male
0
5
10
15
20
25
30
35
40
45
50
55
Source: WHO Health for All, 2006
The reasons for tobacco use among youth are vast and complex, but predominately relate to the behaviour,
attitudes, and expectations of parents, peers, and broader society. Young people are more likely to become
smokers if they have parents, older siblings, and/or friends who smoke.647 Other determinants for youth
tobacco use include cultural and religious norms, availability of tobacco products, tobacco control policies
and strategies (e.g., pricing of cigarettes), and tobacco advertising, promotion, and marketing efforts.
Increasingly, tobacco advertising and promotional activities are playing a role in the onset of smoking in
children and adolescents, especially considering the multitude of new indirect marketing channels that are
used to target children, such as sponsoring sporting events and branding merchandise (e.g., clothing, toys).
In fact, studies have shown that exposure to cigarette advertising is predictive of smoking among youth.648
645
R. Peto et al., "Mortality from Smoking Worldwide," British Medical Bulletin 52 (1996).
J.P. Pierce and E. Gilpin, "How Long Will Today's New Adolescent Smoker Be Addicted to Cigarettes?,"
American Journal of Public Health 86, no. 2 (1996).
647
J.R. Eiser et al., "Adolescent Smoking: Attitudes, Norms and Parental Influence," British Journal of Social
Psychology 28 (1989), S.L. Tyas and L.L. Pederson, "Psychosocial Factors Related to Adolescent Smoking: A Critical
Review of the Literature," Tobacco Control 7 (1998).
648
N. Evans and A. Farkas, "Influence of Tobacco Marketing and Exposure to Smokers on Adolescent Susceptibility
to Smoking," Journal of the National Cancer Institute 87, no. 20 (1995).
646
210
According to the 2000-2001 HBSC survey, the proportion of young people in the EU who has ever
smoked649 rises significantly with age, from 15% for 11-year-olds to 40% for 13-year-olds and 62% for 15year-olds. The increase in the proportion of children who ever smoked is most significant between 11 and
13 years of age, where half of all countries had rates at least three times higher for 13-year-olds than for 11year-olds.650 The proportion of children who ever smoked across all age groups was highest in Estonia,
Latvia, Lithuania, and the UK, while Greece and Malta had a lower percentage of tobacco use. There are
also gender differences in the prevalence of smoking among youth. Among younger children, rates of
smoking are substantially higher for boys than for girls in almost all countries. However, with increased
age, more girls than boys have smoked, with differences being particularly marked in Scotland and Wales.
In terms of smoking frequency, 84% of young people (average of all age groups) do not currently smoke.651
Across all countries, approximately one third of those who smoke do so less than once a week (5%), with
the other two thirds (11%) smoking at least once a week.652 The remaining 7% (approximately half of all
smokers) smoke daily. Again, weekly and daily smoking rates increase substantially with age and gender.
The percentage of children who smoke daily increases from an average of 1% among 11-year olds, to 5%
among the 13-year olds, and it reaches 18% in the oldest age group (Table 8.2). Among the youngest
children, daily smoking habit is highest in Hungary, England and Portugal; while in Sweden, the
Netherlands, and Denmark either no children or less than 0.2% smoked daily among this age group. Gender
differences are similar to those emphasised previously, among 15-year-olds, girls tend to smoke more than
boys in half of the countries, particularly in Northern and Western Europe.
Table 8.2 Percentage of young people aged 11, 13, and 15 years old who smoke every day
11-year-olds
13-year-olds
15-year-olds
Austria
Belgium (Flemish)
Belgium (French)
Czech Republic
Denmark
England
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Malta
Netherlands
Poland
Boys (%)
0.9
0.3
0.7
1.3
0.0
1.5
1.5
0.3
0.8
1.5
0.8
2.4
0.8
0.6
0.5
1.2
0.8
0.0
1.2
Girls (%)
0.4
0.1
0.0
0.3
0.2
0.9
0.3
0.1
0.4
1.3
0.0
0.6
0.6
0.0
0.3
0.5
0.0
0.1
0.1
Boys (%)
3.3
4.5
3.3
6.2
3.0
6.9
7.6
6.6
3.5
10.2
2.7
5.5
2.5
3.4
8.8
6.2
4.1
3.5
7.5
Girls (%)
2.4
3.3
3.3
4.1
2.8
8.9
3.9
6.1
3.2
10.1
1.4
2.8
5.7
2.6
2.5
3.6
5.8
5.7
4.0
Boys (%)
19.5
18.3
16.0
20.2
13.7
15.8
23.3
22.1
19.5
26.3
9.2
20.7
14.6
16.1
21.8
26.6
8.6
18.7
21.4
Girls (%)
24.8
19.1
20.3
22.9
15.8
19.6
11.6
23.3
20.1
28.7
10.6
18.0
16.5
16.1
14.4
11.2
8.4
19.7
11.6
649
This proportion includes a wide range of people, including those who just experimented, those who become regular
smokers and even those who smoked in the past but now have stopped.
650
World Health Organization, "Young People's Health in Context. Health Behaviour in School-Aged Children
(Hsbc)Study: International Report from the 2001/2002 Survey. Health Policy for Children and Adolescent, No.4.,"
(Geneva: World Health Organization, 2004).
651
Children were asked how often they smoke tobacco at present. Responses categories were: ‘I don’t smoke’, ‘Every
day’, ‘At least once a week but not every day’, ‘Less than once a week’.
652
World Health Organization, "Young People's Health in Context. Health Behaviour in School-Aged Children
(Hsbc)Study: International Report from the 2001/2002 Survey. Health Policy for Children and Adolescent, No.4.."
211
1.4
Portugal
0.8
Scotland
1.1
Slovenia
0.9
Spain
0.0
Sweden
0.9
Wales
Source: HSBC, 2000-2001.
1.0
8.0
5.3
13.1
19.5
0.4
0.5
0.5
0.0
0.9
2.7
3.5
5.0
2.8
6.0
5.8
1.8
3.8
3.9
11.9
13.0
22.5
16.6
5.7
12.1
19.2
23.2
23.2
13.8
21.5
Lung cancer is the most common cancer in Europe, nearly 400,000 new cases per year.653 As Figure 8.8
shows, age-standardized incidence rates are markedly higher in the east than in the west. Hungary has the
highest rates of male lung cancer in Europe and in the world, followed in Europe by Belgium. The lowest
rates for men are observed in Sweden and Portugal. For women, the highest rates are registered in
Denmark, Hungary and the United Kingdom; while, the lowest incidence rates are found in Spain, Malta
and Portugal. Male death rates for lung cancer are now decreasing in most European countries included the
new Member States. On the contrary, mortality for lung cancer among women is increasing almost
everywhere, but the UK and to same extent Ireland and Denmark654. The leading contributors of lung cancer
are the number of cigarettes smoked per day, the degree of inhalation and the initial age of smoking.655 The
relative risk of developing lung cancer is 20-30 times higher for smokers than for non-smokers.
Cervical cancer is also relatively common among the new Member States, reflecting high rates of sexually
transmitted diseases, infrequent use of barrier contraceptives, and ineffective, mostly opportunistic
screening. 656
Figure 8.8 Cancer incidence per 100,000, 2003 or latest year available
HU
CZ
DK
IE
SE
DK
FR
UK
SI
FI
EE
AT
NL
LT
MT
SK
BE
LV
BG
PT
PL
RO
CY
0
100
200
300
400
500
600
700
800
Source: WHO Health for All, 2006
653
J.E. Tyczynski, F. Bray, and D.M. Parkin, "Lung Cancer in Europe. European Network of Cancer Registries (Encr),
Vol.1," (International Agency for Research on Cancer, 2002).
654
J. Didkowska et al., "Lung Cancer Mortality at Age 35-54 in the European Union: Ecological Study of Evolving
Tobacco Epidemics," British Medical Journal 331 (2005).
655
Ibid, Tyczynski, Bray, and Parkin, "Lung Cancer in Europe. European Network of Cancer Registries (Encr),
Vol.1."
656
F. Levi et al., "Cervical Cancer Mortality in Young Women in Europe: Patterns and Trends," European Journal of
Cancer 36 (2000).
212
Figure 8.9 Age-standardized lung cancer incidence rates / 100,000 population in Europe, 2003
HU
PL
BE
EE
CZ
SK
SI
NL
LV
LU
IT
LT
EL
FR
ES
RO
DE
BG
UK
DK
MT
AT
IE
FI
PT
SE
ASR female
ASR male
0
20
40
60
80
100
Source: Tyczynski, Bray et al 2004
Cancer survival rates
In Europe, 35% of men and 50% of women diagnosed in the late 1980s with any cancer (excluding nonmelanoma skin cancer) survived at least five years after diagnosis. For most cancers, however, five-year
survival does not mean cure: even 10 years after diagnosis, there is still some excess mortality due to
cancer. At present, more than one third of European patients are cured of their cancer.657
In general, survival is markedly lower in eastern European countries than in Western Europe. However, in
western Europe there is still room for improvement. For many cancer sites, especially those for which early
diagnosis is a major determinant of favourable prognosis, survival was higher in northern countries
(Finland, Iceland, Sweden), intermediate in continental Europe (Austria, France, Germany, Italy, The
Netherlands, Spain and Switzerland), and lower in Denmark and the UK. The highest survival rates were
usually recorded in Iceland, Sweden (South Sweden cancer registry), Switzerland (Geneva and Basel cancer
registries) or The Netherlands (Eindhoven cancer registry). The survival of patients with melanoma was
higher in Nordic countries and the UK than in southern European countries.
With a few exceptions, survival increased in all these countries but this pattern of differences persisted. By
1989, the survival differences between continental and northern European countries were diminishing for
colorectal and breast cancer, melanoma of the skin and Hodgkin's disease.
Comparison of the geographical variation with demographic, sociological and health economic indicators
shows that in general, cancer patients' survival is higher where overall life-expectancy is higher. Significant
factors associated with better survival rates include: proportion of GDP spent on health, level of
657
International Agency for Research on Cancer, Cancer Survival in Europe (1999 [cited July 21 2006]); available
from http://www.iarc.fr/ENG/Press_Releases/archives/pr129a.html.
213
employment, number of hospital beds and number of CT scanners per million population. Within Western
Europe, these factors appear to be responsible for over 70% of the inter-country variability of survival for
prostate cancer, 65% for breast, 60% for rectum and 50% for stomach cancer. Socio-economic differences
may be explaining some of the within-country variation, as has been shown in the United Kingdom.
8.4 Screening programs
Screening can be defined as: a public health service in which members of a defined population, who do not
necessarily perceive they are at risk of, or are already affected by, a disease or its complications, are asked a
question or offered a test to identify those individuals who are more likely to be helped than harmed by
further tests or treatment to reduce the risk of disease or its complications.
The basic criteria to be fulfilled before screening for any condition is introduced have been stated clearly
over many years. They are fundamental to the integrity of the screening process in any country. They are
reproduced in full on the UK National Screening Committee’s website,4 and are summarised in Table 8.3.658
Table 8.3 Summary of criteria for screening
Category
Criteria
Condition
The condition sought should be an important health problem
whose natural history, including development from latent to
declared disease is adequately understood. The condition should
have a recognisable latent or early symptomatic stage.
There should be a suitable diagnostic test that is available, safe
and acceptable to the population concerned. There should be an
agreed policy, based on respectable test findings and national
standards, as to whom to regard as patients, and the whole
process should be a continuing one
There should be an accepted and established treatment or
intervention for individuals identified as having the disease or
pre-disease condition and facilities for treatment should be
available.
The cost of case-finding (including diagnosis and treatment)
should be economically balanced in relation to possible
expenditure on medical care as a whole.
Diagnosis
Treatment
Cost
Source: Holland et al 2006
Screening in adults is potentially big business. Media interest in health is insatiable and anyone who reads
the newspapers, watches television or listens to radio can hardly fail to be aware of the various diseases that
may be lying in wait for them. Above all, before any further national screening program is introduced, it
must be clear that the long established screening criteria are satisfied and the evidence base exists.
658
W.W Holland, S Stewart, and C Masseria, Screening in Europe: A Policy Brief (Copenhagen: WHO on behalf of
the European Observatory on Health Systems and Policies, 2006).
214
Table 8.4 Recommendations for screening in adults
Condition
Comment
Breast cancer
National program should be continued but kept under close review
with emphasis on quality control, staff training and good
information.
Cervical cancer
National program should be continued with review of alternative
types of tests and of age range of those eligible and frequency of
screening. Good information to be a priority.
Colorectal cancer
National screening program by faecal occult blood testing for adults
aged 50-74 years.
Abdominal aortic
Ultrasound screening of men aged 65 and over seems a reasonable
aneurysm
proposition provided the necessary resources are in place.
Diabetic retinopathy
National program of screening for all diabetics aged over 12. It is
essential to be quite clear about how, when and where screening
should happen to ensure effective implementation.
Risk factors for
Surveillance/case-finding approach in primary care
CHD/Stroke
Blood pressure
Cholesterol
Smoking cessation
Weight
Source: Holland et al 2006
Breast and cervical cancer
The national programs for breast and cervical cancer should be continued but kept under review with an
emphasis on quality control and balanced understandable information to enable women to make a truly
informed choice without pressure from health professionals on whether or not to participate. Efforts must
also be made to improve coverage of those at highest risk.
A national program of screening for colorectal cancer by faecal occult blood testing in adults aged from 50
to 74 years has been agreed in the UK but it is essential that adequate diagnostic, treatment and follow-up
facilities are in place before it is introduced.
Based on the directives developed by Europe Against Cancer, the Belgian Communities and the Federal
Government signed, in October 2000, a protocol to organise and finance a national campaign of breast
cancer screening for women between 50 and 69 years old. The responsibility for the coordination of the
campaign rests with 11 recognised screening centres. There are five centres in Wallonia (one per province),
five in Flanders (in the four Flemish universities and in Bruges) and one in Brussels. The screening centres
are responsible for making information available to the target group, sending out the invitations, re-testing
where necessary, recording of data and reporting to the referring doctor. In Flanders the campaign started on
15 June 2001 and in Wallonia and Brussels a year later. A program of cervical cancer screening has been
running since 1994 in Belgium when the Flemish Government decided to reorient the organization of
secondary prevention of cervical cancer according to the European guidelines. The program targets women
aged between 25 and 64 years, who are invited for a Pap smear every three years. The program is
administered and evaluated by the Scientific Institute of Public Health in collaboration with the
Communities. Despite the scientific support, no formal screening program is organised in the French
Community.
Screening programs for breast cancer are established in two of the 14 Danish county councils (Funen and
H:S) for women aged 50-69 years. These two screening programs cover 20% of the target Danish
population. Screening for cervical cancer has recently been made available in all 14 Danish county councils.
Women in the age group 23-59 years are invited to participate, except in Copenhagen, where coverage is
limited to women aged 25-45 years.
215
In Finland, under the terms of the Public Health Act, women between the ages of 50 and 59 years are
invited every two years for breast screening. In Finland, the Public Health Act states that women aged 3060 years old should be invited for screening for cervical cancer every five years.
In France, screening for breast cancer, previously limited to some départements (32 at the end of 2002), has
been extended since January 2004. Every woman between 50 and 74 years (except for those in Guyana) is
invited for a free breast screening every two years. A strategic objective of the Public Health Act (August,
2004) is to ‘reduce the percentage of late-stage breast cancer detected in women, notably by increasing
screening coverage rate up to 80% in women aged between 50 and 74 years.’ This Act called for specific
programs to target isolated, disabled or deprived women who might be reluctant to participate. This has
been partly achieved by the production of videos or tapes for people suffering from visual or hearing
deficiencies and the translation of brochures for immigrants. Several campaigns at national and local levels
are going to be launched. Patients and women’s associations are involved in this information effort.
Cervical cancer screening is offered to women aged 25-69 years every three years. A recent study estimated
that 35% of women in the target age group have never or only rarely been screened. Targeted messages will
be used to reach these women and coverage could be increased by the participation of GPs (96% of Pap
tests are currently carried out by gynaecologists). The 48th objective of the Public Health Act of August
2004 is ‘to continue the annual 2.5% decrease of cervical cancer incidence, notably by increasing screening
coverage rate to 80% for women aged 25-69 and HPV test utilization’.
Phase 1 of BreastCheck - Ireland's national breast screening program - started in February 2000 and already
offers screening in several areas, with coverage expected to be nationwide towards the end of 2007. Breast
screening outside the BreastCheck program is available to all women if they are referred by a GP. In
Ireland, Phase 1 of a National Cervical Screening Program, which offers free cervical screening to women
aged 25-60 years in the Mid-Western Health Board (MWHB) area has recently started.
In Italy, screening policies for breast cancer have been inserted in the package of essential levels of care
provided by the NHS (Essential Level of Assistance) by Decree “DPCM 29/11/2001.” All National Health
Plans have set targets for these areas of prevention. Registers are managed at regional level, however, and
screening programs are more widespread in Northern and Central Italy. There is usually a system for
targeting and recalling patients, but the target population varies according to regional health plans so the
position is varied. In Italy, screening programs for cervical cancer are similar to those for breast cancer.
Registers are managed at regional level and screening policies are more widespread in Northern and Central
Italy.
There is a national program for breast cancer and cervical cancer screening in the Netherlands. National
screening programs for cervical cancer are available also in Germany (for the SHI insured).
Since 1990 Breast Cancer Detection Programs have been implemented in all Spanish Autonomous
Communities. The programs’ target population varies across regions but in most it includes women aged
50-65 years. Cervical cancer screening through cytology is offered to all women aged 35 years and over but
there are regional differences. In Catalonia, for example, there is a personalised register of all target
individuals (women aged 20-64 years). Cervical cancer screening (Papanicolau technique) is recommended
every three to five years. In the Balearic Islands, screening for cervical cancer prevention is opportunistic
rather than population-based.
Swedish National Guidelines from the National Board of Health and Welfare recommend mammography
screening for early detection of breast cancer for age groups 40-74 years. Examination intervals are 18
months for women under 55 years, and 24 months for women over 55. Organised cervical cancer screening
has been implemented in Sweden since the mid-1960s. Guidelines for recommended screening are: every
third year, for women aged 23-50 years and every fifth year for women aged 51-60.
Among the New Member States, a pilot program for breast cancer screening has started in Cyprus and
covers women aged 50-69 years. There is a national policy on screening for cervical cancer based on the
population register and covering all women aged 25-65 years.
216
In Estonia, there is a screening program for breast cancer, financed and administered by the Estonian Health
Insurance Fund. The target population is women aged 45-59 years, and the screening interval is three years.
Mammography screening was introduced in 2002 in Hungary for women aged 45-65 years and screening is
repeated bi-annually with a good participation rate.
Screening for cancer is included in the prophylactic program for adults in Latvia and covered through the
health care budget. For breast cancer, women aged 50 to 69 years are recommended to undergo one
mammography every two years. For cervical cancer, women aged 20 to 35 years are recommended to have
an oncological test every three years. For women aged 35 to 70 years, the test is carried out annually.
In Slovakia, breast cancer screening is provided by the state and paid for by health insurance companies.
The target population is women aged 40-60 years and the method is periodical mammography.
A national strategy for prophylactic cancer screening (2001-2006) was approved in Bulgaria in 2000. Given
the scarce resources available for this strategy, however, it only recommends preventive examinations for
cervical cancer as part of regular gynaecological examinations.
In Hungary, the gynaecological cervical screening program was launched in 2004. It is based on
Papanicolau cytological testing of all women aged 25-65 years every three years.
Since July 2004, Lithuania’s Cervical Cancer Prevention Program has been financed by the Compulsory
Health Insurance Fund. The program targets women aged 30-60 years and screening is performed every
three years.
In Slovenia, there is a national policy on screening for cervical cancer that includes all women between the
ages of 25 and 64 years. There is active follow-up through a central surveillance system and the screening
interval is three years after two initial smears over six months have proved negative.
Colorectal cancer
A trial for colorectal cancer has started in two of the county councils in Denmark where men and women
aged 50-74 years are invited to participate. A pilot project for colorectal cancer screening for 60-69 year old
men and women was introduced in 2004 in several Finnish municipalities.
Colorectal cancer screening is the 53rd objective of the 2004 Public Health Act and is currently the subject
of trials in 22 French départements. People aged 50 to 74 years are invited for a fecal occult blood test
(FOBT) every two years. If the result is positive, a colonoscopy is carried out. The program will be assessed
shortly to define the national strategy for 2007. Initial results showed an increasing rate of participation (up
to 50% in some départements) because of active participation by GPs.
8.4.1 Prevention and screening programs in Austria659
A variety of measures can be related to the promotion of heath:660
•
•
•
•
The promotion of a healthy lifestyle
The improvement of access to health services and the participation of individuals in decisions
regarding their health
The promotion of a healthy physical and social environment which facilitates healthy behaviour of
individuals
The education of individuals about measures to maintain their body in good health
659
Naidoo J & Wills J. Lehrbuch der Gesundheitsförderung. Herausgegeben von der Bundeszentrale für
gesundheitlich Aufklärung BZgA, 2000
660
217
Prevention and health promotion are to a large extent publicly financed by the social insurance, the
federation (Bund), the individual federal states and the local councils.
The central authority for prevention and health promotion in Austria is the Healthy Austria Fund (Fonds
Gesundes Österreich, FGÖ).661 Since the Health Promotion Law (Gesundheitsförderungsgesetz) became
effective in 1998 it has formed the basis for the work carried out by the Healthy Austria Fund. With an
allotted annual budget of around 7.2 million Euros662 the fields of responsibility of the FGÖ include the
promotion and support of projects in key areas, encouraging the building of structures for the purposes of
health promotion, investment in further and continuing education, promotion of networking between those
working in the fields of health promotion and primary information, as well as, provision of information,
explanation and the accompanying public activities. In particular projects in the field of health promotion,
which aim to promote healthier habits and behavioural patterns, which address praxis-oriented primary
prevention, and application-oriented research projects for the further development of health promotion and
primary prevention, are supported by the FGÖ.
