Economics and Finance

Case Management in Austria and Europe: The concept of case management was originally introduced in the USA and aims to accompany patients individually and continuously across various healthcare settings. In the Austrian health system, case management has increased in importance over the past few years. A number of social security institutions offer patients case management as a service or initiate projects in this context. The literature indicates that, although evidence of a general cost cutting effect is lacking, case management can raise quality of care. Health-economic evaluation: Political implications and utility outcome: Like natural outcome measures, utility-based outcome measures, in particular the qualityadjusted life year, have a firm place in health-economic evaluation. Being continuously refined, the method is becoming increasingly meaningful in supporting a decision. It is most advanced – and in many countries used as a standard – in the decision whether to reimburse a drug or not. For more complex interventions, however, it is necessary to continue developing an appropriate method. Despite some continued methodological flaws, health-economic evaluation is essential as long as the outcomes are valued as one of several criteria. Given the far-reaching consequences of decisions on, e.g., reimbursement, decision and assessment makers have to consider the limitations of the underlying method. Health systems more and more have to ask themselves how to distribute the collected means optimally to existing and newly arising technologies. Today's understanding of politics demands such an economic assessment and the allocation of funds by a planner not to be solely oriented to objective, technical criteria, but also to the people’s preferences. However, there are some reservations against methods using utility-based outcome measures, and some overview studies of recent years do not give the use of economic evaluation the best marks. Therefore, intensive efforts are being made to pursue quality assurance in healtheconomic evaluation.

Waiting times for elective operations in Austria: A question of transparency: To analyse the complex subject of elective operations in Austria, we carried out several investigations: a poll of all hospital companies, patient advocates and the Health Ministry, an analysis of the 2006 Austrian Health Interview Survey and our own retrospective patient interviews. This enabled us to quantify waits for certain elective operations as well as their considerably uneven distribution across federal states and patients. There is far too little transparency and coordination in Austria to optimise waiting times. International examples, but also the Styrian hospital company (KAGes), demonstrate that an improvement is possible. Such a solution should be implemented Austria-wide in view of the individual and societal impact of unnecessarily long waits. There are indications that supplementary private insurance or the option of having the operation done by the respective surgeon on a private basis can shorten waiting times. Our patient interviews confirmed the practice, stated by patient advocates, that some doctors promise patients shorter waiting times if they make an out-of-pocket payment or visit their private practices. This needs to be changed as well.

Consumer protection in health care – an international perspective: The view of the patient and insured as health care consumer is increasingly coming to the fore, as the patients' freedom of choice regarding both the health care provider and the individual service is growing internationally. However, this development requires appropriate protection measures. Consumers can be supported and protected in their decisions by passive information, active support, involvement and the mere representation of their interests by authorised institutions. There are numerous international examples of these four areas of activity that could be of interest for Austria, a country with a wide freedom of choice combined with a particularly poor supply of information.

International tobacco control policy: Austria needs to catch up: The link between smoking and numerous diseases and deaths as well as the attributable costs for the public are considered proved. International organisations like WHO, but also the EU, have declared war on smoking, with tax measures and smoking bans in public places considered to be the most efficient means. However, the ways how different countries implement such measures rank from highly active to half-hearted. Austria is in the lower end of the international ranking. Death-related costs in Austria: There is international evidence that a large share of the health expenditure consumed by people during their whole life is concentrated in the last years and months before death. In the European comparison, Austria plays a vanguard role regarding the calculation of deathrelated costs in that the Austrian data situation allows differentiating between intra and extramural death-related costs. Most international studies, on the contrary, are limited to hospital costs. We have calculated the costs during the two years preceding death for both sectors. In the inpatient sector, 80 percent of these costs occur in the last year of life before death, compared to only around 58 percent in the outpatient sector. In 2004, depending on the scenario, 13 to 24 percent of the total inpatient and approximately seven percent of the total outpatient expenditure can be attributed to persons in their last two years of life. Outpatient costs two years before death account for about a fifth of the total death-related costs, relating to an average scenario in the inpatient sector. The costs per death in the inpatient sector are generally higher in younger age groups. Especially for people aged between 20 and 30, they show a significant gender gap, with higher expenditure for women. For both genders, the highest expenditure in the outpatient sector can be found in the age groups between 40 and 70 years. Here again, expenditure is higher for women. Pharmaceuticals form the main component of outpatient expenditures. Aggregated over the whole country, death-related costs increase with the age due to the growing number of deaths in old age groups.

