Austria

Austria

The Austrian medical healthcare system

 

Dr Reiner Brettenthaler, Head of the Austrian UEMO delegation

The Austrian health care system

Austria is a democratic republic and a federal state which is composed of nine provinces. The provinces have their legislative competencies and also participate in legislation at a federal level.

The Austrian health care system is characterized by the federalist structure of the country, the delegation of competencies to self-governing stakeholders in the social insurance system as well as by cross-stakeholder structures at a federal level and at the level of the provinces which possess competencies in cooperative planning, coordination and financing. According to the Federal Constitution, almost all areas of the health care system are primarily the regulatory responsibility of the federal government. The most important exception is the hospital sector. In this area, the federal government is only responsible for enacting basic law; legislation on implementation and enforcement is the responsibility of the nine provinces.

 

Financing of health care

Public health expenditure in Austria is mainly financed by the social health insurance system. These finances are raised and used in a decentralized manner and are not subject to any budget-setting process in a narrower sense, but are the result of the health insurance funds’ obligation to ensure that services are in accordance with the current provisions of social insurance law. For the treatment of insured people in hospitals, the health insurance system contributes a flat rate amount to a (partly) overall budget. The social health insurance system finances around 40% of the total costs for public hospitals.

Tax revenue is particularly used in inpatient care in public hospitals. The financing of acute hospital care is partially budgeted and is carried out according to performance-related criteria within the framework of this budget. The provinces, as owners of the hospitals, are not only responsible for investment and maintenance costs, but also contribute towards the running costs of the hospitals in accordance with federal and regional legislation on hospitals.

 

Social health insurance

There are a total of 24 social insurance institutions in Austria, of which 21 are health insurance funds. With a few exceptions, membership of a health insurance fund is mandatory and is based on belonging to an occupational group. The social insurance institutions are structured either regionally or according to occupational groups (miners, the self-employed, farmers, railway workers, civil servants) or groups of individuals (wage earners and salary earners, farmers, civil servants, etc.). The largest health insurance funds are the nine regional health insurance funds in the individual provinces (for employees except civil servants). Apart from these there are two social insurance institutions for the self-employed (for trade, commerce and industry, and for farmers, the latter, however, being affiliated to the regional health insurance funds of the individual provinces). Health and work accident insurance for most civil servants is also administered by a separate insurance institution.

Health insurance funds collect revenue-related contributions and are responsible for the settlement of health care services including the payment of service providers in the primary and partly in the tertiary sectors.

 

General agreements between the health insurance funds and the Medical Chambers

The relations between the health insurance funds and self-employed physicians are governed by general agreements. These are concluded either at a regional level by the nine regional health insurance funds and the regional Medical Chambers, or at a federal level between the federal health insurance funds and the Austrian Medical Chamber

There is a Medical Chamber in each province and the Austrian Medical Chamber as their umbrella organisation. The Medical chambers are the legal professional representation of medical doctors. Every medical doctor who is authorized to practice in accordance with the Medical Act and entered into the register of physicians automatically becomes a member of the Medical Chamber of the province where he is working.

Important elements of the general agreements agreed between social insurance funds and the Medical Chambers are the rights and duties of contracted physicians, who conclude individual contracts with the health insurance funds on the basis of these general agreements. Further contents are the regulations on fees, which contain detailed provisions on physicians’ services and their payment. The general agreements also include the so-called location plan, which regulates the number and local distribution of contracted physicians.

 

Healthcare provision in the outpatient sector

Patients covered by health insurance can freely choose between service providers in the outpatient sector. Outpatient health care provision in Austria is provided by self-employed physicians who predominantly work in individual practices. There is no gate-keeping system, but patients can access any specialist doctor (except radiologists and medical laboratories) without a referral. In addition, there is direct access to outpatient clinics which are operated by various owners ranging from private individuals to social insurance institutions. The activities of independent outpatient clinics (Ambulatorien) are regulated in the Federal Hospitals Act. Their fields of activity are basically comparable to those of practising physicians. They provide examinations and treatment for individuals who do not require inpatient treatment in hospitals. A permit from the relevant state government is required to establish and operate an independent outpatient clinic. Hospital outpatient departments are also providers of outpatient health care. Patients can attend directly, without a referral. Outpatient departments are available for emergency services and for acute specialist care, as well as for after-care and preventive medical check-ups.

Treatment by physicians within the framework of the social insurance system is predominantly carried out by “contracted physicians”. Around three quarters of all physicians in private practice have a contractual relationship with social insurance institutions. Patients who consult a contracted physician receive benefits in kind, which means that they do not have to pay for the services received. By contrast, patients who consult a physician who has not concluded a contract with a social insurance fund have to pay for the service received, but are refunded about 80% of the amount that would have been paid to a contracted physician for the same service, by their social insurance fund.

 

Supply of medicinal products and therapeutic aids

The population of Austria is currently supplied with medicines by a total of about 1.260 public pharmacies, which require a licence. In order to ensure a balanced supply of medicines, around 934 physicians in private practice also run small pharmacies in their surgeries in rural areas. For each pack of prescribed medicines paid for by the health insurance funds, a prescription fee of € 5,00 is charged. People for whom a particular level of social neediness has already been established are exempted from the prescription fee. Depending on the insurance institution, a co-payment of between 10% and 20% has to be paid for therapeutic aids.