The Supreme Sanitary Council (Oberste Sanitätsrat) was reorganised in May 2005663 and holds a plenary
meeting three times a year. It is split into subcommittees, which examine the topics of “vaccination”,
“AIDS”, “Mother/Child Passport” and “dental medicine and prophylaxis”. The newly founded Public
Health commission is specifically concerned with health at the workplace and “diseases of civilisation”.
Several working groups are active in the federal states within the field of prevention with a social medical
emphasis including, the Association for Prophylactic Health Activities (Verein für prophylaktische
Gesundheitsarbeit, PGA), the Working Group for preventive health care Salzburg (Arbeitskreis für
Vorsorgemedizin Salzburg, avos), the Working Group for Preventive Health Care Tyrol (Arbeitskreis für
Vorsorgemedizin Tirol, AVOMED), the Working Group for Preventive Health Care and Social Medicine
Vorarlberg (Arbeitskreis für Vorsorge- und Sozialmedizin Vorarlberg, aks), the the Health Forum of Lower
Austria (Gesundheitsforum Niederösterreich) (Listed in the Austrian Women’s Health Report 2005/2006664)
Following a survey carried out between July and November 2004 of around 500 Austrian facilities details
of over 100 projects and initiatives, connected with women’s health, were compiled and are described in the
document “Women’s Health in Practice” (Frauengesundheit in der Praxis). A few selected examples are
listed below demonstrating the variety of topics covered:
•
•
•
Exercise to guard against osteoporosis (Osteoporose-Vorbeugeturnen) – run by the Society for the
promotion of aging sciences and senior studies, University of Graz (Gesellschaft zur Förderung der
Alterswissenschaft und des Seniorenstudiums, Universität Graz). This is an exercise program
offered to older women financed by the city of Graz together with course fees. The course aims are
to strengthen the health awareness and the resources of older women, improve self confidence and
the responsibility for ones own health.
Project Gender Mainstreaming in Workplace Health Promotion (Projekt Gender Mainstreaming in
der betrieblichen Gesundheitsförderung) run by ppm forschung + beratung in Linz, Upper Austria.
The program is financed by the FGÖ, the ÖGB665 and the federal state of Upper Austria. The aim
of this project is to pay more attention to the influence of job and work structures on women’s
health and to sensitise those working in the field of Health Promotion in the workplace, as well as
health and safety in the workplace, to gender issues.
Strengthen my back (Meinen Rücken stärken) run by the Women’s Health Centre ISIS in Salzburg
and financed by the Salzburg Sickness Fund. This project took the form of an information day
which looked at the back in connection with health and, amongst other things, had the aim of
661
Incorporated in the Gesundheit Österreich GmbH (Health Care Austria Plc.) in 2006
Healthy Austria Fund (Fonds Gesundes Österreich) (2004). Yearly report 2004. see also www.fgoe.org
663
664
BMGF Eds. (2006). Austrian Women’s Health Report 2005/2006. Compiled by the Ludwig Boltzmann Institut für
Frauenforschung. April 2006. See also www.bmgf.gv.at
665
ÖGB=Österreichischer Gewerkschaftsbund=Austrian Trade Union Federation
662
218
•
providing information on the consequences of lack of exercise, poor posture, poor diet, and
overweight etc. on back problems, and to motivate to undertake preventive exercise programs.
(1) Mammografie-Vorsorge; (2) GYN-Vorsorge; (3) Frauen-ALPHA in Vorarlberg. These are
continuing area-wide programs run by the aks - Working committee for preventive care and social
medicine, non-profit association (Arbeitskreis für Vorsorge- und Sozialmedizin, gemeinnützige
Betriebs GmbH). The aims of the gynaecological and mammography programs are the early
identification and prevention of illness. In the case of the ALPHA program the aim is to increase
wellbeing or quality of life. The programs receive a budget of approx. €180,000 per year for
gynaecological examinations (mammography). The ALPHA program is self financed by
participants.
The Addictive Drug Law (Suchtmittelgesetz, SMG), effective since 1998, forms the central framework for
Austrian addictive drug politics. An overview of the organizational structure concerned with drug addiction
in Austria is given in Figure 8.10 below.666
Figure 8.10 Overview over the organizational structures related to drugs in Austria
Source: ÖBIG (2005). Report on the drug situation. Commissioned by the European monitoring body for drug and
drug addiction and the Federal Ministry of Health and Women. See also www.oebig.at
At a national level policy, planning and administration are carried out by various federal ministries, such as
the Federal Ministry of Health and Women, the Federal Ministry of Justice, the Federal Ministry of Internal
Affairs etc. Implementation of preventive measures in the field of drug addiction predominantly takes
places at a regional, federal state, level. Each state has an addiction commissioner/coordinator and or a drug
commissioner/coordinator. In the Burgenland the role of addiction coordination was transferred to the
Psychosozialer Dienst (PSD) or psycho-social services, which are now the main provider of addiction
support measures in the Burgenland. In Lower Austria there are also plans to transfer addiction service to an
external private insurance carrier. In the year 2001 expenditure in this field was around €8.4 million of
which 68% was provided by the individual federal states, around 21% by the federation, and around 6%
was provided by towns and councils.
666
ÖBIG (2005). Report on the drug situation. Commissioned by the European monitoring body for drug and drug
addiction and the Federal Ministry of Health and Women. See also www.oebig.at
219
Great importance is placed on distinguishing between primary and secondary prevention. Primary
prevention aims to prevent the onset of an addiction in persons who are not in any particular risk group and
in whom an addiction or drug problem has not so far occurred. Secondary prevention is aimed at identified
risk groups and at those people who already have initial, but not yet established problems. In the first
instance the target group for secondary prevention is young people.
Early Detection of diseases and other measures to maintain health of the population are addressed in the
General Social Insurance Law (Allgemeines Sozialversicherungsrecht, ASVG) sections regarding health
promotion and prevention are cited below:
•
•
•
•
•
§ 132a Juvenile health examinations (Jugendlichenuntersuchung) –of 15-18 years olds
§ 132b Regular precautionary health examinations adult population (Vorsorgeuntersuchung) – for
individuals age 18 and older - this has been available since 1973 available and is covered by the
Social Health Insurance, a once yearly health check is possible. The new program started in
October 2005, “evidence based” prevention program. Within the framework of the annual
preventive health checks “Health passports“ are available for age groups mother+child, -40, 40-60,
60+, these come with an additional brochure giving information about a healthy lifestyle and
explaining the health examination. A health passport for 75+ will be available in the next months,
including an age-specific brochure667,
§ 7 mother-child passport examinations (Mutter-Kind Pass Untersuchungen)
§ 132c other measures to maintain health of the population (e.g. active immunization Tick-borne
encephalitis, zytogenetic exams)
§154b Health promotion
Measures to strengthen people’s health
•
•
§155 e.g. convalescent care (Kuraufenthalte)
§ 156 Measures to prevent diseases - voluntary
o E.g. health education, Works-site health promotion, Caring for youth, newborns and
pregnant women
Other Laws addressing health promotion and prevention:
•
•
•
•
•
•
School teaching law 1986 (Schulunterrichtsgesetz, 15.Abschnitt) - Health examination undertaken
by the school doctor (Schulärztliche Untersuchung) –- costs are covered by the ministry of
education. Occurs once a year668
Health Promotion Law (Gesundheitsförderungsgesetz) since 1998
Health Promotion Fund – financed by value added tax, determined by the financial adjustment law
(Finanzausgleichsgesetzes), 7 Million Euro
AIDS – Gesetz 1993 - Oberster Sanitätsrat - the supreme health council of Austria has a committee
for AIDS
Tobacco Law addresses cigarette production, selling, trading, advertising and the protection of nonsmokers
Industrial Law (Gewerbeordnung) § 114 Selling alcohol to young people
Financial support (Kinderbetreuungsgeld) is made available for those parents absolving 5 examinations
during pregnancy and 5 examinations of the child up to the age of 14-18 months. This is covered by the
mother-child pass directive (Mutter-Kind Pass Verordnung) 2002.
667
Project Management by Prim.Katharina Pils, co-operation of Univ.-Prof. Dr. Anita Rieder
Children’s Health Report (Kindergesundheitsbericht der Stadt Wien 2000) since then no evaluation or analysis of
the data, Download available at https://www.wien.gv.at/who/downloads.htm
668
220
Examples of projects run by social insurance carriers
In the course of the realisation of the socalled innovation projects of social insurance (now defined as
standard products of social insurance) a comprehensive project on health promotion and prevention was
performed which included topics such as the new programme for health check ups, the health promotion
and prevention plan as well as health reporting. Within the area of health promotion behaviour-orientated
projects and setting-referred projects were distinguished. The first dealt with topics such as smoking or
obesity, the latter with health promotion at the setting workplace and at the setting schools. Reports of these
projects are situated at the Hauptverband.
Outpatient and inpatient programs to stop smoking are run by the Viennese sickness fund, including also
“Bei Anruf Rauchstopp!” whereby counselling and advice are provided over the telephone.669
Since May 2006 the regional sickness fund of Lower Austria provides the „smoking telephone”
(Rauchertelefon) in co-operation with other social insurance funds and the federal states.670
“A heart for Vienna” (Ein Herz für Wien) – Aim is, amongst other things, to reduce of risk factors for
cardiovascular disease in all target groups by informing and motivating people to make positive changes in
lifestyle factors such as stopping smoking taking more exercise, healthier nutrition etc. This project is run
by the area management for social- and health planning as well as financial management (Bereichsleitung
für Sozial- und Gesundheitsplanung sowie Finanzmanagement, BGF) and by the regional sickness fund of
Vienna (WGKK). 671 The project management is undertaken by the Fund Social Vienna (Fonds Soziales
Wien, FSW) by order of the city of Vienna.
Health promotion and prevention 2006 (Gesundheitsförderung und Prävention 2006) is an area wide
program run by the Lower Austria sickness fund. 256 events were held during which tips for a healthier
lifestyle were passed on and also looking at designing a health promoting environment (school, work place,
local authority). Programs are offered in a variety of areas including exercise, nutrition, cancer and
prevention, and mental fitness.672
„ Slim without dieting” (Schlank ohne Diät) – weight loss program offered by the regional sickness fund of
Lower Austria (NÖGKK). 673
Projekt Betrieb Aktiv – gestalten und bewegen (the active workplace – design and move) – a joint project
between the regional sickness fund of Upper Austria and AUVA, the Austrian Social Insurance for
Occupational Risks (Allgemeine Unfallversicherungsanstalt).674
Project “Trainees in motion” (Projekt Lehrlinge in Bewegung) – A health promotion project in the
workplace run in the Trainee workshops of the Voest Alpine Stahl Linz GmbH.675 The project aimed to
make health-conscious working an integrated part of the training. All trainees who started their training in
autumn 1994 were supervised by a sports scientist, work physicians as well as apprenticeship trainers
during their entire apprenticeship (traineeship) with relation to formfitting (körpergerecht) work. A sport
scientist employed by the regional sickness fund of Upper Austria developed compensation exercises,
solutions for formfitting work based on work related back-school as well as ergonomical options for
improvement. Together with specialists of the centre for work medicine the trainees elaborated workspecific dangers and burdens.676
669
Wiener Gebietskrankenkasse, accessed at www.wgkk.at
Niederösterreichische Gebietskrankenkasse, accessed at www.noegkk.at
671
Wiener Gebietskrankenkasse, accessed at www.wgkk.at
672
Niederösterreichische Gebietskrankenkasse, accessed at www.noegkk.at
673
Allgemeine Unfallversicherungsanstalt, AUVA, accessed at www.auva.at
674
Oberösterreichische Gebietskrankenkasse, accessed at www.ooegkk.at
675
676
670
221
Project “employees move employees” (MitarbeiterInnen bewegen MitarbeiterInnen) – - a joint project of
the Upper Austria sickness fund and the AUVA, the Austrian Social Insurance for Occupational Risks
(Allgemeine Unfallversicherungsanstalt).677
Preventive information dissemination campaigns have been carried out in Austria. These have often been
carried out in schools. Furthermore financial support has been made available for patients.
Screening and Vaccination
The Austrian Federal Institute for Health (Österreichisches Bundesinstitut für Gesundheitswesen, ÖBIG678),
whose activities focus on health management and environmental protection, has produced a series of
documents on the topic of screening and preventive care.
Publications include:
•
•
•
•
•
Mammographie - Screening Austria 2005 (Mammography screening in Austria) – guidelines for
implementation in Austria. These projects were based on the EU-criteria for breast cancer screening
and coordinated by the ÖBIG (Austrian Health Agency)
Screening aus ökonomischer Perspektive - Dickdarmkarzinom (2004) (Screening from an
economic perspective – colon carcinoma 2004) – literature-based analysis on whether CT
coloscopy is a cost effective screening method in the early detection of colon cancer.
Impfungen – ökonomische Evaluation 2003 (Vaccination – economic evaluation). A study of the
Austria vaccination system, an evaluation of the economic benefit of vaccinations (meta-analysis)
and a cost-benefit analysis using the example of measles.
Impfplan 2006 (Vaccination plan 2006) – published by the Ministry of Health and Women. Lists
which vaccinations are recommended and at what age they should be carried out. Also details
which illnesses may be prevented through immunisation.
Recently much attention has been paid to drawing up a ”Pandemieplan” a pandemic plan in light of
the avarian influenza or bird flu threat.
Other Screening Programs in the Health Reform Law 2005 include:
•
•
National Programs on molecular genetic analysis for breast cancer and ovarian cancer.
Screening the newborns – since the mid60s, screening has been carried out for hereditary
metabolic diseases679
Screening costs are covered by the Federation, treatments are covered by the social health insurance.
Evaluation
The evaluation and quality aim of the mammography screening programs is the continual evaluation of
structure, process and results. The data are made directly available to all those concerned in order to achieve
uniform diagnosis and treatment standards.
The report “Life expectancy and Mortality in Vienna” (2003) the increase or rather high rate of breast
cancer is attributed to the “screening-effect”. Mammography screening has been made available free of
charge since 1974. A study has shown that although the number of tumours from stage II has increased in
most age groups since 1982, at the same time a decreasing trend, also in the higher tumour stages, has been
observed in all age groups over the past few years. The authors state that the decrease in advanced stage
tumours and mortality can plausibly be related to the screening prevalence.680
677
Allgemeine Unfallversicherungsanstalt, AUVA, accessed at www.auva.at
Recently integrated into the Health Care Austria Plc. (Gesundheit Österreich GmbH), see www.oebig.at
679
www.kinderklinik.meduniwien.ac.at
680
Vutuc C et al. Wiener Klin Wochenschr 1998;110/13-14:485-490
678
222
Examples of published results of the evaluation of Austrian prevention programs & services681
Vorarlberg Health Monitoring and Promotion Program
Based on the approximately 700,000 health examinations carried out on around 170,000 people in
Vorarlberg between 1985 – 2004, together with the CINDI population surveys, the stability of several
cardiovascular risk factors was tracked over time, the predictive value of raised or lowered total cholesterol
in men and women compared, actual trends for risk factors determined etc. A number of publications have
been published. The long term tracking of cardiovascular risk factors682 showed that whilst fewer than 20%
of the participants were able to lower their BMI between examinations, around 50% did reduce their
heightened blood pressure. The expediency of the health examination recall system was demonstrated.683
Participants who were invited and attended a repeat examination within 1.5 years of the first, had higher
values for various risk factors, but also a comparatively more favourable outcome. The predictive accuracy
of SCORE risk function for cardiovascular disease in clinical practice was evaluated with 44,649 men and
women.684 The mental well-being in women in preventive medicine program was studied and found that the
in terms of depression in women this topic was given too little attention in a general preventive medical
setting.685
Other aspects studied include Gamma-Glutamyl Transferrase as a risk factor for cardiovascular mortality,
seasonal variations in risk factor profiles and mortality, gender differences in risk factors related to
cardiovascular mortality and all-cause mortality. See Appendix 17 for a list of related publications.
20 year evaluation of national blood pressure education campaigns
Public awareness was evaluated following a nationwide educational campaign on hypertension.686 This
study found that although initially awareness was increased the effect dropped off again.
Mother-child-Passport
A marked decrease of infant mortality took place since the middle of the 1970s. Whereas in the 1970ies
almost 300 infants per 1000 newly ‘live’ borns died, since the 90ies this number lies below 10.687 This
success is especially attributed to the introduction of the mother-child-passport and decreased fertility of
women older than 35 years.688 Furthermore the development of birth weight 1970-1995, which has
increased by 60g in the mean birth weight, could partly be due to the extensive use of maternity care
program (mother-child-passport). However the reduced maternity payment in 1997 may lead to reduction in
the use of the program.689
681
Ulmer, H., Kelleher, C., Diem, G., Concin, H. (2003). ”Long-term tracking of cardiovascular risk factors among
men and women in a large population-based health system. The Vorarlberg Health Monitoring & Promotion
Program.” European Heart Journal 24 (11), pp. 1004-1013
683
Ulmer, H., Kollerits, B., Kelleher, C., Diem, G., Concin, H. (2005). Predictive accuracy of the SCORE risk
function for cardiovascular disease in clinical practice: a prospective evaluation of 44 649 Austrian men and women.”
European Journal of Cardiovascular Prevention and Rehabilitation 12(5), pp.433-441
684
ibid
685
Concin, H. Ulmer, H. Hefler, L. (2002). ”Mental well-being in 5000 women participating in the Women-Plus
preventive medicine program.” Maturitas 41 Suppl 1, pp.9-12.
686
Schmeisser-Rieder, A., Kunze, U. (2000). ”Blood pressure awareness in Austria. A 20-year evaluation, 19781998.” European Heart Journal, 21, pp.414-420
687
Life expectancy and Mortality in Vienna (2003). Published by Magistrat der Stadt Wien Bereichsleitung für
Gesundheitsplanung und Finanzmanagement. Vienna
688
Waldhör, T., Vutuc, C. (1995). ”Trendanalyse der Säuglingssterblichkeit unter besonderer Berücksichtigung der
perinatalen Mortalität in Österreich(1965-1991).” Das Gesundheitswesen 57(1), pp.13-16
689
Waldhör, T., Haidinger, G., Vutuc, C. (1997). ”Development of birth weight in Austria from 1970-1995.” Wiener
Klinische Wochenschrift 109(20), pp.804-807
682
223
Evaluation of Austrian Newborn Hearing Screening
The Universal Neonatal Hearing Screening (UNHS) has been gradually implemented since the nineties in
Austrian maternity wards and neonatal intensive care units. An evaluation was carried out by means of a
retrospective analysis of clinical data of 394 Austrian children. It was found that UNHS greatly increases
the proportion of children whose hearing impairment is diagnosed before six months of age.690
Hearing screening of pre-school children at nursery schools in Tyrol, Austria was evaluated and it was
determined that hearing screening is an efficient means of assessing ear and hearing problems in pre-school
children, follow up-rate needs to be improved in order to optimise efficacy.691
Evaluation of the prenatal diagnosis of limb reduction deficiencies – EUROSCAN Group
Data from Congenital Malformation Registries (12 European Countries, including Austria), study Period
1996-98, ultrasound scans in the mid-trimester of pregnancy.692
PSA screening for Prostate cancer
The possible effect of prostate-specific antigen (PSA) testing on prostate cancer mortality has remained
controversial, despite the test's widespread application. In Tyrol a study was carried out to monitor the
impact of prostate screening. PSA test was made freely available from 1993. The study found that a policy
of making PSA testing freely available is associated with a reduction in prostate cancer mortality. Trends in
reduction differ significantly between Tyrol and the rest of Austria693. A significant migration to lower
clinical and pathological stages has been observed since the introduction of this screening program.694
PSA testing became widely available in Austria not before 1989. Age-specific mortality trends for prostate
cancer before and after the introduction of (opportunistic) screening were analysed between1970-2002.
After 12 years of follow-up, significant reductions in mortality rates could not be observed in the age
groups 50-59, 60-69, and 80-89; significant decreases were found in the age group 70-79, which cannot be
related to PSA screening. PSA screening does not appear to reduce prostate cancer mortality in a uniform
cohort of men with equal access to health care, however, given the long lead-time for prostate cancer, even
longer follow up may still be needed to detect any important trends695. The calculations were done for
Austria without Tyrol and for Tyrol.
Evaluation of “Heart for Vienna”696
Ein Herz für Wien (a Heart for Vienna project) was evaluated and the report sent to the Department for
Health Planning and Financial Management (Bereichsleitung für Gesundheitsplanung und
Finanzmanagement). The program was also reported in Weißbuch Prävention! HERZgesund? KKH
Kaufmännische Krankenkasse (Hrsg.).697 The annual report of the KKH (Commercial Sickness Fund
690
Weichbold, V., Nekahm-Heis, D., Welzl-Müller, K. (2005). ” Zehn Jahre Neugeborenen-Hörscreening in
Österreich: Eine Evaluierung.” Wiener Klinische Wochenschrift 117(18), pp.641-6
691
Weichbold, V., Rohrer M, Winkler, C., Welzl-Muller, K. (2004). ”Hearing screening at nursery schools: results of
an evaluation study.” Wiener Klinische Wochenschrift 116(14), pp.478-83
692
Stoll, C., Diesel, A., Quiesser-Luft, A., Froster, U., Bianca, S., Clementi, M. (2000). ”Evaluation of the prenatal
diagnosis of limb reduction deficiencies. EUROSCAN Study Group.” Prenat Diagn.20(10), pp. 811-8.