Efficiency in health care: Is it really that easy? Studies on the efficiency in health care make partly simplifying assumptions, which are not always reported correctly. For example, savings based on comparisons of hospital core measures of Austrian and EU averages are only valid to a limited extent, since several European countries invest more in preventive and primary care. Data Envelopment Analysis, in turn, is one of the methods enabling an estimation of technical efficiency and the resulting saving potentials within the individual sectors. These potentials should indeed be used. In this context, interdependencies of the sectors in terms of efficiency must not be overlooked. For example, reforms of the primary care sector can generate savings not only there, but also in downstream sectors. Such a reorganisation requires of course intelligent measures, which in turn generate costs. Waiting in Europe: An international comparison regarding elective surgery: In many countries waiting times for planned surgery constitute a serious health care problem. The causes can be found both on the supply (capacity and productivity) and the demand side (health status, medical technology). From the medical point of view, waiting times for elective operations are not that problematic, but the degree of suffering the patient experiences increases with the waiting time. Despite this, patients often prefer treatment in their immediate surroundings over shorter waiting times elsewhere. Apart from that, the economic implications must not be underestimated, since a reduction in waiting times mostly results in savings. Numerous countries have taken measures both on the supply and the demand side to get to grips with the waiting time problem.

Clinical practice guidelines: A quality instrument comes of age: Guideline work has made great progress in qualitative and quantitative terms at international level. Greater use needs to be made of quality-assured guideline development. In view of the considerable amount of time and effort required for guideline development, international cooperation is a must. Further implementation methods need to be developed and involve collaboration of all stakeholders. Practically all countries that are leading in terms of guidelines have organisations at national level to promote, methodically support or coordinate guideline work.

Quality indicators:Handle with care: Quality indicators are important tools of quality work that should be increasingly used in the future. Being “hard facts” that significantly influence decisions, they have to be developed and applied very carefully. The ultimate goal and the underlying intentions play a crucial role in the development and application of a quality indicator. At an international level there is a series of examples of the use of quality indicators. Taking a closer look at them can be very instructive. Quality indicators are primarily used in an intramural setting. However, there are already several projects where they have also been implemented in physicians’ practices.

Quality assurance in medical practices: A European perspective: Just as many European countries, Austria has placed the emphasis of its health reforms of the past few years on quality. With the 5th amendment to the Act governing the Medical Profession a mandatory evaluation procedure for all office-based physicians was introduced. It involves a questionnaire and random checks on the spot looking at structure and process criteria. Overall, the procedure has some questionable aspects. The landscape of external quality assurance in Europe is very heterogeneous and still developing. Not all countries have obligatory measures in the first place. We have also found some mandatory evaluation procedures that are focused not so much on control but on quality improvement. Further, some countries involve a higher number of stakeholders with the development of quality requirements.

Europe in motion: Quality of care in physicians’ practices: In times of cost containment programmes and global comparisons of performance, the question of what happens to the quality of our health systems is arising increasingly often. Whereas in the in-patient sector there is already a wealth of quality assurance systems and quality management has currency, it has only been in recent years that the quality discussion regarding care provided by office-based physicians has got going. Existing systems for hospitals have meanwhile been adapted to physicians’ practices, and special systems have been developed to make quality management accessible for the latter, too. To give readers a taste of the primary topic of Health System Watch this year, we have designed the first issue as introduction to quality management, dealing with already existing quality management systems in the health sector, with the main emphasis on physicians’ practices.

Health status: The impact of modern medicine on the 'major killer' cancer: The incidence of cancer has been on the increase throughout Europe for decades. In the EU-15 the age-standardised mortality for all types of cancer decreased, but showed an upward trend in the EU-10 that seems to have slowed down only for the past few years. The example of colorectal carcinoma suggests that diagnostic and therapeutic improvements just as the increased level of attention paid to life style factors and screening seem to have contributed to a more favourable development of mortality in the EU-15. For all three fields mentioned – prevention, diagnosis and therapy – there is evidence that the new member states have not reached the health care level of the EU-15 yet and are not expected to do so in the near future. In addition, all the countries expect waves of innovation in cancer therapy, and along with this, major financial challenges. Focus: Health targets: wide-spread or a mere isolated case in Europe? Numerous European countries have already outlined more or less concrete national health policy targets, ranging from very general “goals” in some countries to very concrete “quantitative targets” in others. The individual health targets cover a broad range of contents. On closer inspection, “reducing non-communicable diseases”, “reducing harm from alcohol, drugs and tobacco”, “settings to promote health” and “improvement of mental health” crystallise into the main subjects. International experience has shown that consensusoriented actors on all levels involved, a number of objectives that has been reduced to a manageable size and the provision of funds required for their implementation are decisive for well-functioning health target programmes.