 

Education and training of medical doctors

Medical training in Austria is characterized by a dual system. Degree courses in medicine, which have a minimum duration of at least six years for all medical professions, can be taken at three public and one private medical universities (Vienna, Innsbruck and Graz in the public, and Salzburg in the private sector). In the course of a comprehensive reform, obligatory practical training was integrated into medical university studies, in order to better prepare students for medical practice.

The number of students accepted for medical training each year is fixed. Students applying for a place at university have to take a qualifying examination. According to the Universities Act, 75 % of the study places are reserved to applicants with a secondary education diploma acquired in Austria, while further 20 % are reserved for other EU students, and the remaining 5% to third-countries students. This law has been challenged before the European Court of Justice. The proceedings were suspended until November 2012 in order to enable the Austrian government to prove that the quota are necessary to prevent a shortage of doctors resulting from an overflow of medical students from Germany who return to their home country after graduation.

In order to work as a general practitioner, practical training lasting at least three years is required. Specialist training in almost all medical specialties requires a minimum training duration of six years. Practical training has to be completed in hospitals which are recognized as training institutions by the Austrian Medical Chamber. Parts of training in general medical practice have to be completed in a recognized surgery run by a self-employed general practitioner, or in a group practice or outpatient department which provides training. However, due to a lack of public funding for recognized teaching surgeries, this part of training is mostly undergone in outpatient hospital departments. General practitioners and specialists have to complete an examination which is a prerequisite for engaging in independent medical practice.

Only after having completed training as a general medical practitioner or specialist doctor, medical doctors obtain the right to carry out medical activities independently. This puts them at a disadvantage when migrating to other countries, where a licence to independent medical practice is awarded upon completion of university studies, or after a short period of practical training. In order to facilitate migration for young Austrian doctors, the Austrian government is currently in negotiations with the European Commission.

Since the number of contracts with social insurance funds to be awarded to medical doctors is limited, many young doctors remain in hospital after having completed their training. Most of them undergo training to become a specialist doctor after already having been trained as a general medical practitioner. Others apply for a contract with social insurance, or establish in private practice without a contract. (In the area of general medical practice, the demand for private medical services mainly focuses on complementary medicine.) There are rather few medical doctors who work outside the health system, such as for companies. At present, there is no shortage of doctors in Austria. However, this might change in the immediate future, since the number of graduates decreases due to the limitation of university places. Besides, it is not clear to what extent foreign medical graduates are subsequently going to remain in Austria and engage in medical activities there.

 

 

Facts and Figures (as of June 1st 2010):

Inhabitants of Austria:                     8.363.040

Total number of MDs:                     39.484

male: 22.050

female: 17.434

 

Self-employed MDs:                        16.059

contract with social insurance: 8.468

no contract with social insurance: 7.591

GPs: 6.468

Specialists: 9.555

Licensed doctors (basic medical training): 36

Average age: 52,4 (GPs 52,1, specialists 52,7)

 

General practitioners:                    12.845

male: 6.198

female: 6.647

 

Specialist doctors:                          19.467

male: 13.093

female: 6.374

 

Employed MDs:                                21.540 (inclusive of 6.923 doctors in training)

male: 10.050

female: 11.490

GPs: 5.215

Specialists: 9.247

Licensed doctors: 155

 

 

Legal reform regarding the Austrian Medical Chamber

In the year 2009, the Austrian Medical Chamber had intense discussions with the Austrian government, about the assignment of tasks to the Austrian Medical Chamber.

In the course of an amendment of the Austrian constitution, the existence of the Austrian Medical Chamber was enshrined in the constitution in 2008. This means that the functions of the Austrian Medical Chamber had to be defined by law in a new way.

According to the Austrian constitution, a self governing body, such as the Austrian Medical Chamber, has inherent spheres of action and delegated spheres of action. In both areas it is the Austrian Medical Chamber that decides about the individual issues through its competent bodies, but within the delegated sphere of actions, the minister of health is authorised to give instructions to the Austrian Medical Chamber, which the chamber has to implement in its regulations, whereas with regard to its inherent spheres of action, the Austrian Medical Chamber acts independently. In both spheres, regulations issued by the Austrian Medical Chamber have the same legal force and effect as acts or regulations passed by the ministry of health.

Inherent spheres of action of the Austrian Medical Chamber are those that concern only medical doctors. Delegated spheres of action are those that affect also patients, hospital owners etc., who are not members of the Austrian Medical Chamber. There were a lot of discussions about the assignment of the tasks of the Austrian Medical Chamber to either of the two spheres, especially with regard to the fields of postgraduate training, CME and quality assurance.

Whereas in the first legal drafts the government allocated most tasks into the delegated sphere of action, after intense negotiations having lasted for months, the following solution was accepted by the Austrian Medical Chamber and passed by the Austrian parliament:

 

Delegated spheres of action:

·         contents of postgraduate medical training

·         hospitals visitation rules

·         rules of quality assessment in the medical practice

·         recognition of training centers and training posts

Inherent spheres of action:

·         examinations/assessments during postgraduate training

·         control of postgraduate training and issuing of specialist diplomas

·         register and registration of medical doctors

·         rules of CME/CPD for medical doctors

·         structured education in special medical fields

·         quality control of medical practices

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