693
Bartsch, G., Horninger, W., Klocker, H. et a (2001).“Prostate cancer mortality after introduction of prostate-specific
antigen mass screening in the Federal State of Tyrol, Austria.“ Urology 58, pp.417-424
694
Horninger, W., Berger, A., Pelzer, A., Klocker, H., Oberaigner, W., Schonitzer, D., Severi, G., Robertson, C., Boyle, P., Bartsch, G.
(2004). ”Screening for prostate cancer: updated experience from the Tyrol study.” Curr Urol Rep. 5(3), pp.220-5.
695
Vutuc, C., Schernhammer, E.S., Haidinger, G., Waldhör, T. (2005). ” Prostate cancer and prostate-specific antigen
(PSA) screening in Austria.” Wiener Klinische Wochenschrift 117(13-14), pp.457-61
696
Rieder, A. (2006). A Heart for Vienna – a Viennese prevention program. Presentation
See also: Aigner G. (2006). Legal aspects of prevention and health promotion. Document for the university course
„Master of Public Health: prevention and health promotion (MPH)“ 2005/2006 Vienna.
697
Walter U et al. (2004). Abschnitt 10.4 “Ein Herz für Wien“ – eine Stadt widmet sich der Herzgesundheit ihrer
Bewohner. In Weißbuch Prävention “Herzgesund?” Jahresreport der Kaufmännische Krankenkasse Hannover 2004
224
Hannover) 2004. The external evaluation included and expert inquiry, telephone survey (6,000 interviews)
preparation of an external report evaluating the results, professional external report on the program. The
evaluation showed a positive reaction to the program among both the experts and the general public. The
aims were classified as important and correct. The strengths of the program lie therein, that the social
environmental factors are taken into account and are built around evidence-based interventions. The
program was found to be well incorporated in the medical and health promotional professional
environment.
8.5 Health inequalities
International studies in socioeconomic determinants of health are helpful to determine the patterns of
socioeconomic health inequalities in Europe. Large education-related inequalities in self-assessed health
were observed in Austria, Denmark, England, Italy, the Netherlands, Norway, West Germany, Spain, and
Sweden (Table 8.5) with large differences in magnitude.698 Between the 1980s and the 1990s,
socioeconomic inequalities in self-assessed health remained, on average, stable for men but slightly
increased for women. Increasing inequalities were observed in Italy, the Netherlands and Spain, but this
was not seen in Northern countries. This suggests that Northern countries’ welfare states had mechanisms to
protect people in lower socioeconomic classes from the health effects of the economic crises in the 1990s.
However, large socioeconomic inequalities in reported health status still persist in all the 10 western
countries analysed.
Table 8.5 Magnitude of educational differences in fair/poor self-assessed health: men and women
aged 25-69 years (Odds ratiosa, 95% confidence intervals)
Men
Women
Country
1980s
1990s
1980s
1990s
Finland
3.15 (2.55-3.88) 2.99 (2.44-3.66) 2.86 (2.28-3.58) 3.29 (2.60-4.18)
Norway
2.37 (1.71-3.29) 2.37 (1.70-3.30) 3.32 (2.37-4.66) 3.06 (2.22-4.23)
Denmark
2.93 (2.16-3.9) 2.30 (1.73-3.04) 3.10 (2.13-4.50) 2.84 (2.10-3.82)
England
3.11 (2.27-4.25) 3.08 (2.57-3.68) 2.08 (1.59-2.71) 2.66 (2.21-3.19)
Netherlands
2.95 (2.46-3.52) 2.81 (2.39-3.30) 1.95 (1.63-2.35) 2.12 (1.81-2.49)
W. Germany
1.50 (1.20-1.88) 1.76 (1.44-2.14) 1.89 (1.43-2.50) 1.91 (1.50-2.44)
Austria
3.39 (2.92-3.93) 3.22(2.79-3.71) 2.75 (2.37-3.19) 2.67 (2.31-3.07)
Italy
2.05(1.79-2.34) 2.94 (2.54-3.40) 1.86 (1.62-2.15) 2.55 (2.20-2.95)
Spain
1.86 (1.56-2.17) 2.58 (1.81-3.67) 1.97 (1.63-2.37) 3.10 (2.18-4.41)
Tot (excl. Italy) 2.61 (2.41-2.83) 2.54 (2.35-2.75) 2.48 (2.28-2.69) 2.70 (2.50-2.92)
a
The reference category in all countries in higher educational level
Source: Kunst et al. 2005.
Education-related inequalities in common chronic diseases were found in Belgium, Denmark, Finland,
France, Great Britain, Italy, the Netherlands, and Spain.699 Most diseases showed higher prevalence among
people with low educational level, only allergy was more common in the high education group (Table 24).
High inequalities favouring the better-off are observed for stroke, diseases of the nervous system, diabetes
and arthritis. No statistically significant inequality was found for cancer, kidney and skin diseases. The size
of socioeconomic differences in chronic diseases varied between men and women. For diabetes,
hypertension, and heart diseases inequalities were higher among women; while for back and spinal cord
disorders inequality was higher among men. By comparing the working-age and the elderly population
groups, it is evident that on average education-related inequalities decreased when age increased, the only
exceptions were chronic respiratory diseases, headache and migraine. Among the working-age group cancer
698
A.E. Kunst et al., "Trends in Socioeconomic Inequalities in Self-Assessed Health in 10 European Countries,"
International Journal of Epidemiology 34, no. 2 (2005).
699
J.A.A. Dalstra et al., "Socioeconomic Differences in the Prevalence of Common Chronic Diseases: An Overview of
Eight European Countries," International Journal of Epidemiology 34, no. 2 (2005).
225
was more prevalent in the low educated group but in old age the pattern reversed; among older people
cancer appears to affect the better educated.
Socioeconomic differences in self-assessed health status are found also in eastern European countries such
as Russia, Estonia, Lithuania, Latvia, Hungary, Poland and Czech Republic; and the findings are not
dissimilar from those in the EU-15.700 Education and material deprivation are important determinants of
health status; people with higher education are less likely to report poor health (OR: 0.36). Low perceived
control in work was also significantly associated with poor health, even after adjusting not only for age and
gender but also for education, deprivation, and inequality.
Table 8.6 Education differences (low compared to high education) for chronic disease groups in
Europe (OR with 95% confidence intervals)
Total
Men
Women
Men and
women (25-59
years)
Men and
women (60-79
years)
Stroke
1.64 (1.401.93)
1.70 (1.352.14)
1.56 (1.251.96)
1.89 (1.252.51)
1.53 (1.27-1.86)
Diseases nervous
system
1.63 (1.511.77)
1.57 (1.401.77)
1.57 (1.411.75)
1.81 (1.641.99)
1.33 (1.17-1.52)
Diabetes mellitus
1.60 (1.431.80)
1.30 (1.111.51)
2.19 (1.822.63)
1.64 (1.381.94)
1.57 (1.34-1.84)
Arthritis
1.56 (1.401.73)
1.50 (1.271.77)
1.46 (1.261.68)
2.04 (1.762.36)
1.17 (1.01-1.36)
Hypertension
1.42 (1.341.50)
1.10 (1.001.22)
1.52 (1.421.62)
1.55 (1.431.67)
1.30 (1.20-1.40)
Stomach/duodenum
ulcer
1.40(1.221.60)
1.41(1.191.67)
1.56(1.251.95)
1.37(1.151.62)
1.461.16-1.83)
Genitourinary diseases
1.35(1.241.47)
1.29(1.131.48)
1.53(1.361.72)
1.51(1.361.69)
1.15(1.00-1.31)
Headache/migraine
1.35(1.271.43)
1.18(1.061.32)
1.29(1.20-1.3)
1.28(1.201.37)
1.62(1.42-1.84)
Osteoarthrosis
1.34(1.211.49)
1.32(1.121.55)
1.29(1.121.48)
1.51(1.301.75)
1.20(1.03-1.38)
Liver/gall diseases
1.26(1.081.46)
1.10(0.871.40)
1.30(1.071.58)
1.31(1.071.60)
1.19(0.95-1.49)
Chronic respiratory
diseases
1.24(1.151.33)
1.33(1.201.48)
1.19(1.071.33)
1.13(1.031.25)
1.42(1.26-1.61)
Heart diseases
1.22(1.101.35)
1.18(1.041.34)
1.51(1.281.79)
1.29(1.091.53)
1.18(1.04-1.33)
Back and spinal cord
disorders
1.19(1.111.29)
1.33(1.191.49)
1.05(0.941.16)
1.29(1.181.41)
0.98(0.86-1.13)
Cancer
1.13(.0981.30)
0.96(0.781.20)
1.22(1.021.46)
1.64(1.021.46)
0.77(0.64-0.93)
Kidney stones and
other kidney diseases
1.11(0.951.31)
1.03(0.831.27)
1.34(1.041.72)
1.17(0.951.45)
1.03(0.80-1.33)
Chronic disease
group
700
M. Bobak et al., "Socioeconomic Factors, Material Inequalities, and Perceived Control in Self-Rated Health: CrossSectional Data from Seven Post-Communist Countries," Social Science and Medicine 51 (2000).
226
Skin diseases
0.99(0.911.08)
0.99(0.861.14)
0.98(0.871.11)
0.98(0.881.09)
10.3(0.86-1.23)
Allergy
0.73(0.660.81)
0.67(0.570.79)
0.72(0.630.82)
0.69(0.610.78)
0.82(0.68-0.99)
Source: Dalstra et al. 2005
There has been some attempt to compare health inequalities across countries. One such study found that
education- and occupation- related inequalities in mortality favouring the better-off have increased between
1981-1985 and 1991-1995 in Denmark, England and Wales, Norway, Sweden, Italy (Turin), and
particularly so, among Finnish men.701 The main cause of this widening gap was the proportional faster
relative decline of mortality in the higher socioeconomic classes although the decrease in absolute mortality
has been similar in the lower and upper groups.
A similar decline in cardiovascular mortality was recorded for all six countries and in all socioeconomic
classes, but again the relative decline was larger among the rich.702 Socioeconomic differences in
cardiovascular mortality explained almost half of the widening relative gap in mortality in all populations
but Italy. Changes in other causes of deaths also contributed to the widening gap. The authors considered
also the socioeconomic change in three other causes of mortality: neoplasms, other diseases and injuries.
The occupation gap for neoplasms between the 1980s and 1990s increased in Sweden, England/Wales and
Italy; for other diseases an increase was seen in Finland and Sweden; and for injuries in Finland and Italy.
The widening in inequality in total mortality was also caused by increasing rates of mortality in the lower
socioeconomic classes for lung cancer, breast cancer, respiratory diseases and gastrointestinal diseases
among both men and women in almost all countries but Italy.
Men and women with lower education level had significantly higher stroke mortality than those with a
middle/high educational level in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland,
Austria, Italy (Turin), and Spain (Barcelona and Madrid).703 The magnitude of education inequalities in
stroke mortality was similar across Europe; only Austria reported larger than average differences for both
men and women. The risk of dying from stroke was approximately 26% and 28% higher for men and
women with low educational level than those in high education. On average, educational differences tended
to decrease with age; faster declines were seen in Norway, Austria, and Barcelona. The reduction with age
was not statistically significant in England/Wales, Turin and Madrid. The contribution of education
inequalities in stroke mortality to the overall education differences in life expectancy at age 30 years was
7% among men and 14% among women. The elimination of education inequalities in stroke mortality
would have reduced education differences in life expectancy by 9% among men and 18% among women in
Turin, and by 7% and 18% respectively in Austria.
As emphasized above, income and income inequality affect material circumstances both directly and
indirectly through social participation and degree of control. Indeed, OECD countries with greater trade
union membership and female political representation have lower child mortality.704 Quality of the
psychosocial environment is only moderately and inconsistently associated with mortality; but greater
distrust and lack of control are related with higher coronary heart disease mortality. Low control in the
workplace was related to higher risk of cardiovascular disease in the Whitehall II study705. Less control is
701
J.P. Mackenbach et al., "Widening Socioeconomic Inequalities in Mortality in Six Western European Countries,"
International Journal of Epidemiology 32 (2003).
702
Ibid.
703
M. Avendano et al., "Educational Level and Stroke Mortality: A Comparison of 10 European Populations During
the 1990s," Stroke 35 (2004).
704
J. Lynch et al., "Income Inequality, the Psychosocial Environment, and Health: Comparisons of Wealthy Nations,"
Lancet 358 (2001).
705
H. Bosma et al., "Low Job Control and Risk of Coronary Heart Disease in Whitehall Ii (Prospective Cohort)
Study," British Medical Journal 314 (1997).
227
also associated with higher death rates also in Latvia, Lithuania, Estonia, Hungary, Poland and Czech
Republic.706
Public health policies to tackle inequalities in health
Health inequalities are increasingly recognised as an important public health issue throughout Europe.
Reducing inequalities in health requires a multi-sectoral approach that addresses not only health and social
care service provision and poverty alleviation, but also housing, environment, diets, smoking and alcohol
consumption. The extent to which countries are embracing this inter-sectoral approach to policy-making is
described in more detail below. Almost all EU Member States have identified the reduction of health
inequalities as a goal of the public health or broader health policy; however in some countries this goal is
outlined more explicitly than in others. Significant policy developments have been seen in England, the
Netherlands and Sweden in reducing health inequalities, although to date there has been little evidence that
they have been successful.
In contrast to the more central-led policies in England, the Netherlands has embarked on program of local
experiments with a strong emphasis on evaluation. However national implementation has been hindered due
to a period of political instability between2002-2003.
According to a recent report funded by the UK Presidency reviewing national-level policies and strategies
to reduce social inequalities in health, there is no EU Member State that is making a concerted effort to
reduce the social gradient in health.707 Despite widespread attention paid to socioeconomic inequalities in
health across countries, there remains considerable variation in the form and nature of the policy goals and
targets. These differences can be attributed to: availability of data about the nature and extent of
inequalities; differing levels of political will; state of economic development; and the role of international
agencies. The report goes on to categorise countries according to the scope of their national strategies to
reduce health inequalities:
1. The UK and Ireland have well-developed and coordinated action plans
2. The Netherlands, Finland, Denmark, Hungary, Italy, Poland and Sweden incorporates health equity
into broader public health policies
3. Belgium (Flanders) and France have developed a series of programs to reduce health inequalities,
but they are not necessarily part of a broader policy
4. Cyprus and Greece lack a distinctive focus on health inequalities, but have developed some
programs directed towards social determinants of health at national and local levels
The remaining countries have no explicit national health inequalities policy, but many acknowledge the
problem, as reflected in various policy statements.
Since the mid-1980s, reducing inequalities has been a major policy objective in Sweden.708 The formation
of the National Institute for Public Health in 1991 further strengthened the support for equality in health.
More recently, Sweden has undergone structured policy developments in the area of health inequalities709.
To address the relationship between labour market and working conditions and health inequalities, Swedish
labour market policies offer strong employment protection and actively promote participation in the labour
market for people with chronic illness. These policies have been found to protect these vulnerable groups
from labour-market exclusion. In addition, Sweden has made considerable progress in health impact
assessments, specifically in assessing the effect on health inequalities of the European Community
agricultural policy. Furthermore, general social policy measures are in place to improve the health and well706
M. Marmot and M. Bobak, "International Comparators and Poverty and Health in Europe," British Medical Journal
321 (2000).
707
K. Judge et al., "Health Inequalities: A Challenge for Europe.," in Report prepared for the UK Presidency of the
EU. (2005).
708
B. Burström et al., "Sweden," in Reducing Inequalities in Health: A European Perspective, ed. J Mackenbach and
M Bakker (London: Routledge, 2002).
709
J.P. Mackenbach and M.J. Bakker, "Tackling Socio-Economic Inequalities in Health: Analysis of European
Experiences," Lancet 362 (2003).
228
being of lone mothers, such as subsidized public childcare. The recent national public health program has
the goal of creating the “societal conditions that ensure good health on equal terms for the entire
population”. This program emphasizes social connections such as social capital, supportive social
environment, and a secure bond between children and their parents. In addition, there are strong ethical
undertones, such as a sense of solidarity. Although for many years Sweden has been pursuing equalityoriented health and social policies, there are nowadays some indications that inequalities are increasing.
Therefore, continued efforts to research and develop wide-reaching policies are needed.
In England there has been considerable effort directed to researching and developing policies to reduce
health inequalities – being some of the largest in Europe. Indeed some argue that the program in the United
Kingdom is one of the most coherent and ambitious to date.710 In July 2003, a national health inequalities
strategy was launched: Tackling Health Inequalities: A Program for Action. This strategy aimed to review
progress against the 2010 health inequalities Public Service Agreement (PSA) target from 2002 and 12
national headline indicators. The target was:
By 2010 to reduce inequalities in health outcomes whole by 10% as measured by infant mortality
and life expectancy at birth.- both between routine and manual groups and the population as a
whole, and local authorities with the fifth of areas with lowest life expectancy at birth and the
population as a whole.
The overall aim was to prevent health inequalities from worsening, given that the long-term trend showed
that the gap in mortality between professional (social class I) and unskilled manual men (social class V) has
increased by two and a half times since 1930–32. By 2004, there was no narrowing of health inequalities
against the PSA target. On the contrary, there was a widening of inequalities in infant mortality and life
expectancy (between 1997 and 2005), reflecting the long-term trend. However, on a more positive note,
some progress has been made in reducing child poverty (the proportion of children in absolute poverty has
been halved in five years) and improving housing (specifically, the proportion of households living in nondecent housing”). According to the most recent national public health policy in 2004 (Choosing Health), all
government departments now systematically take into account the impacts of new policy proposals on
health and health inequalities.
In Cyprus, two simultaneous policies to reduce health inequalities were developed in 2003: 1) the National
Action Plan for Social Inclusion included among its targets the reduction of disparities; and 2) the Health
Council identified the need to increase health services in rural areas and implementing preventive programs
in community and schools in an attempt to reduce inequalities.
Greece passed legislation in June 2005 regarding the organization and operation of public health
services, with emphasis placed on reducing socioeconomic inequalities.
One of the difficulties encountered in developing and monitoring a strategy to reduce inequalities is limited
data on inequalities, as seen in Italy. In the Czech Republic, inequalities in health are not identified as a
priority issue in health policy and little data are available. Similarly in Malta, health inequalities are not
featured prominently on the political agenda, partly due to lack of epidemiological data and research in this
area, and party due to the misconception that by offering health service free at the point of use to poor
members of society inequalities would stop being a problem. Although there is increasing evidence on the
presence of health inequalities in Estonia, they have received little attention to date. Latvia and Lithuania
address health inequalities explicitly in their public health policies. In addition, Latvia is beginning to
develop the first national action plan on poverty and social exclusion for 2004-2006 (as in Malta). In
Hungary there is some focus on regional inequalities in health – and current health policies are addressing
this issue alongside data collection in order to continue to measure its progress. While the primary focus of
policies addressing inequalities in health is the socioeconomic dimension, some countries, like Hungary,
also address ethnic differences (specifically, the Roma population).
710
A. Couffinhal et al., "Policies for Reducing Inequalities in Health, What Role Can the Healthcare System Play? A
European Perspective. Part Ii. Experience from Europe.," in News bulletin in economy of health, no. 93. (Paris:
IRDES, 2005).
229
8.6 Health trends in Austria
This section gives a general overview of the trends in certain population health indicators over the past 10
years.711 Between 1995 and 2004, life expectancy at birth increased from 77.12 to 79.47 years. Male life
expectancy increased from 73.67 to 76.52 years, and women’s life expectancy increased slightly less, from
80.27 to 82.18 years, thus narrowing the gender gap. Life expectancy at birth lies slightly above the EUaverage and has developed better than the EU-average over the past ten years. Within Austria there is a
visible east-west divide in male life expectancy. While men in the western provinces of Tirol, Vorarlberg
and Salzburg live particularly long, the life expectancy of Viennese men is approximately one year below
the Austrian average. Compared to the Austrian average, life expectancy of Viennese women is even more
unfavourable than it is for men.712
Figure 8.11 Life expectancy at birth in Austria
84
82
80
78
76
74
72
70
68
1995
1996
1997
1998
1999
2000
Austria total
EU total
Austria women
EU women
2001
2002
Austria men
2003
2004
EU men
Source: Health for All Database, updated January 2006, accessed: 7.03.06
Life expectancy at older ages provides an indication of advances in health care and also public health
programs. In 1995, life expectancy at the age of 65 was approximately 17.45, similar to the EU average, but
has slightly diverged from it since then, to 18.87 in 2004 (EU-average: 18.29). This recent improvement is
due largely to declining mortality for older men.
Healthy life expectancy (HALE), referring to the estimated period of a lifetime spent in full health was 71.4
years in 2002. Men can expect to live 69.3 years in full health, while women can expect 73.5 years.
However, that also entails that while women live longer on average, they also spend a longer period of their
lives not living in full health. Healthy life expectancy remained more or less stable from 1999 to 2002. That
may indicate that the increase in overall life expectancy can rather be attributed to improvements in
treatment of diseases than to the prevention of disease.
711
712
The majority of this section was written by Mag. Daniel Hentschel, MSc.
BMGF (2004). Healthcare report Austria.Vienna
230
Figure 8.12 Life expectancy at the age of 65 in Austria
25
20
15
10
5
0
1995
1996
Austria total
1997
EU total
1998
1999
2000
Austria men
2001
2002
EU men
2003
Austria women
2004
EU women
Source: Health for All Database, updated January 2006, accessed 07/03/2006
Table 8.7 Infant mortality (per 1000 live births)
1995 1996 1997 1998
5.42 5.08 4.74 4.92
Austria
6.01 5.28 5.57
Belgium
Cyprus
7.7
6.05 5.86 5.21
Czech Republic
5.06 5.51 5.15 4.43
Denmark
14.88 10.5 10.1 9.37
Estonia
3.98 3.92 3.93 4.13
Finland
4.86 4.77 4.73 4.58
France
5.3
4.98 4.86 4.67
Germany
8.15 7.25 6.44 6.68
Greece
10.66 10.91 9.86 9.7
Hungary
6.37 5.98 6.08 5.86
Ireland
6.19 6.15 5.65 5.26
Italy
18.85 15.92 15.35 14.99
Latvia
12.48 10.08 10.34 9.27
Lithuania
4.06 4.39 3.45 4.83
Luxembourg
8.89 10.72 6.41 5.35
Malta
5.46 5.74 5.04 5.19
Netherlands
13.6 12.21 10.18 9.53
Poland
7.51 6.87 6.43 6.02
Portugal
10.99 10.19 8.7
8.79
Slovakia
5.53 4.74 5.17 5.21
Slovenia
5.49 5.54 5.03 4.86
Spain
4.03 3.83 3.63 3.56
Sweden
6.18 6.09 5.86 5.69
United Kingdom
1999
4.36
2000
4.83
2001
4.84
2002
4.06
2003
4.46
2004
4.47
6
4.62
4.17
9.58
3.7
4.32
4.54
6.15
8.43
5.88
5.21
11.29
8.65
4.12
7.2
5.23
8.85
5.63
8.31
4.51
4.47
3.4
5.78
5.56
4.1
4.96
8.42
3.61
4.38
4.38
5.91
9.22
6.17
4.51
10.37
8.61
2.97
5.96
5.13
8.11
5.54
8.58
4.9
4.38
3.42
5.58
4.9
3.97
4.63
8.79
3.22
4.45
4.31
5.1
8.13
6.04
4.67
11.04
7.92
4.95
4.32
5.37
7.67
5.06
6.24
4.23
4.08
3.66
5.48
5
4.15
4.08
3.9
3.75
5.69
2.97
4.1
4.22
5.12
7.16
6.98
3.21
3.34
4.23
4.02
7.29
4.14
9.85
7.93
3.93
5.89
5.02
7.52
5.07
7.63
3.83
4.15
3.28
5.23
9.44
6.73
4.9
5.7
4.8
7.04
4.19
9.38
7.89
3.48
5.92
4.39
3.98
3.92
231
EU
6.72
6.36
5.9
5.66
5.4
5.21
5.06
4.89
4.77
4.75
Source: Health for All Database (World Health Report), Update January 2006, accessed 07/03/2006
Infant mortality in Austria has decreased significantly in the course of the past decades (from approximately
27 deaths in 1970 to approx. 4.5 in 2004 per 1000 live births ), which can mainly be attributed to a decline
in perinatal deaths (see following table).713 This is due to technological improvements, improved access to
pre- and postnatal care for pregnant women as well as better nutrition. As a result, Austria is one of the
European countries with the lowest infant mortality. Throughout the past years, infant mortality has
remained relatively stable, possibly indicating that a further decrease cannot be attained solely by medical
measures, but only through a reduction of the prevalence of risk factors such as alcohol, overweight and
smoking.
Table 8.8 Perinatal mortality rate per 1000 births
1995
1996
1997
1998
4.4
4.2
3.98
4.07
Austria
6.96
7.21
7.38
Belgium
Cyprus
4.96
4.82
4.28
4.5
Czech
Republic
5.91
6.09
6.51
5.87
Denmark
10.46 9.62
9.75
7.59
Estonia
4.2
3.84
3.84
3.96
Finland
7.42
7.22
7.04
6.99
France
4.57
4.41
4.31
3.96
Germany
10.33 9.51
9.42
8.78
Greece
6.73
6,3
6.95
6.12
Hungary
10.59 9.98
9.6
9.47
Ireland
5.47
5.43
5.01
6.44
Italy
17.12 15.92 14.79 11.85
Latvia
10
7.21
7.69
8.01
Lithuania
5.7
4.38
6.87
8.49
Luxembourg
9.94
13.47 9.26
8.2
Malta
8.09
8.41
7.93
7.84
Netherlands
10.5
9.62
8.33
7.93
Poland
7.21
6.77
5.93
5.8
Portugal
7.76
8.5
7.55
8.42
Slovakia
5.04
4.81
5.6
5.68
Slovenia
6.02
6.42
6.3
5.88
Spain
4.34
4.08
4.59
4.25
Sweden
8.88
8.67
8.3
8.27
United
Kingdom
7.07
6.86
6.54
6.52
EU
1999
3.79
2000
3.87
2001
3.55
2002
3.43
2003
3.61
2004
3.2
4.72
4.01
3.78
3.97
3.65
3.58
5.67
7.83
3.15
6.55
3.91
8.77
5.39
5.95
5.32
6.37
3.71
6.56
6.07
7.81
5.74
9
5.18
5.79
3.39
6.88
5.94
4.28
6
3.38
4.17
5.84
3.42
3.59
5.16
2.97
5.91
5.89
5.7
9.7
5.83
7.01
5.38
8.98
5.34
4.8
9.97
6.69
5.36
9.92
7.89
7.55
5.46
7.17
4.89
5.57
4.57
8.23
9.26
8.27
6.78
4.6
7.85
6.68
5.2
6.57
4.09
9.02
5.72
6.2
5.09
7.92
6.34
4.88
6.48
4.54
10.5
7.29
5.59
6.65
7.66
5.75
4.97
6.39
5.15
7.7
5.47
5.64
4.72
7.37
5.6
6.15
6.61
4.34
7.75
5.08
4.75
5.91
4.68
8.15
4.44
8.02
3.96
8.28
3.87
8.48
4.99
6,28
6,54
6.48
6.42
6.45
6.42
5.69
4.16
713
Waldhör, T., Vutuc., C., Haidinger, G., Mittlböck, M., Kirchner, L., Wald, M. (2005). Trends in infant mortality in
Austria between 1984 and 2002.Wiener klinische Wochenschrift 117 (15-16), pp.548-553
232
Table 8.9 Childhood mortality (under 5 years of age) per 1000 children under 5
1960 1970 1980 1990 1995 2000 2003
Austria
43
33
17
9
7
6
5
35
29
15
9
9
6
5
Belgium
36
33
20
12
10
7
5
Cyprus
25
24
19
11
8
5
4
Czech Republic
25
19
10
9
7
5
4
Denmark
52
26
24
17
20
11
9
Estonia
28
16
9
7
4
5
5
Finland
34
24
13
9
7
5
5
France
40
26
16
9
7
6
5
Germany
64
54
23
11
9
6
5
Greece
57
39
26
16
12
9
8
Hungary
36
27
14
9
7
6
6
Ireland
50
33
17
10
7
5
4
Italy
44
26
26
18
20
13
12
Latvia
70
28
22
14
16
12
11
Lithuania
41
26
16
9
6
6
5
Luxembourg
42
32
17
14
11
8
6
Malta
22
15
11
8
6
6
5
Netherlands
70
36
24
19
15
9
7
Poland
112
62
31
15
9
6
5
Portugal
40
29
23
15
12
9
8
Slovakia
45
29
18
9
7
5
4
Slovenia
57
34
16
9
7
5
4
Spain
20
15
9
6
4
4
3
Sweden
23
14
10
7
7
6
United Kingdom 27
Source: Unicef Statistik, http://www.childinfo.org/areas/childmortality/u5data.php, accessed 08/03/2006
Childhood mortality in Austria has declined to the common level of 5 deaths per 1000 children under 5
years of age in Western European countries, having been significantly above average in 1960.
During the time period from 1995 to 2004, maternal mortality in Austria ranged between 1.13 (1995) and
6.63 (2001) deaths per thousand live births, not only significantly lower than the EU-average, but also lower
than comparable countries such as Germany , the Netherlands or Sweden. While, to some extent, maternal
mortality strongly varies in most countries, the EU-average has decreased rather consistently, from 7.36 to
5.71.
Table 8.10 Maternal mortality per 1000 live births
1995 1996 1997 1998 1999
1.13
4.5
2.38
4.92
1.28
Austria
9.52
5.15
8.6
Belgium
0
0
Cyprus
6.24
7.74
5.52
6.63
10.06
Czech
Republic
10.03 5.91
17.74 15.11 13.59
Denmark
51.82 0
15.9
16.44 16.1
Estonia
1.59
3.29
5.06
5.25
3.47
Finland
2000
2.56
2001
6.63
2002
2.55
2003
2.6
2004
3.8
0
9.9
36.73
8.82
4.31
7.47
8.19
45.92
5.29
3.06
7.92
5.34
7.69
5.4
30.68
3.53
28.59
12.12
233
France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Slovakia
Slovenia
Spain
Sweden
United
Kingdom
EU
9.59
5.36
0
15.17
0
3.23
37.05
29.13
18.45
21.68
7.35
12.7
8.4
8.14
5.27
4.4
3.87
6.97
13.21
6.41
4.96
11.4
5.92
3.79
40.44
17.92
0
20.23
12.14
7.71
5.44
4.97
26.61
3.86
5.25
6.55
9.63
6.03
0
20.93
5.68
4.37
42.49
23.8
0
7.38
4.8
5.96
4.23
1.85
2.67
41.25
16.48
7.79
10.91
5.31
3.38
11.01
2.17
3.32
5.37
10.16
5.6
6.94
6.17
3.71
3.38
48.89
18.91
18.57
22.28
11.53
7.58
7.93
8.68
11.2
3.83
7.86
6.84
7.36
7.54
6.45
5.61
23.21
9.48
7.33
5.17
10.67
17.11
5.26
1.13
5.29
10.25
1.83
2.97
24.69
11.71
17.47
0
8.71
7.93
2.5
1.81
22
3.77
4.42
6.77
7.03
7.23
6.06
6.11
7.26
3.68
3.91
5.15
5.48
2.07
25.43
12.68
8.82
2.92
0.97
8.26
8.26
4.24
1.92
7.4
0
5.24
5
19.99
14.3
3.27
50.83
6.91
3.53
5.32
15.64
22.89
4.18
3.28
7.47
0
9.9
5.37
6.99
7.87
0
3.34
4.17
5.98
0
3.99
3.99
7.11
3.87
9.83
16.44
18.34
0
5.15
5,64
5,38
5.29
4.2
0
5.58
4.53
5.71
More than 76% of all deaths are attributed to cardiovascular diseases and cancer. The remainder of this
section focuses on the major risk factors for disease.
8.6.1 Obesity and overweight
Diseases and deaths associated with eating habits play an increasingly important role in Austria. According
to the nutrition report of 2003, 37% of Austrians are overweight (BMI between 26 and 30), and 9.1% are
heavily overweight/obese (BMI>=30). The Austrians’ average consumption of fat is 35-40%, which is
significantly above general nutritional recommendations. Compared to the EU-average, more red meat
(mostly pork) and sugar is consumed, whereas vegetables and dietary fibres are neglected714. Since
Austrians do not appear to assess their weight situation realistically, it would be important to raise
awareness of the importance of healthy lifestyles and initiate specific preventive measures. The “Healthy
Austria Fund” (Fonds Gesundes Österreich) supports several projects encouraging good health, such as
those supporting exercise, nutrition and life conduct. Obesity and overweight prevention projects have been
carried out. The fund also addresses the public via media campaigns. On the internet, nutrition-specific
information is increasing. However, the quality of this information can often not be judged.
714
BMFG (2005). Public Health in Austria. Vienna
234
Figure 8.13 Epidemiology of obesity in Austria per cent (1999)
Burgenland
Lower Austria
Styria
Upper Austria
Vienna
Vorarlberg
Carinthia
Tyrol
Salzburg
0
2
4
6
8
10
12
14
Source: BMGF, Institute of Nutritional Sciences University of Vienna (2003). Austrian Nutrition Report 2003, page
26
Further activities against obesity are undertaken at a national level (publication of the first obesity report,
formation of the plattform "the fat chance“ (die dicke Chance715), publication of the children’s health care
plan in August 2004716) as well as by Austrian social insurance funds (health check-ups, standard product
health care promotion and prevention, pilot project of the sickness fund of the civil servants for inpatient
treatment of severely obese children). The federal states also have started various initiatives. Furthermore a
great number of self-help groups throughout Austria are dealing with the issue.
There are no reliable statistics on high blood pressure, blood lipids (cholesterol) and diabetes, as it can be
assumed that the estimated number of unreported cases is significant. Experts estimate that the number of
hypertonics in Austria is 1.5 million (18.3% of the total population) and the number of diabetics is at least
500,000 (6.1% of the total population).
Physical inactivity is also an important determinant of health, and is linked to overweight and obesity.
Approximately 60% of the Austrian population are more or less physically active (once or twice a week)
and 18% can be considered athletic (physical activity more than 3 times a week).717 The Eastern Austrian
population shows the lowest degree of awareness for both healthy nutrition and physical activity as means
of preventing diseases or maintaining good health (BMGF health report 2004).
In the course of an international study (Pan-EU-survey) an activity index for each population was calculated
thus making a comparison with international recommendations on the minimum required physical activity
possible. They found that 62% of the Austrians older than 15 meet the recommended minimal health care
standard (weekly energy use of about 1000 calories achieved by physical activity during which the
metabolic rate is 3-6 times higher than in state of inactivity). 38% of the Austrian population are
insufficiently active, 16% are totally inactive. Compared to other European countries Austria performs very
well (58% do not meet the minimum standard, 32% are totally inactive). Within the EU there is a northsouth divide whereby Austria is one of the more active countries, following in the ranking after Sweden,
715
www.diedickechance.at
Federal Minstry of Health and Women, accessed at
http://www.bmgf.gv.at/cms/site/attachments/8/8/9/CH0083/CMS1117802910284/kindergesundheitsplan_kurzfass
ung.pdf
717
BMGF (2005). Public Health in Austria. Vienna
716
235
Finland and Ireland. Favourite leisure activities of the Austrian population are walking, biking, gardening,
swimming and hiking. The survey results showed that the EU average for physical inactivity was higher for
women and increased with age. Moreover a correlation with education level was demonstrated, adults with
compulsory education (Pflichtschulabschluss) are nearly twice as inactive as adults with higher
education.718
Figure 8.14 Frequency of weekly physical activity aimed at physical training of 45-64 year-olds in the
Austrian population*
* Männer: men, Frauen: women, keinmal: not at all, ein- bis zweimal: one or twice, öfter als zweimal: more than twice
Häufigkeit der körperlichen Betätigung (mit Schwitzen) pro Woche: Frequency of physical activity (including
perspiration) per week
Pflichtschule/Lehre: compulsory education/apprenticeship, BMS: school providing lower vocational education
AHS/BHS: high school/school providing higher vocational education, Hochschule: university
Anteile in %: share in %
Source: BMFG Health Report 2004, based on ST.AT-Microcensus-Special Report
“Questions about health” 1999
Figure 8.15 Physical Activity in the EU-15 member states
Yellow: insufficiently active, red: totally inactive
Source: Pan EU Survey in Samitz, G. (2004). ″Physical activity and Public Health – Are Mr. and Mrs Austria
sufficiently active? A comparative analysis by Mag. Günther Samitz part 1.″ ASVÖ Newsletter 4 ,pp.4-5
718
Samitz, G. (2004). ″ Physical activity and Public Health – Are Mr. and Mrs Austria sufficiently active? A
comparative analysis by Mag. Günther Samitz part 1.″ ASVÖ Newsletter 4 ,pp.4-5
236
8.6.2 Tobacco consumption
In Austria 29% of the adult population (older than 15 years) smoke.719 The total number of smokers
remained static between 1972 and 1997 (the share of men fell (-10%) whilst the proportion of women rose
by about the same amount), since it has increased by quite a bit in spite of anti-smoking campaigns and
increases in price. The Microcensus in 1997 defined 30% of men and 19% of women as smokers.720
International studies report that the share of adult smokers in Austria has risen form 32% in 1995 to 40% in
2002721. The proportion of men has slightly dropped whilst the proportion of women has demonstrated a
strong increase and has nearly caught up with the share of men.
In April 2006 minimum prices for cigarettes were introduced by law. So far it is not clear yet if this
regulation will withstand inspection of EU authorities.
Regarding adolescents smoking at least occasionally, Austria holds the first rank in Europe with 4% of the
11 year olds, 15% of the 13 year-olds and 45% of the 14year-olds. The share of 15 year-olds smoking daily
is 20% for boys and 26% for girls which is significantly above the rest of the EU. The following graph
depicts the trend in smoking for adolescents between 1990 and 2001.
Every year about 14,000 persons die of the consequences of tobacco-related diseases722; about 3,000
persons die of lung cancer whereby 90-96% of them are caused by smoking.
Figure 8.16 Percentage of 15-year-old school children smoking daily, by sex723
pink squares…girls, blue diamonds…boys
Source: HSBC WHO Study, HSBC factsheet Nr. 1, 2003
719
Groman E., Bayer, P., Kunze, U., Schmeiser-Rieder, A., Schoberberger, R. (2000). ″Analysis of the needs for
diagnosis and therapy of tobacco dependence in Austria.″. Wiener Med Wochenschrift 150(6), pp.109-114 in Knopp,
A., Sprenger, M., Ertl, B., Starl, T., Püringer, U. (2004). Innovation-Project concept for the future health promotion
and prevention, risk factor smoking. Wissenschaftszentrum der Versicherungsanstalt für Eisenbahnen und Bergbau für
Gesundheitsförderung und Prävention, Josefhof, Graz
720
Statistics Austria, Microcensus 1997
721
Special Eurobarometer 183/Wave 58.2, Smoking and the Environment, Action and Attitudes, 2003 in Knopp, A.,
Sprenger, M., Ertl, B., Starl, T., Püringer, U. (2004). Innovation-Project concept for the future health promotion and
prevention, risk factor smoking. Wissenschaftszentrum der Versicherungsanstalt für Eisenbahnen und Bergbau für
Gesundheitsförderung und Prävention, Josefhof, Graz
722
http://www.einherzfuerwien.at/rauchen.htm, accessed 02/0872006
723
WHO (2003). HSBC Study. HSBC Factsheet No. 1, Smoking, Alcohol, Cannabis, Eds. Federal Ministry of
Social Security, Generations and Consumer Protection, Federal Ministry of Education, Science and Culture,
Ludwig Boltzmann-Institute for Medicine and Health Sociology. Vienna
237
Activities to reduce tobacco consumption724
The Insurance Fund of the Austrian Railway and Mining Industry, the Insurance Fund of the Civil Servants,
the regional sickness fund of Upper Austria as well as the occupational fund of the Austria Tabak offer
inpatient smoking secession. Numerous sickness funds provide ambulatory smoking secession for their
insured (the regional sickness funds of Vienna, Lower Austria, Styria and Upper Austria as well as the
health care information centre of the regional sickness fund of Burgenland and Salzburg. Furthermore the
insurance fund for civil servants and the occupational fund of Austria Tabak).
All federal states boast a big number of places which individuals, who want to give up smoking, can visit. A
variety of initiatives to quit smoking have started, an important one being the extension of smoke-free areas.
8.6.3 Alcohol
Alcohol is serious problem in Austria. Approximately 5% of the adult population can be considered
chronically addicted to alcohol.725 The rate of deaths due to cirrhosis of the liver is the highest in Europe.
Over the past 10 years, alcohol abuse by the population has decreased from 18 to 16%. However, the
corresponding percentage of women up to 39 years of age has increased significantly. The average amount
of alcohol consumed daily by people older than 15 is 30g. (men 51g, women 13g). Significantly greater
consumption by men is reflected in accordingly higher potentially alcohol-associated male mortality.
Table 8.11 Alcohol consumption in Austria
Category
2004
Abstinent
31%
Minor alcohol consumption
36%
Moderate alcohol consumption
18%
Problematic alcohol consumption
12%
Extreme alcohol consumption
4%
1993/94
23%
37%
21%
18%
n.a.
Low alcohol consumption: Men under 24g, Women under 16g of pure alcohol daily (0.3/0.2 L of wine)
Moderate alcohol consumption: Men up to 60g, Women up to 40g (0.75 L/0.5L of wine daily)
Problematic alcohol consumption: Men over 60g, Women over 40g (0.75 L/0.5L of wine daily)
Extreme alcohol consumption: Men over 120g, Women over 80g
Source: BMGF (2005). Public Health in Austria, Representative survey for the BMGF by Uhl et al.2005, accessed at
www.bmgf.gv.at
82% of 14-17 year-olds stated that they had consumed alcohol in the past month - an absolute peak value in
Europe. Only Denmark shows similarly high alcohol consumption in adolescents.726 The overall life
expectancy of Austrians is reduced by 2 years, due to a shortened life expectancy by 20 years for persons
with high alcohol consumption.
724
Pühringer, U., Knopp, A., Sprenger, M., Ertl, Brigitta, Starl ,Tanja (2004). Innovation-Project concept for the
future health promotion and prevention, risk factor smoking. Versicherungsanstalt für Eisenbahnen und Bergbau
Wissenschaftszentrum
725
BMGF health report 2004
726
BMGF Public Health in Austria 2005
238
Table 8.12 Abuse of alcohol and alcoholism in Austria (whole population)
Missbraucher und Alkoholkranke nach Geschlecht in Zahlen (und Prozent)
Alcohol diseased
Alcohol abusers (excl.
Alcohol diseased)
Alcohol ambusers and
alcohol-diseased
90,000 (27%)
280,000 (39%)
370,000 (35%)
Men
245,000 (73%)
444,000 (61%)
685,000 (65%)
Total
335,000 (100 %)
720,000 (100%)
1,055,000 (100%)
Women
Source: Repräsentativstudie Uhl et al., 2004, abgeruf en unter: Fonds Gesundes Österreich,
http://w w w .f goe.org/der-fonds/inf os/plonearticle.2006-05-29.8117585778 am 30.06.06
Figure 8.17 Alcohol intoxication of adolescents
Repeated alcohol intoxication of Austrian adolescents
15-year-old boys
46%
15-year-old girls
30%
13-year-old boys
13-year-old girls
0%
16%
9%
10%
20%
30%
40%
50%
Source: Dür and Hutter (1997 and 2001). Health Behavior of School-Aged Children (HBSC).Vienna. accessed at the
Healthy Austria Fund at http://www.fgoe.org/der-fonds/infos/plonearticle.2006-05-29.8117585778 on 30/0672006
8.6.4 Poverty and health
International studies show that mortality and morbidity are significantly higher in lower social classes than
for individuals of higher socio-economic status. Presumably, this applies to Austria as well. Exact figures
and information on class-specific differences concerning health risks, morbidity and mortality are rare.
Individuals whose weighted per capita income lies below the threshold level of 60% of the average Austrian
per capita income are endangered by poverty. People additionally facing rigorous restrictions in major areas
of life, such as extensive arrears of rent and heating costs or lack the financial means to invite someone to
their homes at least once a month are considered acutely or manifestly poor. Those most endangered by
poverty are male and female workers, farmers and unemployed persons. Women are generally more
affected than men. As in all European countries, the number of “working poor” whose household expenses
exceed the gross individual income is increasing continuously.727
727
239
Results from the EU-SILC March 2006-06-25
According to the newest data (March 2006) from the EU-SILC (Statistics on Income and Living
Conditions), the weighted per capita income of a one-person household in Austria is €16.969 per year. That
corresponds to an amount of €1.414 per month. The population quarter with the lowest income level of the
Austrian population disposes of less than €12,868 per year. In contrast, the richest population quarter has an
annual income of at least €22.404.
According to the European standard, the so-called poverty threshold is 60% of the average income. People
with less than €10.182 per year at their disposal (or €848 per month) are considered to be endangered by
poverty. In 2004, approximately 1,030,000 people in Austria were concerned, comprising 13% of the
population.
The risk of poverty is 11% for persons born in Austria, and 23% for immigrants who have been granted
Austrian citizenship.728 Male and female immigrants run the highest risk of poverty, at 28%. The risk of
poverty for persons who have only completed compulsory education is 18%.
While the risk of poverty for the employed is only 8%, the figures are significantly higher for the
unemployed.
•
•
•
•
Male and female retired persons 13%
Individuals undergoing education 19%
Male and female homemakers 22%
Unemployed persons 32%
The number of employed persons of working age whose households are below the poverty threshold is
approximately 250,000. The so-called “working poor” constitute almost half of all persons endangered by
poverty in this age group.
Women are particularly threatened by poverty. Women’s lower labour force as well as lower incomes have
an impact on the risk of poverty. Persons living in households where the basic income is provided by
women are threatened by poverty almost twice as often (19%) as people living in households where men
provide the major share of income. The risk of poverty for single parents with only one income lies above
average, at 24%. Single households are generally at a higher risk of experiencing poverty, the probability of
living in poverty being 25% for women who are clearly more frequently endangered by poverty than male
singles (16%).
23% of families with 3 or more children are endangered by poverty. Living in a household with more
people involves a risk of poverty that is below average, provided the number of income providers is high. In
families with 3 or more children and families with small children, there is an increase of poverty,
particularly when the woman is not working. 6% of the Austrian population are manifestly poor. 23% of
those endangered by poverty cannot afford basic necessities such as sufficient heating for their homes. In
6% of the population, low income is combined with a low standard of living, consequently classifying them
as poor by definition.
In principle (theoretically), poor people do not receive a lower quality of care by the Austrian health system
than wealthier people. The social security system provides access to an extensive health care package for
about 98% of the population. However, a correlation between low income, poorer subjective health and
modified utilization of health care can be shown in Austria as well729. In Microcensus surveys, members of
the “underclass” assess their state of health as significantly worse, are sick more often and take medications
more frequently than members of higher social classes. Additionally, they consult general practitioners
more frequently, but rarely consult specialists and dentists. The access to ambulatory health care entails
728
Persons who have been granted Austrian citizenship and did not have EU- or EFTA citizenship before
Freidl, W., Stronegger, W.J., Rásky, É., Neuhold.C.(2001). “Associations of income with self-reported ill-health
and health resources in a rural community sample of Austria “ Sozial- und Präventivmedizin 46, pp. 106-114
729
240
longer travel times and waiting periods.730 Those who are socially weaker take less advantage of sick leaves
and have check-ups less frequently, for fear of losing their jobs, and consistently receive prescriptions for
cheaper medications.731 However, in contrast to several European countries, where the gap between socioeconomic classes has even increased throughout the past decades, the situation in Austria has improved at
least marginally during the 1990s.
A positive connection between the standard of living and life expectancy in Austria has been shown: there
is a strong correlation between the proportion of living category D (sub-standard) in urban and rural
districts and life expectancy.
For a proportion of 2.5%, the life expectancy is approximately 77 years. For 16%, it is only slightly over 75
years. Particularly in Austria, remarkable statistical correlations between mortality caused by malignant
neoplasms of the respiratory organs and living conditions have become apparent.732
8.6.5 Socio-economic status and health
Morbidity, measured in the number of episodes of illness and the duration of the episodes, decreases with a
higher level of education. For men a more or less linear decrease was experienced with the highest
morbidity of men having lower secondary education in comparison to the lowest morbidity of university
graduates. For women, female university graduates are an exception, displaying the second highest level or
morbidity, otherwise morbidity also falls with higher levels of education.733
Unemployed feature a higher morbidity than employed. According to social insurance data unemployed had
33 days of sickness whereas wage and salary earners had only 13 days. Employed men have more days of
sickness whereas unemployed women are sick more often (see following diagram). Data from the
household survey in 1999 (micro-census) shows a smaller difference between unemployed and employed
(23 vs. 9.3 days of sickness). Based on these surveys women have in general more episodes of illness, also
in the group of employed. The strong increase in morbidity for the unemployed in the 90ies originates from
a larger share of older citizens among the unemployed as well as the increasing morbidity rates of the
population older than 30.
730
Hofmarcher, M., Röhrling, G., Riedel, M. (2003). ″Age structure and health expenditure: Are the EU-countries
prepared for the EU-health-politics? Focus: Diagnosis poverty?″ Health System Watch III, pp. 10-20, supplement
to the journal of Austrian Social Insurance, Soziale Sicherheit
731
Habl, C. (2004). ″Options for reducing social inequalites in health care.″ WISO 2, pp. 93-104
732
Source: Survey Women and Poverty
733
Biffl G. (2004). Health and Employment Status. The Case of Austria. WIFO Working Papers 219, pp. 1-25
241
Figure 8.18 Morbidity rate of employed and unemployed by gender
Source: Biffl G. (2004). Health and Employment Status. The Case of Austria. WIFO Working Papers 219, pp. 1-25
As already mentioned before, the risk of poverty is situated at 11% for persons born in Austria, and at 23%
for immigrants who have been granted Austrian citizenship. Male and female immigrants run the highest
risk of poverty, at 28%.734
An analysis performed by the Hauptverband735 shows that the per capita cost for physician services,
pharmaceuticals and dental care is lower for consumers of services with foreign citizenship of all ages
compared to the per capita cost of consumers of services with Austrian citizenship. Especially for insured
older than 55 years there is a remarkable difference between the two groups. For more details see
Appendix 18.
8.6.6 Evidence on measures of mortality amenable to medical intervention: variation across regions736
The WHO European Health Report 2005737 published figures for mortality amenable to primary or
secondary prevention: average deaths per 100,000 population, figures for Austria and the UK are given in
the table below (Table 8.13).
Table 8.13 Mortality rates of diseases amenable to prevention (rates per 100,000 population, all ages)
Mortality amenable to primary prevention
Mortality amenable to secondary
prevention
Cancer of the
Cancer of the
Motor
vehicle
traffic
injurya
Cerebro
vascular
disease
Chronic
liver
disease
liver
lung
skin
breast
Cervix
Other
parts of
the
uterus
2.5
Upper
airway
and
digestive
tract
5.6
Austria
10.2
9.2
13.8
17.8
1.5
15.3
2.0
2.2
UK
5.7
10.7
6.7
0.8
5.0
17.2
1.4
20.6
2.7
1.2
734
Results from the EU-SILC, see Statistics Austria at www.statistik.at
Grillitsch (Hauptverband der österreichischen Sozialversicherungsträger, HVB). 23 June 2006 via email
736
737
WHO European Health Report 2005, available at http://www.who.dk/document/e87325.pdf
735
242
Analysis of amenable mortality, i.e. deaths that would be preventable if all the relevant knowledge, services
and resources of the health system and society were optimally applied can address how much health
systems specifically contribute to health. The primary prevention figures could show the impact of
interventions to reduce exposure to lifestyle and occupational risk factors. Secondary prevention figures
comprise impact of screening, early detection, diagnosis and treatment.
Table 8.14 shows the potential number of lost years of life (per 100,000) of under 70 year olds by cause of
death, in Austria for 1970 and 2000738. In Austria in recent years a number of health reports have been
published, which have for the first time compiled all available data on various topics, including diabetes,
obesity, allergy and neuropathic pain. These have been used as sources of information on mortality.
Table 8.14 Potential number of life years lost (per 100,000) of under 70 year olds
Women
Cause of death
Men
1970
2000
1970
2000
Infectious diseases
125,5
10,3
212,3
30,0
Malignant growths
1.338,0
816,9
1.517,0
1.003,7
Bowel cancer
130,8
65,9
167,8
83,6
Lung cancer
55,0
113,9
384,1
259,9
Breast cancer
255,0
200,7
-
-
Cervical cancer
87,0
22,8
-
-
Prostate cancer
-
-
25,1
24,1
Cardiovascular System
863,0
389,2
1.990,0
967,2
Ischaemic heart diseases
243,6
119,5
1.140,2
529,2
Acute myocardial infarction
171,8*
87,9
760,6*
383,2
Cerebrovascular diseases
285,4
94,7
459,0
140,2
Variations across regions
Regional differences have been determined in, for example, mortality due to cardiovascular diseases
CVD mortality
•
•
Statistical Information on health care in Vienna 2000/2002 (Statistische Mitteilungen zur
Gesundheit in Wien 2000/2002) – includes chapter on epidemiology covering mortality in Austria
and Vienna due to cardiovascular diseases.
Mortality - heart disease – across federal states – across districts of Vienna: further information
(various graphs) available on differences in morbidity and mortality comparing Vienna with the
other federal states and the districts in Vienna in general there appears to be an east west gradient
with mortality being higher in the western regions. See Figure 8.19 below.
738
City of Vienna. Life expectancy and mortality in Vienna. 2003 (Stadt Wien. Lebenserwartung und Mortalität in
Wien. 2003)
243
For further information on the “big city factor” analysis see Appendix 19 (slides from a presentation held
by Univ.-Prof. Dr. Rieder at the Hauptverband 22 March 2004) and the Viennese report on Myocardial
infarction 2004 (Wiener Herzinfarktbericht 2004) – Mortality data relating to cardiovascular disease
Figure 8.19 Ischemic heart disease mortality of under 75 year olds
1990 - 1999 by federal state and sex
100 = mortality in Austria
133
137,3
Vienna
98,9
104,2
Burgenland
100
100,7
Lower Aust.
93
94,3
Styria
90,5
85,4
Upper Aust.
Men
Women
87,9
80,2
Tyrol
85,7
78,9
Vorarlberg
Carinthia
73,4
82,6
80
79,3
Salzburg
0
100
Source: Statistische Mitteilungen zur Gesundheit in Wien 2000/2
Figure 8.20 Mortality of <75 year old men due to cardiovascular disease in Vienna, by district
149,1
140,6
139,3
137,4
131,2
130,7
130,6
130,5
130,1
130
128,6
126,7
124
123,4
20
15
11
10
3
14
12
5
16
21
22
7
9
2
17
6
13
23
4
8
18
19
1
92,7
50
116,2
111,4
110,6
109,7
105,1
104,6
102,9
102,4
100
100
= mortality in Austria
150
244
Figure 8.21 Mortality of <75 year old women due to cardiovascular disease in Vienna, by district
15
12
20
11
16
10
2
5
14
17
21
22
3
6
7
13
9
8
1
23
19
4
18
143,8
142,8
138,2
137,8
136,6
132,6
131,2
129,4
128,9
128,7
126,9
123,8
121,9
114,1
106,8
106,1
100,6
100,2
97,3
95,3
94,5
94
91,8
50
100
100 = mortality in Austria
150
Maternal mortality
Shortcomings of official registrations of maternal deaths, thus maternal mortality cannot be seen as a
reliable basis for health policy decisions, between 1980 and 1998 119 maternal deaths were registered at
Statistics Austria, confidential enquiries showed 191 maternal deaths.739
Infant mortality
Austria has one of the lowest infant mortality rates in Europe. The mortality rate has been fairly static
between 1999 and 2002, a further reduction cannot be achieved by advances in medicine alone. It will be a
challenge for public health, politics, physicians and society to reduce well known risk factors, such as
alcohol abuse, heavy overweight and smoking during pregnancy.740
Cancer
Cancer mortality decreased between 1970 and 1996, the decrease in total cancer mortality is promoted by
three tumour sites (the leading causes of cancer in 1970), stomach cancer, followed by colorectal cancer in
women and lung cancer in men. The observed changes in mortality are primarily related to changing
incidence and early detection, rather than improvements in treatment.741
Analysis of cancer mortality 1970-2002, observed changes (decreasing rates) are primarily related to
changes in incidence and in the last decade to improved treatment and early detection, but neither of these
contributions can be quantified.742
Examination of the prevalence (Self-reported) of cervical cancer screening and impact on cancer mortality
show that mortality has nearly been halved between 1980 and 1996, most of its reduction must be attributed
739
Karimian-Teherani, D., Haidinger, G., Waldhoer, T., Beck, A., Vutuc, C. (2002). ”Underreporting of direct and
indirect obstetrical deaths in Austria 1980-1998.” Acta Obstetricia et Gynecologica Scandinavica 81:4, pp.323-327
740
Waldhör, T., Vutuc., C., Haidinger, G., Mittlböck, M., Kirchner, L., Wald, M. (2005). Trends in infant mortality in
Austria between 1984 and 2002.Wiener klinische Wochenschrift 117 (15-16), pp.548-553
741
Vutuc, C., Waldhör, T., Haidinger, G. Ahmad, F., Miksche, M. (1999). ”The burden of cancer in Austria” Eur J
Cancer Prev 8 (1), pp. 49-55
742
Vutuc, C., Waldhoer, T., Haidinger, G.(2004). ”Cancer mortality in Austria: 1970-2002.” Wien klin Wochenschrift
116, pp. 19-20
245
to the screening activities in the 1970s and a further decrease as a result of the expanded screening activities
in the 1980s.743
Survival of women with breast cancer in Austria by age, stage and period of diagnosis show between 199397 age –adjusted mortality decreased overall by 3.3%, it is concluded that treatment improvements, which
are accessible to all patients countrywide due to the compulsory state insurance system, may or impact on
mortality and survival, opportunistic screening to some extent contributed to some extend beginning in the
early 1990s.744
Lung cancer mortality in Austria reached its peak in 1973 and decreased gradually after a plateau by 23%.
As far as women are concerned, the risk of dying from lung cancer has risen dramatically for the last 20
years. Nowadays Austria has to cope with an increasing number of children and adolescents (especially
females) starting smoking very early.
Diabetes
In Austria in 2002 2028 deaths (874 men and 1154 women) were recorded with the diagnosis of diabetes
mellitus (E10-14in accordance with ICD10) (see figure 8.22).745 Altogether 76 131 Austrians died in 2002.
The deaths due to diabetes mellitus, therefore make up 2.7% of all deaths (2.5% of deaths amongst men and
2.8% of deaths amongst women). With the exception of the over 75’s the number of deaths was higher
amongst men.
Looking in more detail at the individual federal states the most deaths due to diabetes were registered in the
eastern regions of Lower Austria, Vienna, and Styria, see Figure 8.22.
Figure 8.22 Number of deaths in Austria in 2002 with the diagnosis Diabetes Mellitus (E10-14
according to ICD 10) by sex and federal state
Source: own calculations using data from: Statistics Austria in the Austrian Diabetes Report 2004
Looking at the age standardised death rates for the various federal states in can be seen that, with the
exception of Vorarlberg, the death rates amongst men are higher than those of women. Furthermore death
rates due to diabetes are highest in Vienna, Lower Austria, Burgenland and Styria and are lowest in the
western states of the Tyrol, Salzburg, and Vorarlberg, see Figure 8.23.
743
Vutuc C, Haidinger G, Waldhör T, Ahmad F, Breitenecker G. (1999). ”Prevalence of selfreported cervical cancer
screening and impact on cervical cancer mortality in Austria.” Wien Klin Wochenschr. 111, pp. 354–359.
744
Vutuc, C., Waldhoer, T., Klimont, J., Haidinger, G., Jakesz, R. Kubista, E. , Zielinski, C. (2002). ”Survival of
women with breast cancer in Austria by age, stage and period of diagnosis.” Wien Klin Wochenschr. 114, pp.438-42
745
Austrian Diabetes Report 2004
246
Figure 8.23 Number of deaths in Austria in 2002 with the diagnosis Diabetes Mellitus (E10-14
according to ICD 10) by sex and federal state standardised rates per 100 000 living and of the same
sex
total
20
Men
Women
17,84
16,46
15,11
15
12,42
14,7
13,89
13,05
16,25
14,78
14,45
13,84
13,46
12,56
13,09
11,87
11,27
10,2
11,74
11,43
10,26
9,55
10
13,41
9,12
9,49
8,69
7,85
7,63
9,14
7,72
5,42
V
ie
nn
a
V
or
ar
lb
er
g
T
yr
ol
S
ty
ria
S
al
zb
ur
g
A
us
t.
U
pp
er
Lo
w
.A
us
t.
C
ar
in
th
ia
A
us
tri
a
0
B
ur
ge
nl
an
d
5
Source: own calculations using data from: Statistik Austria in the Austrian Diabetes Report 2004
It must be noted, however, that the interpretation of the Austrian cause of death statistics is afflicted with
many limitations, precisely with regards diabetes mellitus, and as such mortality rates are likely to be
underestimated: In the cause of death statistics those deaths with the diagnosis diabetes mellitus are
recorded on the death certificate when it is the underlying disease in a chain of illnesses. This underlying
disease is, however, often not known to the doctor present at the time of death and is as such not recorded
on the death certificate. Many deaths with underlying diabetes mellitus are, therefore, not documented as
diabetes deaths.
A further important limitation of the cause of death statistics is that omission of cardiovascular diseases as a
complication of diabetes. These are not provided for in the ICD 10 and are therefore not recorded in the
cause of death statistics.
For more information on mortality due to diabetes in Austria see Appendix 20 and the Austrian Diabetes
Report 2004.746
8.6.7 Factors contributing to changes in health status747
Some examples of factors that contribute to observed changes in health status include:
•
•
•
•
Lung cancer is increasing in women - see Appendix 21 – is considered to be linked with smoking.
Diabetes report (Diabetesbericht) – shows an increase in the incidence of diabetes
The acute myocardial infarction in Vienna – an analysis from 2002 (Der akute Herzinfarkt in Wien
– eine Analyse aus dem Jahr 2002)
More on reduction of mortality due to screening – see section on prevention and screening
programs further on
Obesity
The first Austrian Obesity Report was published in August 2006. Obesity is associated with a higher
morbidity and mortality. Obesity related diseases and disorders include diabetes mellitus type 2, diseases of
the gallbladder, insulin resistance, breathlessness, sleep apnoea (relative risk > 3), cardiovascular diseases,
osteoarthritis of the knee, hyperuric aemia, gout (relative risk 2 – 3), cancer of the breast, endometrium and
746
747
Download available at www.bmgf.gv.at
247
colon, disturbances of the sexual hormones, polycystic ovary syndrome, back pain, increased risk of
complications during surgery, and foetal defects (relative risk 1 – 2).
In 2004 5,839 cases were documented with a primary discharge diagnosis of obesity from Austrian
hospitals, this is equivalent to a rate of 71 per 100,000 inhabitants of the same sex and age. Almost two
thirds of these discharge cases (3,740) were women, the peak age being lower than that for the prevalences
of obesity. The overall duration of stay was 73,400 days, equivalent to 12.6 days per case (15.9 for men and
10.7 for women). The actual situation is vastly underestimated since obesity is seldom documented as the
primary discharge diagnosis.
A special analysis of the hospital discharge statistics of the Viennese Hospital Network allows certain
conclusions to be drawn with regards the frequency of obesity related co-morbidities in Austria, causalities
could however not be deduced: In 2005 obesity was most frequently registered as a secondary diagnosis for
the primary diagnosis group of circulatory disorders (29%), and here above all with ischemic heart disease
(12% of all cases). 13% of discharge cases with obesity as the secondary diagnosis had a primary diagnosis
of diseases of the musculoskeletal system and connective tissue, 11% had a primary diagnosis of diseases of
the digestive system.
For both sexes the frequency of occurrence of diabetes mellitus is highest amongst the obese compared to
over and normal weight persons. In 1995 it was estimated that 12.5 per 100,000 new cancer cases amongst
men and 14.9 per 100,000 amongst women were associated with overweight and obesity. Obese persons
have a significantly higher risk for various forms of cancer (Men: colon, rectum, pancreas; women: uterus,
non-Hodgkin-lymphoma, breast in women > 65 years).
Obesity increases mortality and shortens life expectancy, especially of younger people. An extremely obese
young person (20 – 30 years, BMI > 45 kg/m2) probably loses 13 (man) or 8 (woman) life years as a
consequence of obesity. Overweight 40 year olds lose 3 life years, obese persons of the same age 6 – 7
years.
Table 8.15 Inpatient cases treated with main diagnosis of obesity (E66 according to ICD-10) or
localised obesity (E65) by federal state, Austria, 2004
Federal State
Lower Austria
Vienna
Upper Austria
Styria
Tyrol
Carinthia
Salzburg
Vorarlberg
Burgenland
unassigned
Total
Males
Females
623
384
295
284
124
112
93
71
100
13
2.099
Total
787
641
592
421
442
264
236
254
84
19
3.740
1.410
1.025
887
705
566
376
329
325
184
32
5.839
Source: Statistics Austria, own calculations
Table 8.16 Inpatient cases treated with main diagnosis of obesity (E66 according to ICD-10) or
localised obesity (E65) by federal state, Austria, 2004
Federal State
Males
Females
Total
Vorarlberg
40
140
90
Lower Austria
81
98
90
Tyrol
37
125
82
248
Carinthia
Burgenland
Upper Austria
Vienna
Salzburg
Styria
Total
41
74
43
50
37
49
53
91
59
83
76
87
69
89
67
66
64
64
63
59
71
Source: Statistics Austria, own calculations
Notes: Rates per 100.000 inhabitants of the same sex and federal state. For more information see the Austrian Obesity
Report 2006748.
According to available data an increasing trend in prevalence of obesity can be observed in Austria: In the
adult population obesity rose by 7% from 8.5% to 9.1% between 1991 and 1999 (self reported). Measured
data from Vorarlberg, a region traditionally having a low prevalence of obesity, show an increase in
prevalence of obesity of 14% for men (from 8.5% to 9.7%) and 17% for women (from 11.7% to 13.7%),
within the same time frame. In 1991 3.3 % of recruits to the Austrian federal armed forces were obese, in
2002 5.3% were obese (an increase of 61%).
International data point out that there are practically no countries in which the prevalence of obesity is not
rising. Even in countries with a traditionally low prevalence, as well as, in many so called developing
countries, an increasing trend in prevalence of obesity has been observed, above all in the echelons of
society who have embraced a western lifestyle. A further increase in prevalence of obesity has been
predicted for the future, at the current rate of increase half the adult population will have a BMI > 30 kg/m2
by the year 2040.
8.6.8 Are these factors related to health care, public health, health policy, lifestyle or other aspects
It is to be expected that all of the above factors influence health status. In the case of the effect of altering
lifestyle factors international studies are used as indicators of the possible successes of implementing
preventive lifestyle measures. In the case of coronary heart disease the BMJ published a paper modelling
the decline in CHD deaths in England and Wales 1981-2000: comparing contributions from primary and
secondary prevention.749 For details see Appendix 22.
Health reports have shown increasing trends in various risk factors. As outlined in 8.3.2 above, obesity
plays a major role in the health of Austrians750 (Österreichischer Adipositasbericht, 2006). The 1st Austrian
Allergy Report751 has also compiled all available data on allergies in Austria. From the evaluation of data
from military health examinations carried out for all 18year old men eligible for national service between
1986 to 2005 it was possible to gain an idea of the trends. These data showed that the prevalence of all
allergies is increasing amongst 18-year old men eligible for national service. The Viennese health and social
survey (Wiener Gesundheits- und Sozialsurvey) from which data was also presented in the Allergy Report,
lists smoking, passive smoking and environmental pollution as possible influencing factors leading to a
worsening of allergies, see Tables 8.17 and 8.18.
748
www.alternmitzukunft.at
Unal, B., Chritchley, J.A., Capewell, S. (2005). ” Modelling the decline in coronary heart disease deaths in England
and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention.” BMJ 331, pp.
614-619
750
Erster Österreichischer Adipositasbericht 2006, accessed at:
http://www.welldone.at/upload/3031_AMZ_Adipositas_3108_final.pdf
751
downloadable from www.alternmitzukunft.at
749
249
Table 8.17 Aggravation of allergic rhinitis through the environment
Worsening of allergy
related cold through:
Smoking
Passive smoking
Environmental pollution
yes
No
5,3
18,4
20,0
33,3
50,7
50,7
Not applicable
(don’t smoke)
43,1
8,0
4,5
Don’t know
No response
8,8
13,1
15,1
9,6
9,8
9,8
Don’t know
No response
9,2
11,2
15,3
16,3
16,3
15,3
Source: Wiener Gesundheits- und Sozialsurvey, own calculations
Table 8.18 Aggravation of Asthma through the environment
Worsening of asthma
through:
Smoking
Passive smoking
Environmental pollution
yes
No
22,4
32,7
34,7
11,2
32,7
32,7
Not applicable
(don’t smoke)
40,8
7,1
2,0
Source: Wiener Gesundheits- und Sozialsurvey, own calculations
It was also found that children whose mothers smoked during pregnancy had a high risk for developing
allergic rhinitis. A potential protective factor, on the other hand, was growing up on a farm.
Other factors are mentioned below:
•
•
•
•
According to Kalla K, et al. (2006) implementation of guidelines improves the standard of care: A
significant improvement in clinical outcomes, with respect to in-hospital mortality, was associated
with implementation of guidelines.752
Could be linked with lack of knowledge (e.g. of own blood pressure).753
Survival of women with breast cancer in Austria by age, stage and period of diagnosis show
between 1993-97 age –adjusted mortality decreased overall by 3.3%, it is concluded that treatment
improvements, which are accessible to all patients countrywide due to the compulsory state
insurance system, major or impact on mortality and survival, opportunistic screening to some
extent contributed to some extend beginning in the early 1990s.754
In 1997, an activity-based hospital financing system (so called LKF-system) was implemented in
Austria. This fundamental change was a switch from a reimbursement system to a purchasing
system combined with a fixed budget. This could have consequences for data such as hospital
mortality data and discharge statistics.
Overall factors having the most influence on the health of Austrians appear to be lifestyle related. The
Austrian Health Report 2004755 lists following factors:
•
•
Overweight - Between 1991 and 1999 the number of overweight persons aged over 15 years
(Body- Mass-Index - BMI - between 26 and 30) has risen. In the same period the share of
massively overweight persons (BMI over 30) also rose.
Hypertension and lack of awareness - In the sample census on health of 1991, approximately 8.3%
of the respondents (Austrians over 15) indicated that they suffered from hypertension (i.e. around
752
Kalla, K., Christ, G., Karnik, R. et al. (2006). ” Implementation of Guidelines Improves the Standard of Care.
The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI
Registry).” Circulation 113 (20), pp. 2398-2405
753
Fodor, J.G., Lietava, J., Rieder, A., et al. (2004). ” Work-site hypertension prevalence and control in three Central
European Countries.” Journal of Human Hypertension 18 (8), pp.581-585
754
Vutuc, C., Waldhoer, T., Klimont, J., Haidinger, G., Jakesz, R. Kubista, E. , Zielinski, C. (2002). ”Survival of
women with breast cancer in Austria by age, stage and period of diagnosis.” Wien Klin Wochenschr. 114, pp.43842
755
Download available at www.bmgf.gv.at
250
•
•
•
530,000 people), with women more strongly affected than men (8.8% v. 7.7%). Here the number of
incorrect statements is likely to be high, as according to experts, Austria has approximately 1.5
million hypertension patients.
Nutrition - Only around 37% of the respondents (sample census 1991) reported having a healthy
diet, with women of any age group attaching more importance to healthy nutrition than men. The
2003 Austrian Report on Nutrition gives a favourable assessment of the trends regarding food
eaten, in particular the rise in use of vegetables, fruit and fish was generally regarded as positive.
However, it also showed that Austrians still eat too much rich food and that total fat intake is too
high.
Lack of exercise – Only around 37% of the population pursue exercise or practice sports to
preserve health or to prevent diseases.
Smoking - 30% of the population are daily cigarette smokers. The share of male smokers (36%) is
significantly higher than the share of women smoking (27%). However, the share and number of
female smokers (in particular young people) are rising.
8.7 Health targets in Austria756
Health targets have been defined or at least discussed in one way or the other in various European countries
as a tool to aid the development and monitoring of health policies.757 Thus, health targets are meant to serve
as steering instruments but should also be used to measure results.
8.7.1 National health targets
The discussion on targets in health care was revived in 2002. This is documented in the conference report of
the 3rd Austrian health care conference.758 At that occasion thoughts on the development of a national health
care plan were presented which however did not come into effect at that time. The government programme
for the XXII legislative period envisaged the formulation of Austrian health care targets and set up a list of
certain activities planned in the health care sector. These activities were entirely of administrative and
structural sorts and not related to the health care status of the population. The Austrian health care
conference was recorded to be a medium for efficient discussions between all in charge in order to achieve
better coordination in the area of health care. The federal Minister of Health and Women, Maria RauchKallat presented the “health care goals 2010” on the occasion of the health care conference 2003. These
goals consist of three general objectives or principles and the definition of five activity areas.759
Health care goals include:
-
Best quality of medical care provided
Clear, efficient structures
Expenses are realigned with income
Five fields of activity:
-
Health promotion
Quality assurance
Innovations
Structures
Finances
756
Mag. Daniel Hentschel MSc.
Marinker, M (2002). Health targets in Europe: polity, progress and promise. London: BMJ Publishing Group.
758
BMGF (2002).Health care conference. accessed at
http://www.bmgf.gv.at/cms/site/attachments/3/5/8/CH0011/CMS1038854676005/gesundheitskonferenz_2002.pdf
759
Rauch-Kallat, M. (BMGF) (2003). Health Care Targets 2010. Presentation given November 10, 2003 (Austrian
Health Care Conference), accessed at www.bmgf.gv.at
757
251
In addition the following “health care dialogues” were established as a participative method for the further
development and specification of goals:760
-
Consumer orientation in the health care sector
Health promotion
Public Health / Food safety
Liberty vs. addiction
Quality assurance in health care
Children’s health care plan
Action programme hospice
Health care professions
Management of pharmaceuticals
Digitalisation in health care
Health care insurance
Health care agencies
In the course of the health care reform in 2005 three health targets were defined:761
-
Reduction of cardiovascular mortality by 40% until 2020 (for the population younger than 65
years)
Reduction of the prevalence of carcinomas by 15%
Reduction of the prevalence of diabetes by 20%
In the agreement according to article 15a of the Federal Constitutional Act, which was signed by the
Federation and the federal states in 2005 the following goals were defined:762
-
Support measures for health promotion
Introduce a compulsory quality system for the Austrian health care system which will improve
efficiency. This should be continuously developed further.
Create the requirements for an effective and efficient use of information technology in health
care
Achieve integrated and co-ordinated planning and steering of all areas in health care
Improve interface management between the institutions providing health care services
The Austrian People’s Party (Österreichische Volkspartei, ÖVP) took up the topic of health targets in a
brochure763, but didn’t pursue it with great emphasis.
In August 2006 the federal minister of health, Maria Rauch-Kallat presented the initiative „Austria: Health
Care World Champion 2010“ in the course of which ten health care targets for the year 2010 were defined.
The initiative is, according to the federal minister, aimed at “mobilising all actors in the health care system
as well as the entire Austrian population to make the Austrian health care system the best health care system
and the Austrian population the healthiest” worldwide764. The ten targets are the following:765
1.
2.
3.
Reduction of people younger than 65 years dying of cardiovascular disease by 20%
Reduction of the number of people dying because of cancer by up to 7%
Reduction of the amount of damages caused by diabetes by about 1/3
760
Hofmarcher, M., Kraus, M., Riedel, M. (2004). Health targets and indicators as steering instrument of social health
insurance, Project report. Commissioned by the Hauptvebrand der österreichischen Sozialversicherungsträger. Institute
of Advanced Studies. Vienna
761
Organisation on behalf of the European Observatory on Health Systems and Policies.
762
Article 15a of the Federal Constitution, Preamble
763
Austrian Peoples’ Party (OEVP) (2006). Plant ideas, harvest future, perspective for Austria – materials for the
future talks 2006. brochure, accessed at
http://www.oevp.at/loadcontrol.aspx?type=download&fstep=2&f=677&bi=19
764
Bundesministerium für Gesundheit und Frauen, www.gesundheitsweltmeister.at
765
Further information can be found on the website of the initiative www.gesundheitsweltmeister.at.
252
4.
5.
6.
7.
8.
9.
10.
Containment of adiposity
Reduction of communicable diseases
Reduction of the number of accidents by 25%
Improvement of psychosocial well-being
Reduce tobacco consumption considerably
Reduce alcohol consumption considerably
Improve the status of dental care
Further information can be found on the website of the project, www.gesundheitsweltmeister.at.
8.7.2 Regional health care goals
On the regional level the regional sickness funds of the federal states of Upper Austria (OÖGKK), Lower
Austria (NÖGKK) and Styria (STGKK) have developed health care targets766 (the goals of the OÖGKK and
the NÖGKK are in the Appendix 23).
Political practicability and effectiveness of health care targets depends strongly on the existence of clear,
qualitative indicators. To be able to assess the degree of concretisation of health care targets Czypionka et
al. differentiate between the following levels of classification:767
-
Goals: general description of what is to be achieved in the long term, based on values and
principles
Objectives: more specific description of how a target can be reached, can partly be achieved within
a planning period
Qualitative Target: more specific than an objective, is to be achieved by a certain deadline
Quantitative Target: includes a mechanism for evaluation with measurable indicators , designed
to monitor progress or development
Based on this classification the authors assign the targets which were published by the Ministry of Health
and Women solely to the “goals” category. Only 5 areas of activity are defined as well as 3 very general
health targets from which it is not possible to derive quantifiable indicators related to the health care status.
The 10 health care targets of the regional sickness fund of Upper Austria however are qualified as tangible
“quantitative targets”. It can be seen in Appendix 23 that these goals effectively specify not only the
quantitative extent of aspired changes (e.g. reduction of consequences of diabetes by 10%) but also the time
frame (e.g. by the year 2010). The targets of the regional sickness fund of Lower Austria are partially
precisely specified (20% less individuals suffering from alcohol related diseases by the year 2010), and
partially rather vague (e.g. higher usage of preventive services).
8.7.3 Targets in Social Insurance
Beginning with the year 2000 Austrian social insurance funds have to define short- and medium term goals
related to health politics and social politics. These have to be harmonised with politics. Social insurance
uses the Balanced Scorecard method, a target steering instrument. Innovation projects were defined in the
areas of hospital funding, controlling of services, controlling of contributions, questions related to provision
of dental services and psychotherapy, disease management, health promotion, evidence-based
reorganisation of preventive services, development of new tariff models for transportation, quality
development and development of the learning organisation.
766
Probst, J.(2005). Starting position and visions for the Austrian health care sytem. In: Sprenger, M. Eds. (2005).
Public Health in Austria und Europe, Lengerich, Pabst Science Publishers.
767
Czypionka , T., Kraus, M., Riedel, M.., Röhrling, G. (2005). “Focus: Health targets: wide-spread or a mere isolated
case in Europe?" Health System Watch IV, supplement of the Austrian journal of social insurance, Soziale Sicherheit,
pp.8-14
253
Goals of Social insurance 2006
The catalogue of goals of Austrian social insurance for 2006 defines 21 precise targets, which are
subdivided into the areas “continuous development and learning”, “optimised processes”, “consolidation of
finances” as well as “optimal care of customers”. Even if these targets may be exemplary in terms of
definition and quantification, most of them can not be defined as “health goals” in an actual sense. The
majority of targets relates to internal processes and structures, only very few, like for instance those on
disease management projects for diabetes have a direct connection with the health status of the population.
Some of the targets are exhibited in a table in Appendix 23.
Further considerations
In the process of setting national-, regional- and other targets, international goals such as the WHO Health
for All goals should be also taken into consideration and mapped with the Austrian goals on the lower
levels. An example for such a mapping exercise is the outcome of the project “Metamodel Quality” in
which a relationship was established between the quality targets of social insurance and the WHO Health
for All targets. In the realm of this project a model based on the WHO Health 21 – Health for all in the 21st
century goals (released in 1998) was set up and a matching exercise performed between the quality related
projects in social insurance and the Health for All targets. A matrix was chosen as display instrument and
followed up by an assessment. The project report comes up with 21 recommendations for actions. More
information related to this project can be found in Appendix 10.
254
9. SUMMARY AND CONCLUSIONS
Measuring performance of health systems has gained attention in recent years, as marked by an increase in
international and national efforts to compare health system performance across countries. Many attempts at
performance measurement have been based on a composite indicator generated according to a set of two or
three criteria which are typically related to health status without reference to the other functions of the
health system. While these exercises provide general impressions of the state of health care in one country
compared to another, and may allow countries to be ranked on the basis of the chosen criteria, they fail to
identify the specific areas where shortcomings exist and the means by which improvements can be made.
Therefore, it is more useful to undertake analyses of health systems from the perspective of the multiple
functions of the system including financing, payment methods, resource allocation, access to care, quality
of care and satisfaction, and its overarching objective – health improvement.
Financing health care
Analyses of health systems generally begin with a discussion of financing, which includes overall level of
spending and rates of growth, sources of financing, and implications in terms of progressivity or
regressivity. Overall, health spending has increased consistently in the past decades across Europe and other
developed countries. While previous estimates of health expenditure in Austria have placed it about average
among European countries, more recent estimates using the OECD system of health accounts places it
much higher: the share of the GDP spent on health care in Austria amounted to 9.6% in 2004 compared to
7.5% based on the former calculation method. This value places Austria above the EU 25 average of 8.6%
with only Germany and France showing higher health care spending within Europe. Spending on health
care continues to rise in all countries; average annual growth rate from 1992-2002 in Austria was slightly
lower than that of the EU15: 6.3% compared to EU15 average of 6.9%.768
Separating the components of financing into public and private sources, it appears Austria has a relatively
larger share of private funding than most other European countries. Indeed, the level of private expenditure
increased at an annual rate of over 4% from 1997 to 2002, mostly because of increasing user charges. In
2004 Austria had the 3rd highest proportion of private funding in the EU15 and the 9th highest among 30
OECD countries. Within this private component, private health insurance makes up about a quarter, with
the remainder derived from out-of-pocket payments. Private insurance in Austria only amounts to 2.4% of
total health care expenditure. It is mainly used to pay for better accommodation in the private ward of
hospitals, treatment by a certain doctor and reductions in waiting time. However, private health insurance
accounts for 7% of the revenue of public hospitals.
The reduction of the proportion of total revenue generated through wages (wage quota) in the past has
various implications for social insurance. First, it results in a reduction in social insurance contributions.
Moreover, revenue generated by social insurance contributions in the branch of health insurance rose
between 1993 and 2000 by 26% whilst expenditures in this area increased by 32.3%. Wages depicted a
relatively smaller increase than the GDP; the growth rate of expenditures of social health insurance is
higher than the GDP growth. In such a situation (the erosion of the contribution base of social insurance) it
is important for social insurance to create new options for acquiring funds, such as including income
generated through assets in the contribution base. Moreover, inequality in wage income has increased
during the past three decades. With respect to gender specific differences in income, the women’s median
income is situated at 67.2% of the of men’s median income.
Unfortunately comparative analyses of progressivity (the extent to which individuals on higher income are
contributing relatively more to the financing of the system) have excluded Austria. However, one can infer
on the basis of our analysis of the financing system that Austria would rank relatively low on the scale of
progressivity. This results partly from the significant private component to financing, of which two-thirds
consists of the most regressive form of funding – out-of-pocket payments, and the other third consists of
private health insurance which is largely available to higher income earners and civil servants. Although
user charges constitute a significant portion of health spending in Austria, a range of exemptions apply
limiting their regressivity. Moreover, since social health insurance, or payroll taxes, are less progressive
768
This growth rate estimate was based on the previous method of expenditure calculation.
255
than the most common funding alternative – general taxation – the level of progressivity in the Austrian
system is lowered.
Examining the components of health care financing in Austria more closely, it appears that taxation on
income is progressive up to a certain income limit, above this it is regressive, while consumption taxes (e.g.
value added tax), which represent the largest share of tax income, have a regressive effect. The share of
taxes exercising a progressive effect (income tax, revenue tax, tax on assets) is relatively low. Social
insurance contributions are calculated based on the insured’s ability to pay. The burden of insurance
contributions of income increases proportionally until a defined earnings limit for chargeable contributions
is reached. Beyond this limit contributions are regressive. Social insurance resource redistribution takes
place, between high- and low income earners, between generations, between the healthy and the sick and
between insured without and with dependants.
Access to health care
Not only is the performance of the health system measured by the fairness and efficiency of financing, but
also by the extent to which access to services is fair, or equitable. Equitable access to health services, i.e.
access based on need and not ability to pay, is an oft-pursued goal among European governments. The
following barriers are applicable to preventive health services and also to health care services in general:
disability (inadequate disabled access to facilities and knowledge of the needs of disabled, discrimination,
difficulties in communication (Braille, sign language)), migration (language, entitlement to benefits), and
lack of health insurance. Reasons for not accessing health services may be unemployment (less investment
in own health), multiple burdens (caring for family members, single parent families) often combined with
risk of poverty and lack of knowledge.
This report presents the results of two comprehensive analyses of equity in health care use among a
selection of European countries. The first uses European Community Household Panel Survey data and
analyses equity in the probability of a health care visit and the mean number of annual visits. While GP
services are largely equitable or pro-poor, for specialist care, individuals on higher income are more likely
to access services after controlling for need (therefore there is pro-rich inequity) in all countries, especially
Portugal, Ireland, Italy and Spain. Among the 12 countries included in an analysis of equity in inpatient care
particularly significant pro-rich inequity is seen in the probability of an inpatient admission in Portugal,
Greece, Italy, Austria, Ireland and Germany. The second study uses data from the Survey of Healthy
Ageing and Retirement in Europe to analyse equity in health care utilization among the over-50 population
in ten European countries. For GP services, the only countries with pro-rich inequity are Italy, Sweden and
Switzerland; however specialist care is pro-rich in Spain, Austria, Sweden, Germany, France, Italy,
Switzerland and Denmark. Inpatient care only appears inequitable favouring higher income groups in
Greece.
In terms of equity in health care utilization, Austria fares quite well. In both comprehensive studies, despite
having pro-rich inequity in specialist care, it appears lower than most other countries, and there is no
inequity in GP services. However, in the first study, pro-rich inequity in inpatient care in Austria is quite
high – indeed Austria is ranked third highest out of 12 European countries. However, this finding is
complicated by the fact that it only measures the probability of a hospital admission, and not the number of
separate admissions. The causes of inequity appear to largely be income and education.
In principle people in Austria receive equal treatment, independent of their income (especially emergency
care). There are few indications that services of social insurance in Austria are more easily accessible and
consumed more frequently by individuals with a higher income (e.g. visits to specialists). As far as
emergency care is concerned treatment is thought to be independent of income, although for elective care
waiting times may be shorter for individuals covered by private health insurance. An analysis performed by
the regional sickness fund in Carinthia in 2002 showed that patients of the lowest income group incur
double the expenses for the fund as patients of the highest income group. High users (the group of insured
responsible for 50% of the expenses of the regional fund) mostly belong to the group of the low income
earners (€0-900).
Cost-sharing arrangements may contribute to inequitable access to care. In Austria some health insurance
funds impose user charges for physician visits (flat rate (farmers) co-payments (self-employed, civil
256
servants), insured according to the ASVG law pay a yearly charge of €10 for the e-card. Other countries
such as France, Italy, Sweden and Switzerland, also impose user charges for physician visits. Austria also
has a flat co-payment for prescription drugs and an inpatient co-payment per day up to a 28 day maximum.
While exemption mechanisms are in place to protect the most vulnerable groups, such as low income
earners and older people on pensions, it is still possible that user charges may deter individuals from
seeking care. Further exacerbating potential inequalities resulting from cost sharing, in Austria since
insurance funds are authorised to implement fund-specific co-payments, these levels differ across insurance
funds.
The financial burden of user charges placed on an individual varies according to the affiliation to a certain
sickness fund. A couple of studies have calculated average user charges of each group; comparison is
difficult though because different definitions of user charges and varying reference bases are used (insured
with or without dependents). With respect to income, women of the lowest educational group spent roughly
twice as much as women of the highest education group. For men the difference amounts to about a fifth. A
study performed by the regional sickness fund in Carinthia shows that insured in lower income groups pay
higher average user charges than those in the higher income groups. User charges increase with the age of
the insured. Moreover, costs per prescription range between €17.48 (insurance fund of farmers) and € 24.20
(Austrian Social Insurance Authority for Business) in 2005. However, in a study commissioned by the
WHO only 4.7% of the individuals questioned in Austria stated that they could not afford a certain
treatment during the past year. In general it is assumed that user charges in Austria do not, due to extensive
exemptions, restrict access to health care in a significant way.769 This is consistent with the analysis of
SHARE showing less than <3% of the sample declared to forego care because of costs (among 50+
population), low in comparison to other European countries.770
It is also important to consider specific population groups that may be experiencing significant barriers to
accessing health care such as migrants, asylum seekers and refugees. While European law is attempting to
harmonise the conditions for asylum seekers to receive health care, there are still obstacles present in some
countries. In Austria, about 4.5% of asylum seekers remain without health care cover. Migrants are more
likely to be endangered by poverty (28%) than people who are born in Austria (11%), however access to
health services should be equal for both groups. Apart from lack of insurance coverage language or cultural
barriers may exist, partially combined with lacking knowledge on benefits entitlement. Foreigners may
delay seeking medical advice thus then being at risk of having a more severe and chronic sickness
spells/illnesses.
Geographical barriers to access may exist such as overall availability of services, distance to health care
facilities, and difference in proximity to health services across income groups. Austria has among the
highest supply of hospital beds in Europe, next to Germany, Czech Republic, and Lithuania. Despite this
high availability, data from a Eurobarometer survey in 2002 show that about 40% of Austrian respondents
reported access to a hospital in less than 20 minutes, compared to 60% in Belgium, 65% in Italy, and 70%
in the Netherlands. Perceived access to GPs is, predictably, much better, with almost 80% of Austrians
reporting access within 20 minutes (same as the EU average). When examining the difference in proximity
across income groups, Austria fares very well, with almost the lowest discrepancy in reported distance to a
hospital between the lowest and highest income quintile in the EU.
The number and distribution of contract physicians is regulated by the Location Plan (Stellenplan) which
should grant a fair and efficient provision of care through physicians in primary care. Beyond the Location
Plan another instrument that aims to ensure an equal distribution of health care facilities is the Austrian
Structural Plan for Health Care (Österreichischer Strukturplan Gesundheit, ÖSG). Geographical access in
case of emergency is in general in line with international standards. Access to other types of care may,
especially in rural areas, be accompanied by longer travel distances, which are largely considered
acceptable (max. 1.5 hours). Reimbursement of travel costs varies among the sickness funds. Another
instrument to improve access to care is the analytical tool developed by the Hauptverband called
REGIOMED with which benchmarks for the provision and utilization of medical services in the ambulatory
setting can be calculated to identify over and underprovision. These are used in negotiations related to the
Location Plan.
769
770
“Who pays for your health care” accessed at http://www.gewinn.co.at/kredite/content.php?article=888m on 5.01.06
SHARE data can be accessed at the following website: http://www.share-project.org/
257
In addition, it is important to examine the extent to which accessibility in terms of supply of services and
personnel may vary across Austria’s regions. Vienna has the most practicing physicians, GPs, specialists,
dentists per capita, while Vorarlberg and Burgenland have the least doctors per capita, and Lower Austria
and Upper Austria depict a low number of dentists per capita. Most contract doctors per capita can be found
in Vienna, the least in rural areas such as Vorarlberg, Burgenland, Upper Austria and Tyrol. Rehabilitation
clinics for inpatient care integrated with social insurance funds are mainly situated in the federal states of
Upper Austria, Lower Austria and Styria, and integrated ambulatory clinics in Vienna, Styria, Upper
Austria and Lower Austria. Tyrol and Vienna had the highest density of doctors per bed in hospitals in
2005; Salzburg and Carinthia were the federal states with the lowest density. The highest density of nonmedical personnel in hospitals (per 100,000 inhabitants) can be found in Vienna, Styria and Carinthia, the
lowest in Burgenland. As far as physiotherapists are concerned Vienna has a significantly higher number
per capita than other federal states, most of the midwives per capita are in Vorarlberg and Carinthia.
Hospital bed density varied considerably in the federal states in 2005, the highest density being in Carinthia
(918.07), Salzburg (909.51) Vienna (812.93) and Styria (875.29, the lowest in Vorarlberg (600.12) and
Burgenland (565.2)). The highest number of homes for elderly people is in Styria, Upper Austria and Lower
Austria, most CTs and MRIs are located in Vienna.
Other evidence of equity in the use of services in Austria suggests that socioeconomic factors are impacting
utilization patterns, and there are regional inequalities in utilization within the country. Based on 1999
micro census data, participation in health-check ups increased for individuals with a higher level of
education. Visits to GPs and ambulatory clinics decreased for individuals with a higher education, while
visits to specialists and dentists increased. Participation in health check ups was highest in Vorarlberg
(22.9%), followed by Tyrol (20.9%) and Carinthia (17.2%), it was lowest in Lower Austria (4.9%), Vienna
(8.7%) and Upper Austria (9.2%).Visits to GPs are most frequent in Lower Austria, Upper Austria and
Styria, visits to ambulatory clinics in Vienna. Citizens in Lower Austria, Vienna, and Carinthia consult
dentists most often, citizens in Burgenland and Upper Austria least often. Average length of stay per citizen
was lowest in Tyrol (5.17 days) and highest in Lower Austria (9.64), the Austrian average being 6.58 days
per inhabitant. In 2004 prescriptions per insured (13.8) as well as costs per insured (€ 281.13) were lowest
for insured of Austrian Social Insurance Authority for Business and highest for insured of the insurance
fund of the Austrian Mining Industry (27.9 and €569.69 respectively). Average days spent in hospital in
2005 were between 6.8 days (insurance fund for the self employed) and 7.9 days (occupational sickness
funds, sickness fund for the Austrian Mining Industry). The fewest billed cases per contract physician (all
medical specialities) were provided in 2005 in Vorarlberg (4,141), the most in Upper Austria (4,664). The
tariff reimbursed per case varied between €41.41 in Upper Austria and €51.77 in Lower Austria. The tariff
per physician was highest in Lower Austria €219.14 (in 1,000 Euros) and lowest in Carinthia (€193.54).
Regulating health care
Regulation involves many functions and takes place at many levels of the health system. There are three
principle models of organizational relationship between purchasers and providers: (1) integrated; (2)
contract; and (3) direct payment to providers. Government may play a regulatory role at national, regional
and district levels; many countries have independent monitoring agencies (e.g. UK). Also regulatory
functions may be the responsibility of at non-governmental independent or arms-length bodies. There is a
general continuum of state authority and supervision that ranges from: command-and-control (e.g. NHS
trusts in the UK; public hospitals in Austria and Germany), to arms-length approaches such as private notfor-profit entities with statutory responsibilities (e.g. sickness funds) and private-for-profit companies with
or without service agreements with public payers (e.g. private hospitals in Italy and Portugal). In almost all
EU countries, health technology assessment (HTA) programs have been established (e.g. through the
Federation of Austrian Social Insurance Institution/Drug Evaluation Committee) with the aim to aid
national or regional priority setting and health policy processes. As seen in the rest of Europe, HTA is
increasingly being used for decision-making; however, further elaboration of HTA activities should be
encouraged.
Governments are beginning to acknowledge the importance of collecting and reporting data on quality and
other performance indicators in an attempt to better regulate the system and improve performance. Austria
could take the lead from other countries, such as Germany with the new national quality benchmarking
projects, and Demark with the widespread collection of quality indicators, to better inform regulators and
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decision-makers about areas of strength and weakness in the system, and inform patients who could also
stimulate quality improvements.
Health care provision in Austria is conducted by (1) integrated providers (institutions owned by social
insurance funds), (2) by health care providers who have signed a contract with social health insurance, and
(3) by private health care providers. The latter may also be accessed by insured persons, whereby they have
the option of claiming a refund from their sickness fund afterwards. For the provision of hospital services to
the insured population social insurance pays a lump sum based on the so called agreement pursuant to
article 15a of the Federal Constitutional Act, signed by the Federation and the federal states.
The Austrian health system does not have an independent supervisory commission that is comparable to the
Audit Commission in the UK. The Austrian system is hierarchical whereby duties and responsibilities are
primarily defined by law. It is mainly organized in a federal way, not only in the area of social insurance
funds but also in hospital care. Depending on the region the sanitary agencies of the federal states may have
a range of duties and responsibilities, primarily in the area of hospital care but formally also in the area of
ambulatory care (physicians in surgeries).
One serious challenge in Austria is the fragmentation of responsibilities for funding and providing services,
especially for secondary care. Although regulation is strongly based on federal (and some state) legislation
(in the SHI system, the Federation defines rules and insurance funds implement them and purchase
services), regulatory functions are largely decentralized. Thus, Government relies heavily on delegation of
regulatory functions and devolution to federal states, for example in the case of hospital care.
The Austrian Constitution stipulates that central responsibility for the health care system lies, apart from a
few exceptions, with the Federation. Government delegates most of these tasks to the federal states by
indirect federal administration arrangements (e.g. hospital care) or to social insurance by way of self
governance (e.g. provision of physician care). Recently a new independent institute for research and
planning has come into existence, the Health Care Austria Plc (Gesundheit Österreich GmbH). It merges
the Healthy Austria Fund (Fonds Gesundes Österreich), the Austrian federal institute for health care
(Österreichisches Bundesinstitute im Gesundheitswesen, ÖBIG) and will also include the Austrian federal
institute for quality in health care (Österreichisches Bundesinstitut für Qualität im Gesundheitswesen,
BIQG). The new institute will be responsible for providing the basis for decision-making for structural
planning in health care provision as well as for developing guidelines for quality assurance and health care
promotion.
Regulation and collection of taxes is primarily performed by the Federation; the revenue is distributed
among the Federation, the nine federal states and the communities according to the Financial Equalization
Act. A significant legal foundation for the system of funding, particularly for inpatient care, pertaining an
important co-ordinating function is the agreement reached between the Federation and the federal states
pursuant to article 15a of the Federal Constitutional Act. Funding within Social insurance is equally
regulated by law, namely in the General Social Insurance Act (ASVG) and in the relevant Social Insurance
Acts for the other professions (Self Employed, Civil servants, Farmers, etc.).
The Austrian Social insurance system is a pay-as-you-go system. The Federation renders a contingent
liability (Ausfallshaftung) in pension insurance, provided that the contributions of the insured do not cover
all the expenses. With the self-employed, Federation substitutes the employer and pays the difference
between the own contribution and the total sum. Physician services are mainly funded by social health
insurance, partially also by private households (non-contract doctors). The areas of prevention and health
promotion are financed by social insurance contributions and by tax payments. Social welfare payments are
covered mainly by the federal states and the communities, long term care services by the Federation and the
federal states.
Risk adjustment in Austrian social insurance does not assume a major importance although various
instruments for financial equalization are adopted. The intention of these systems is to promote coordination between the funds as well as equalization. The Hauptverband is in charge of equalizing and
distributing financial resources. The equalization fund of the regional sickness funds should, according to §
447a ASVG guarantee an equal financial performance i.e. liquidity of the regional sickness funds, and
render payments to the funds in accordance with the available financial resources and the legal definitions.
Initially the equalization fund included all sickness funds until this was declared unconstitutional (Now only
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the regional funds are part of the fund). In 2005 a restructuring of the equalization fund was agreed upon
which aimed at formulating a scientific model for the structural equalization between the regional sickness
funds. Now equalization is based on the revenue generated by contributions and by the prescription charge.
The average cost for each insured (by age and sex) as well as for insured generating extraordinarily high
costs is regarded. In addition to these aspects certain supply related factors such as regional burdens are
taken into consideration. Another risk pooling instrument is the equalization fund for hospital financing
whereby the sickness funds pay a lump sum for hospital services to the health care agencies established in
the federal states (Landesgesundheitsfonds).
Allocative efficiency
Measures of allocative efficiency, although difficult to estimate, provide an indication of the extent to which
the amounts and types of health services are efficient and maximising health gain. One indicator of
allocative efficiency is the level of expenditure by health sector. Next to Italy, Austria has the highest level
of spending directed to inpatient care (42% of the health care budget) among 14 European countries with
available data. This may be indicative of inefficiency since inpatient care is among the most expensive and
may reflect deficiencies in the lower levels of the system – primary care and prevention. Indeed, if spending
levels are commensurate with the quality of care, spending on public health and prevention represents only
2% of total health spending, less than half the level of many other countries including Finland, Germany,
and the Netherlands.
One can examine the allocation of health spending across the different sectors, but also the method of
allocating funds to the purchasers – typically from governments to health authorities or sickness funds.
There has been a trend in Europe gradually moving away from full retrospective reimbursement towards
fixed fee schedules, fixed budgets, and activity-based payments. Capitation payments with risk adjustment
are becoming an increasingly common method of allocating resources. Risk adjustment seeks to improve
equity in resource allocation, based on the premise that individuals’ health care needs vary according to
personal, social and geographical characteristics. While most countries make use of a capitation system
with risk adjustment, only Austria, Greece and Ireland do not.
Funding responsibilities in the Austrian Health care system are fragmented, especially in the area of
hospital care, in which the Federation and the federal states as well as social insurance funds and
communities occupy an important role. Financial resources of social insurance are raised and used in a
decentralized way. 77% of the funds are generated by contributions of the insured, 16% by contributions of
the Federation and 8% by other income. Funding of hospital care is partially organized by budgets. Use of
financial resources of health insurance funds is, apart from inpatient care, handled autonomously by the
individual sickness funds and is based on the obligation to provide services stated in the social insurance
laws. The amount of financial resources used for health care is decided by the different funding institutions,
social insurance funds, central government, the nine federal states and the communities.
In Austria geographical differences in per capita health expenditures exist, however data or research on the
topic is very limited. It is possible to link the cost for services to the place of residence of the insured by
using the service information system of social insurance (Leistungsinformationssystem, LIVE). Results of
comparative analysis should however be treated with great caution. Great variations between the sickness
funds in terms of expenditure per insured/beneficiary do exist. In the course of the calculation of health
expenditure based on the system of health accounts, it is planned in future to calculate expenditures not only
on a national but also on a regional level.
Technical efficiency
Although it is incredibly difficult to measure efficiency in a complex sector like health, it is widely agreed
that improvements in technical efficiency in the health systems of Europe and around the world, are needed.
Comparative analyses of technical efficiency on an aggregate level – for example, by measuring health
attainment according to the level of health resources and social environment – have attempted to identify
high and low performing health systems. Among the higher performing systems include France, Greece,
Ireland, Norway, Spain and the UK; and among the lower performing systems include Austria, Belgium,
Germany, the Netherlands and Switzerland. Like general measures of performance, there is little value in
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these broad-brush comparisons. Rather, analyses of the functions of the health system that impact technical
efficiency are more revealing.
Administrative costs in a health system can reveal inefficiency, since these are resources that are not
directly involved in health improvement. Comparing 14 countries’ administrative costs shows that some
countries are doing better in keeping costs down – in particular the systems funded by taxation – than
others. Austria however is performing quite well, by spending 3.6% of total health expenditure on health
administration compared to almost 6% in Germany and over 4% in the Netherlands. This slightly lower
level of inefficiency in terms of administration is likely attributed to the lack of choice of insurance fund
and corresponding risk adjustment mechanisms in Austria unlike Germany and the Netherlands.
Supply of resources may be appropriate or inefficient, depending on the mix of services, skills and highand low-cost options. Austria appears to have a relatively high supply of high technology diagnostic devices
such as CT and MRI scanners per capita compared to other countries. While this extra capacity may prevent
access problems such as waiting times, they may not be used efficiently. Regarding human resources,
Austria has a level of physicians that is at about the EU average, but a lower than average number of nurses
per capita; therefore there is relatively little opportunity for skill substitution. The efficiency of the hospital
sector is often identified in terms of activity statistics such as occupancy rates and average length of stay.
Across Europe, the average length of stay in hospital has declined significantly. Current levels suggest
Austria is on the low end of the scale, with average length of inpatient stay at around 7 days compared to
about 14 in France, and over 10 in Germany. However the number of hospital beds in Austria (especially
acute beds) is above the average of the EU countries. Over the past twenty years efforts have been
undertaken to reduce beds. Hospital beds per 100,000 inhabitants declined from 9.89 in 1991 to 7.73 in
2004. The number of acute beds has experienced a significant decline in Austria during the past 15 years
but is still situated far above the European average.
Much of the indicators of technical efficiency depend on the payment methods for health care providers
including physicians and hospitals. It is generally argued that among physician remuneration methods, feefor-service promotes increased activity and hence efficiency, while salary and capitation encourages
reduced activity and increased referrals, but lowers overall costs. Most health systems rely on a mix of the
three general remuneration options. Fee-for-service is the most prevalent payment method in some
countries, such as Austria, Belgium, France and Germany. Some countries have been experimenting with
introducing more specific incentives into the remuneration scheme, such as payment that is linked to a set
of quality indicators as in the UK. Hospital payment methods tend to be based to some extent on
performance, in the form of a mix of DRGs and/or fixed budgets for example. Physicians in hospitals are
paid by a salary which they receive from the hospital carrier. They are allowed to undertake additional parttime jobs, e.g. to open their own private practice. The payment of a salary could limit productivity in
hospital, the scope of activities undertaken outside of the hospital might have an effect on performance in
the hospital, and private payments may influence the behaviour of doctors. Payment of other health care
personnel can also impact efficiency. For instance, with pharmacists in Austria paid on a margin rather than
a flat payment, there is no incentive for pharmacists to dispense cheaper drugs, therefore improve
efficiency.
The way health care providers are paid for their efforts can strongly influence their behaviour. In Austria,
physicians who signed a contract with social health insurance are usually paid by a blended system, which
is based on fee-for service payment and supplemented by a capitated payment (per patient, for a certain time
span). The level of the capitated payment varies amongst the sickness funds and may also depend on the
specialty of the doctor. Special insurance funds (Sonderversicherungsträger), SVA, BVA and VAEB pay
their contract partners (physicians) by fee-for service payment only, some sickness funds have a very low
basic reimbursement (Carinthia, Lower Austria).
This type of reimbursement would lead to the assumption that physicians are incentivised to maximise the
number of services they provide. In order to counteract this, health insurance funds implement steering
mechanisms in their reimbursement catalogues and/or general contracts, for instance billing restrictions,
capping of benefits provided and degressive payments (price-volume trade-off once a certain volume of
benefits is reached). Reimbursement for preventive services is not linked to the fulfilment of defined
targets, such as reaching a certain number of people.
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Social insurance pays a lump sum for public hospitals according to § 447 para.1 ASVG. The lump sum
covers all services in the areas of inpatient care, part-inpatient care, day-clinical and outpatient care. On
January 1 in 1997 a performance orientated reimbursement system for hospitals, Leistungsorientierte
Krankenanstaltenfinanzierung, LKF, was introduced, substituting the existing reimbursement based on
undifferentiated daily payments. About half of costs are based on performance orientated funding and on
countrywide standardized point values per diagnosis related group (LKF core area). This system is
complemented by lump sum budgets. It entails the incentive of increasing the amount of services provided
(maximising points), of admitting certain ambulatory patients to inpatient wards or of engaging in DRG
creep. A partial lack in depth of the case groups (considering the severity of the disease) exists and it is not
always possible to distinguish between acute and chronic. There are no incentives for the provision of
preventive services. Moreover there is duplication of services and no integration of primary and secondary
care may lead to fragmented care.
The LKF system has increased transparency in inpatient care; implicit standards are defined and a
relationship between diagnosis and services is established. The introduction was followed by a decrease of
the average length of stay in hospitals. However the number of inpatient-admissions has gone up constantly,
driven partly by the increase in day-clinic cases (which are categorised as inpatient). Increases in costs were
contained by capping expenditures. Studies state that the reduction in the increase in costs only had a short
term effect and that the LKF System has led to the practice of upcoding.
Other indicators of efficiency include the extent to which substitution policies are in place and continuity of
care is encouraged. Substitution can take place between prescription drugs and also health care personnel.
Generic prescribing in Austria is not encouraged, furthermore, generic substitution by the pharmacist is not
allowed. Health insurance funds undertake a range of efforts to increase the share of generics (generic
products) prescribed, partially employing financial incentives to motivate physicians. With respect to
substitution of personnel in the health care sector a tendency of patients to directly consult a medical
specialist instead of a GP has been observed. Areas of responsibility of physicians partially shift to other
health professionals; duties of GPs will be extended (e.g. administration and monitoring of disease
management programs). A couple of studies have compared the cost of providing treatment inside or
outside of the hospital largely finding lower costs in the latter. Hofmarcher et al.771 concluded that a
potential for substitution between outpatient departments in hospitals and practices of medical specialists
does exist, however the scope of this potential is not clear. Furthermore they urge that a simple comparison
of average costs is not valid and that the aims of service provision of each provider have to be taken into
consideration.
Health care delivery is one of the key functions of the health system, and can be organized in a multitude of
ways that each impact performance. The extent to which there is continuity of care is of utmost importance
and greatly influences the efficiency and effectiveness of the system. Continuity of care consists of both
care of an individual (across illnesses, services, etc) and care over time. Better continuity of care can lead to
improved efficiency through shorter consultation times, more effective clinical decisions, and fewer errors
and duplications.
Continuity of care is an essential part of health systems in light of the ageing population, increasing
prevalence of complex chronic diseases and co-morbidities, and the aim to improve efficiency. The
Austrian health system is characterised by a large number of actors, who are involved in funding and/or
providing health care services, the most important being social insurance, the federal states, the federation,
the local governments and private providers. Due to this fragmentation there is a considerable lack of
continuity of care at all levels of the Austrian health care system as well as a lack of communication
between the different levels. Continuity of care and co-operation between ambulatory providers (physicians,
other health care professionals) hardly takes place, though the introduction of the e-card (increased use of
information technology incl. computers) and the future introduction of the electronic health record may
encourage and facilitate communication between providers. Continuity of care between ambulatory and
secondary care is hampered once again due to fragmentation of funding and responsibility. Social insurance
pays for a great share of inpatient care but does hardly have any say in service provision. Continuity of care
771
Hofmarcher, M., Riedel, M., Röhrling, G. (2001).″ Focus: Doctor's Practice or Outpatient Department: One case is
not one case.". Health System Watch IV, supplement of the Austrian journal of social insurance Soziale Sicherheit, pp.
11-23.
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following discharge of hospital, especially for patients who require more extensive care such as chronically
ill patients is subject to considerable regional variations, no standardized procedures exist.
Health care provision in long-term care and for social services is fragmented. It is difficult to compare
providers and services vary across the regions. Also the provision of other services in health care, such as
emergency services involves multiple actors making co-ordination extremely complicated. Instruments
encouraging integrated care are for instance planning instruments such as the Structural Plan for Health
Care (Österreichischer Strukturplan Gesundheit) or the Location Plan. Mechanisms to promote coordination and prevent shifting of resources are the agreement according to article 15a of the Federal
Constitutional Act, the co-ordination mechanism and sanctioning mechanism and the recently introduced
Reformpool. A range of projects to promote integrated care exist on various levels. In social insurance the
regional sickness fund of Vienna has recently become the competence centre for integrated care.
The new e-card was introduced to improve continuity of care and efficiency in the delivery of health
services. In the first stage of expansion the e-card only replaces the paper-health insurance voucher and
verifies the patient’s entitlement towards the physician in Austria with respect to utilising services of
contract physicians in real time. In addition the e-card infrastructure is used to handle the prior authorisation
for pharmaceuticals. Insured received their e-cards between May and November 2005 by mail. A yearly
service charge of €10.00 is levied by the employer. This results in lower expenses for severely or
chronically ill patients as costs are not linked to the amount of times the patient accesses services. Self
employed and civil servants do not pay any service charge. In the future the card should fulfil a variety of
additional purposes, amongst others it will be used in other areas of care such as inpatient care, for the
administration of the e-prescription or the transmission of sensitive data. The e-card infrastructure links all
physicians in Austria electronically. A few population groups are not yet included in the e-card scheme but
for most of them strategies for future involvement have already been elaborated.
Quality of care
Another dimension by which to analyse the health system is quality of care. There are a multitude of
possible indicators of quality that can be collected, although the difficulty defining and measuring quality
has led to a relative paucity of reliable data on an international level. One indicator of quality is patient
satisfaction. Satisfaction with health care varies quite a lot across Europe, as revealed through various
European-level surveys, and on the whole, Austria comes out on top.
During the past years not only the notion of quality but also the awareness that more ought to be done to
improve quality has received increasing attention in Austria. Quality is defined in the Quality in Health
Care Act (Gesundheitsqualitätsgesetz), in § 2 para.2 as “Degree of fulfilment of the attributes of patientorientated, transparent and efficient provision of health care services”. The Quality in Health Care Act came
into effect on January 1 2005 and represents an embracing of all hitherto existing quality regulations which
are distributed across a range of laws. Provisions not only apply over the whole of Austria but span all
professions and sectors (coverage of all actors in the health system).
In the course of the negotiations related to the agreement according to the article 15a of the Federal
Constitutional Act on the restructuring of the health care system and hospital funding, valid through 20012004, the Structural Commission (Strukturkommission) was given the responsibility of initiating a country
wide system of quality reporting. For the first time it was debated to establish a database for quality projects
as well as a database for quality related strategies in hospitals. Both were realised in the form of pilot
projects. The results and the final report on quality reporting and the pilot projects were handed over to the
ministry but have, to date, not been published. Other institutions such as the Austrian Social Insurance for
Occupational risks and the Vienna Hospitals Association publish quality reports.
In Social insurance the topic of quality has received increasing attention, which is visible in the targets in
the Balanced Scorecard but also in the rising number of projects in this area. The sickness funds perform
numerous projects looking at topics such as developing guidelines for certain indications, defining
standards for care, improving the quality of PAP smears, increasing the share of generics and improving
prescribing behaviour. Measures for quality control in integrated health care institutions exists as well as for
contract partners. Controls of contract partners are usually ex-post controls to check compliance with
quality provisions in the tariff catalogue as well as reactions to patient complaints. A considerable problem
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is the fact that social insurance only disposes of few possibilities to actually measure the quality of the
services provided, another that it does not have appropriate instruments to sanction, only in the case of
fraud, severe treatment errors or the suspicion of abuse. Quality targets of the sickness funds are usually
related to the provision of services and included in the general contract or the tariff catalogues.
In the area of inpatient care quality standards of the Austrian Structural Plan for health are mandatory. The
1993 amendment to the Hospital Act dictated the establishment of commissions for quality assurance in
hospitals. Quality control in ambulatory care takes place by means of voluntary (certification, accreditation,
quality circles, peer reviews, guidelines and recommendations) as well as, mandatory measures introduced
with the fifth amendment of the Physician Act. It is organised as a self-assessment. By 2008 about 15,000
practices will be evaluated, which are then re-assessed every two to three years. Evaluations started midApril 2006. The responsibility for the quality assessment, according to § 118a Physician Act, lies with the
Quality assurance association ÖQMed which was founded especially for this reason and is owned to 100%
by the Physicians.
On a national level Austria does not have an own agency or institution to ensure patient safety. Some
projects promoting patient safety were initiated. In the course of the Quality in Health Care Act directives
related to patient safety may be enacted in the near future, the new Federal Institute for Quality in Health
Care (now part of the Health Care Austria Plc.) will most likely be responsible for patient safety in some
way or the other.
In case of damages resulting from medical treatment or omission, two avenues of approach may be chosen:
judicial and extrajudicial. Patients may appeal to civil courts or, in the course of an extrajudicial settlement,
to patient lawyers who aim at obtaining a compensation payment by appealing to the liability insurance
either of the health care institution or of the doctor who provided treatment. Responsibility of court depends
on the origin of the matter in question (penal law or civil law).
Medical errors represent a significant cost and health burden in Europe; surveys reveal patients in some
countries are more concerned with medical errors (e.g. in Greece, Poland, the UK, Slovenia) than others
(e.g. Austria and Sweden); and are more confident in their doctors in some countries (e.g. Austria and
France). So far Austria has not developed a national concept for reporting medical errors. Some areas in
health care have already developed mechanisms or set up structures (reporting of adverse effects of
medicines, introduction of a heamovigilance register). A couple of initiatives have been started i.e. are
encouraged by the Ministry, the Hauptverband and the ÖGAM (Austrian Association of General
Practitioners). For instance, more hospitals are using error reporting systems. Until now the legal and
structural framework for error reporting has been missing, equally the awareness for the importance of the
topic. Patients cannot access data on medical errors nor can they assess medical risks. In the future greater
transparency should be ensured by means of quality reporting.
Patient choice
Patient choice of insurance, provider, and treatment options exist to varying degrees in Europe. While some
argue that patient choice has intrinsic value, others suggest that in some contexts patient choice can
stimulate competition between providers which can lead to improvements in quality and efficiency of care.
European surveys reveal that levels of patient choice of provider in Austria are among the highest in
Europe. Although this high level of choice is valued by the population, one may question the extent to
which this current level compromises continuity of care.
In Austria social insurance is governed by law and is based on the principle of compulsory insurance.
Affiliation to one of the 20 social health insurance funds of an insured person is based on their employment
(type, place) and in a few cases by his place of residence (e.g. for pensioners) more or less eliminating the
chances of risk selection. Dependants are covered, as well as pensioners, unemployed, low-income earners
or students. Foreigners, tourists and asylum seekers are covered under certain circumstances. At the end of
June 2003 up to 205 000 people from the age of 15 years or 3.1% of the resident population from age 15
years are not covered by national health insurance. Options are very limited in the Austrian social insurance
system, a change to an alternative fund occurs only in a few cases. Those insured with the Austrian Social
Insurance Authority for Business have the most options available. Voluntary insured persons also have
choice of sickness fund.
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The Austrian social insurance allows the insured person free choice of which doctor they visit. They can
visit doctors having a contract with social insurance, doctors in contract group practices, doctors in facilities
provided by health insurance funds (clinics), doctors in contract establishments (e.g. hospital outpatient
departments) or private doctors (who do not have a contract with a sickness fund), doctors in private group
practices, or doctors in private facilities across the whole of Austria. The number of physicians (specialists)
accessed within a defined time period (e.g. per quarter) may be limited; regulations at the sickness funds
vary. It must be taken into consideration, that the freedom of choice can be exercised more readily in more
highly populated areas than in rural areas primarily because the concentration of health care provided is
higher. Basically the person insured with social health insurance is permitted to personally select the
hospital at which he is to receive in-patient treatment. Restrictions may arise because of reimbursement of
transportation costs to the hospital.
Due to the system of statutory social insurance risk selection is very restricted, resulting in a more equitable
health care system. Some insured of Austrian Social Insurance Authority for Business (§ 5 GSVG) as well
as voluntary insured persons have some options of choice of insurance (i.e. the possibility to opt out of
mandatory social insurance). The first group includes professionals who tend to have a higher income and
lower risk, who, by opting out of the statutory system may reduce the overall level of revenue for the
system. Persons choosing to take out voluntary insurance are people who are not affected by any provisions
of statutory insurance and who are not covered as dependants.
Service coverage of the legal health insurance is comprehensively regulated in the social insurance laws
(ASVG, B-KUVG, GSVG, BSVG and FSVG). Health insurance funds retain only limited scope to deliver
additional voluntary services (regulated in their statutes). With respect to decisions on including new
services in the benefits package no standardized procedure exists for all sickness funds. Evidence based
medicine, HTA and health economic evaluations are only slowly gaining ground in Austria. However
negotiations and policy making is still highly influential when deciding on benefits or tariffs. However,
differences in the spectrum of services provided by different insurance funds can occur due to various
reasons, such as legal variations, differing contractual provisions, variations in the statutes of the funds, in
their financial situation, differing levels of co-payments or the branch of the fund (health care-, accident-,
pension insurance).
Health improvement
The ultimate goal of the health system is to improve the health status of individuals, leading to aggregate
improvements on a population level. Improvements have been seen across Europe in terms of crude
measures of population health such as life expectancy at birth and at age 65. Although health status has
improved in all EU-15 Member States since the 1970s, significant inequalities remain between and within
countries. In terms of the new Member States in which the political and economic transition significantly
worsened health, some have experienced noticeable improvements in recent years and in some cases
approach or surpass the EU average in health attainment.
Austrians’ life expectancy is above EU average and appears to be increasing. Taking the EU 15 ranking
Austrian female life expectancy has changed over time from 11th (1980) to 7th (2003) and Austrian male
life expectancy from 14th (1980) to 9th (2003). Based on the OECD data female life expectancy was ranked
19th in 1980 and 10th in 2003 out of 30 countries. Male life expectancy in Austria was ranked 22nd in 1980
and has increased to hold the 15th rank in 2003. Austria is one of the European countries with the lowest
infant mortality; maternal mortality is significantly lower than the EU-average. In terms of avoidable
mortality, evidence suggests there has been better progress in treatable than preventable diseases in Austria.
This may reflect the curative focus of health care in Austria until recently, which has lately changed to a
prioritization of prevention.
In Austria, the prevalence of overweight and obesity has increased, in accordance with the international
trend. It is on the rise in all age groups, but especially for children and young people. An East-West divide
can be observed such that obesity prevalence is higher in the East than the West. In Austria 29% of the adult
population (older than 15 years) smokes. Tobacco consumption is increasing among women but falling for
Austrian men. Austria holds the first rank in Europe with 4% of the 11 year olds, 15% of the 13 year-olds
and 45% of the 14 year-olds. The share of 15 year-olds smoking daily is 20% for boys and 26% for girls
which is significantly above the rest of the EU. For women the risk of dying from lung cancer has risen
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dramatically over the last 20 years. Alcohol is a serious problem. Approximately 5% of the adult population
can be considered chronically addicted to alcohol. Moreover, the rate of deaths due to cirrhosis of the liver
is the highest in Europe.
Inequalities in health are evident in Austria. The risk of poverty is 11% for persons born in Austria, and
23% for immigrants who have been granted Austrian citizenship. Male and female immigrants run the
highest risk of poverty, at 28%. Women are particularly threatened by poverty, single households are
generally at a higher risk. In families with 3 or more children and families with small children, there is an
increase of poverty, particularly when the woman is not working. 6% of the Austrian population are
manifestly poor. In principle poor people do not receive a lower quality of care by the Austrian health
system than wealthier people. However, there is a correlation between low income, poorer subjective health
and modified utilization of health care. In addition, morbidity, measured in the number of episodes of
illness and the duration of the episodes, decreases with a higher level of education. Unemployed report a
higher morbidity than employed. An analysis performed by the Hauptverband shows that the per capita cost
for physician services, pharmaceuticals and dental care is lower for consumers of services with foreign
citizenship of all ages compared to the per capita cost of consumers of services with Austrian citizenship.772
Especially for insured older than 55 years there is a remarkable difference between the two groups.
In terms of preventive care, social health insurance offers comprehensive preventive health check ups
(youth check ups, 16-18 years, and for adults> 18); a new “evidence based” program started in October
2005. Further prevention-related services are certain vaccinations and genetic examinations. In addition
health promotion efforts (for healthy, workers, pregnant, newborn, children), programs to improve dental
care as well as health care education. Measures for health promotion offered by social insurance are for
instance treatment in spas or in convalescent homes. Other initiatives include examinations of school
children, mother-child examinations and physical examinations of young men before performing the
military service.
A national mammography screening program will be adapted in the near future (National Programs on
molecular genetic analysis for breast cancer and ovarian cancer) although structural requirements have to
still be met before introducing it at a national level. However for other disease categories, screening
programs are only opportunistic and should be elaborated based on international evidence. Screening
programs which have been evaluated include “the 20 year evaluation of national blood pressure education
campaigns” (temporary effects of improving blood pressure awareness) the maternity care program
“Mother-Child-Passport (may have led to an increase in the mean birth weight) and the “Evaluation of
Austrian Newborn Hearing Screening” (greatly increasing the proportion of children whose hearing
impairment is diagnosed before six months of age). Furthermore evaluation of PSA screening for prostate
cancer for the region of Tyrol (trends in the reduction of prostate cancer mortality differ significantly
between Tyrol and the rest of Austria).
9.1 Options for research
Research could be done to identify high service users and then assigning them to a personal doctor or
clinical team to improve continuity of care. Clinical information could be better shared across areas and
levels of care. One could also evaluate continuity of care analysing if patients shop around when accessing
care or if they remain with the same health care provider
Additional quality indicators and standardized measures of waiting times could be developed and eventually
released to the public, in order to increase transparency and empower patients. Alternative models for
dealing with the shortage of qualified nursing staff and the lack of standards for care could also be
evaluated.
Research assessments on the current needs and also projections of future human resources need could be
undertaken with the aim of meeting health care needs of the population and ensuring an efficient skill mix.
It would also be worthwhile to further evaluate the potential for substituting hospital for community care.
772
Grillitsch (Hauptverband der österreichischen Sozialversicherungsträger, HVB). 23 June 2006 via email
266
Provider payment schemes could be evaluated in terms of impacts on costs and outcomes; possible
elaborations to the current schemes may be assessed and considered in terms of creating incentives for
quality and productivity improvements. With regards to hospital payments, further research on hospital
productivity would be useful, in particular continuing to monitor and evaluate the new activity-based
financing scheme in light of the possibility of DRG-creep. Also payment methods for doctors in hospitals
could be evaluated in terms of the impact on their behaviour (e.g. fees for private patients, part-time jobs).
Data could be collected on possible risk selection of providers based on patient characteristics and the
affiliation of a person to a certain sickness fund.
More research can be done on the financing system to investigate the level of progressivity. Furthermore, an
integrated data base could be created to evaluate trends in income distribution. And further research on
redistribution of income could be performed since the current data is fairly old, and unsatisfactory. The risk
equalization scheme represents an important step towards ensuring equity in the system though effects
might be limited as the equalization fund is restricted to the nine regional sickness funds only and
encompasses a comparably small amount of financial funds. However, this scheme should be evaluated, and
possibly elaborated to better measure need. With regards to user fees, a study on the willingness of patients
to make co-payments when utilising health services could shed light on what is the appropriate level of fees.
Further activities in the field of patient safety could be encouraged, and projects performed so far could be
evaluated in order to create a legal and structural framework for error reporting (national standards).
The e-card should be continually evaluated in terms of the impact on continuity of care, efficiency, and any
possible impact of the introduction on the utilization of services (for example, increased access to specialist
care).
In the field of effectiveness of the health system in Austria there is a need for further evidence that public
health programmes and interventions are successful. Evidence is needed that the intervention is effective,
but further it must be investigated whether the intervention works in the short term and whether its effects
are sustained over longer periods. In addition evidence must be gathered as to whether the programme is
suited to the particular epidemiological setting, health system and cultural context. More specifically, the
new mammography screening program should be evaluated for effectiveness and cost-effectiveness, and
extensions to other disease areas should be considered based on this evaluation and international evidence.
The new health check-up program also reflects the increasing importance paid to prevention; however, this
should also be subject to monitoring and evaluation.
Furthermore, as the health trends indicate emerging and persistent health threats such as alcohol
consumption, obesity, and smoking, particularly among young people, more research is needed to develop
national surveys focusing on these areas, and to initiate public health programs targeting population groups,
such as youths, most at risk.773
The new diabetes management program should be evaluated in terms of health outcome and patient
satisfaction. Further programs for other disease areas could also be introduced. Further, in light of the
ageing population, initiate research and prevention activities for elderly people living at home alone.
Research into avoidable mortality which provides an indication of the quality and overall performance of
health care should be updated and perhaps conducted on a regional level, thus highlighting and variation in
performance within the country. Data could also be collected on postoperative mortality and re-admissions
to hospitals (on an individual basis).
Although there is evidence of barriers to access and inequalities in utilization of health services, further
research could address regional variations in access to care, costs and health outcomes. More detailed
surveys of utilization and socio-economic factors can shed light on the existing inequalities on a more
micro-level, for example focussing on specific disease or service areas. Also, activities of the sickness funds
to inform and educate their insured population such as the health care information centres established in
Salzburg and Burgenland (Gesundheitsinformationszentren, GIZ) could be evaluated. In light of the
773
Reference should be made to: Dür, W., Mravlag, K. (2002). Health and behaviour related to health care of children
and adolescents. Results of the 6th HBSC survey 2001 and trends from 1990 to 2001. Series original work, studies,
research reports, Federal Ministry of Social Security, Generations and Consumer Protection. Vienna).
267
increasing cross-border patient mobility, the care needs of migrants could be investigated with the aim at
harmonising the care provided.
Research could be commissioned at Austrian level in areas of health economics, health services research
and health policy to evaluate the current status to better understand the dynamics of the Austrian health
system. A special fund for research could be set up drawing on funds from federal and state government and
insurance funds that is at an arms-length from government. This institute could commission work to local
institutions such as universities and research centers in order to address the above areas.
268

Framework Performance Assessment

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