(De-)Zentralisierung in der Krankenversicherung - Kontext, Vor- und Nachteile

Für Strukturreformen gibt es immer einen historischen Kontext; Vor- und Nachteile entfalten sich erst darin. Im Laufe von 2017 wurden mehrere Studien vorgelegt, die sich mit der Straffung der Steuerung der Krankenversicherungsträger beschäftigen und verschiedene Szenarien von Zusammenlegungen bewerten.

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Dabei hat die notwendige Weiterentwicklung der Versorgung in Richtung bessere Abstimmung zwischen Gesundheit und Pflege und Prävention über den Lebenszyklus wenig Raum. Diese Aspekte sind jedoch in Zukunft von zentraler Bedeutung für das Gesundheitswesen und haben durch die vorgegebenen Zuständigkeiten Entwicklungschancen auf Ebene der Bundesländer. Während die Fragmentierung der öffentlichen Finanzierung zwischen administrativen Ebenen sehr wahrscheinlich Qualität und Effizienz beeinflussen, dürften die Richtung und das Ausmaß dieser Auswirkungen von den spezifischen Regelungen abhängen. Insbesondere dürfte eine starke Zentralisierung der Funktionen Mittel-einhebung, Mittelzusammenführung, und -verwendung und Steuerung weniger geeignet sein als sanftere Formen, die wichtigsten Herausforderungen für die Versorgung in der Zukunft zu bewältigen. mehr

Health sector employment growth calls for improvements in labor productivity

While rising costs of healthcare have put increased fiscal pressure on public finance, job growth in the health sector has had a stabilizing force on overall employment levels – not least in times of economic crises.

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In 2014 EU-15 countries employed 21 million people in the health and social care sector. Between 2000 and 2014 the share of employed persons in this sector rose from 9.5% to 12.5% of the total labor force in EU-15 countries. Over time labor input growth has shifted towards residential care activities and social work while labor in human health activities including hospitals and ambulatory care still comprises the major share. About half of the human health labor force works in hospital. Variation of health and social care employment is large even in countries with generally comparable institutional structures. While standard measures of productivity in health and social care are not yet comparable across countries, we argue that labor productivity of a growing health work force needs more attention. The long-term stability of the health system will require care delivery models that better utilize a growing health work force in concert with smart investments in digital infrastructure to support this transition. In light of this, more research is needed to explain variations in health and social care labor endowments, to identify effective policy measures of labor productivity enhancement including enhanced efforts to develop comparable productivity indicators in these areas. See the article in Health Policy.

Headline Indicators for structured monitoring of Health System Performance in Europe.

We propose a prioritised set of indicators identified in 43 national and international health system performance assessment (HSPA) initiatives with the aim to inform comparative analysis of policy impacts in a gradual manner.

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We documented over 2000 indicators which were consolidated for overlaps. Through implementing the euHS_I survey the resulting indicators then led to a balanced set of 95 indicators which were assessed by European experts for their relevance for specific HSPA domains, i.e. access, efficiency, equity and quality of care, and their priority levels. Headline indicators that monitor performance related to key objectives in public health were identified.

Priority setting methods in health information

BRIDGE Health Technical Report 04/2017 on Recommendations of priority setting methods for a European Research Infrastructure Consortium on Health Information for Research and Evidence-based policy (HIREP-ERIC), together with Perić N, Simon J 2017

Health system performance assessment landscape at the EU level: A focused synthesis of actors and actions.

Together with Perić N (Lead author), Simon J (2017): Archives of Public Health, 75(5). DOI: 10.1186/s13690-016-0173-5.

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Many policy makers and other stakeholders in the EU have expressed interest in better understanding the performance of their own health systems to identify opportunities for improvement in effectiveness, efficiency and equity. Health system performance assessment (HSPA) has received considerable attention at EU level as an instrument to improve transparency and accountability. This is equally important for population health and sustainable health spending. The goal of this paper is to synthesise and map the current state and developments in the field of HSPA relevant in the EU context and by this aid the navigation in the growing HSPA system, understand the available tools and identify opportunities for improvement.


Structured synthesis of the literature on initiatives in the field of HSPA at EU level was carried out. Key literature was identified by a focused review performed between October 2015 and June 2016 on websites of key institutions including the EU, OECD and WHO and Google engine. We used six predefined criteria for identifying key literature. Identified initiatives were classified according to analytical and conceptual output or whether a guiding or advisory role was resumed. A visual map of the relationships between the different actions and actors involved in HSPA was developed. In addition, expert opinion was sought to refine the map.


We identified a total of 64 relevant initiatives and their relationships in the field of HSPA. These include institutions such as the European Commission (73%), European Council (8%), OECD (9%) and WHO-EUR (9%). 24 initiatives produced analytical outputs, four developed conceptual outputs and six had a guiding role. The role of the EU in HSPA and collaboration with other key actors have intensified considerably since the adoption of the EU Health Strategy in 2013. The EU HSPA landscape is complex with seemingly few streamlining activities.


Knowledge transfer and exchange of expertise are key to HSPA. While cooperation between the key actors have intensified recently and clearly reflect the “Health in all Policies” (HIAP) approach, there is considerable room for improved streamlining activities to share knowledge and avoid overlapping efforts, especially within the European Commission.

Priority setting and transferability of health information to policy now and in a future EU Health Information System

BRIDGE Health looks at priority setting and transferability of health information to policy now and in a future EU Health Information System.

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In the previous issue of Adjacent Government, the first concepts of the EU Health Information System were explained and the current activities of BRIDGE health within these. BRIDGE Health operates through work packages and horizontal activities (HA), www.bridge-health.eu. In this issue, the focus will be on two of those HA, which are key topics in the field: priority setting methods in health information (HI) and the transferability of HI and data for policy. For more information see: PDF, in English

EuroReach continues in the context of the BRIDGE Health project

Since May 2015 the EuroReach project has continued its activities in the research field of the BRIDGE Health project: Evaluation of health care systems.

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Solid evaluation of health care systems requires reliable data and indicators on health system inputs, outputs and on care processes. To unify reporting standards of relevant data and indicators and to support capacity building of a EU health information infrastructure WP 12 aims to produce blueprints. This concerns key health system indicators and data, project outcomes and performance assessment frameworks. Collaboration across work packages and structured dialogs with Member States and international organizations will inform the development of blueprints. Starting point of WP 12 is the Health Data Navigator which will be developed further and adapted to feature building blocks for enhanced comparative evaluation of health care systems. BRIDGE Health stands for BRidging Information and Data Generation for Evidence-based Health policy and research. The BRIDGE Health project aims to prepare the transition towards a sustainable and integrated EU health information system for both public health and research purposes.

Personalized Medicine Takes Foresight and Smart Public Policies

Governments and health care payers everywhere seek ways how to design public funding policies for high-cost drugs, which are increasingly personalized and often only effective in small population groups or sub-groups. Access to drugs is usually preceded by health technology assessment.

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Challenges for access to effective drugs at the patient level remain, as the current reimbursement environment is not ready to encompass the complexity of Personalized Medicine. A high level of uncertainty remains as to how, for whom and which type of Personalized Medicine should unfold in the future. Foresight modeling may come into play here. Foresight is a systematic approach to look into the longer-term future of science and technologies and their potential impacts on society. It aims at identifying research and development areas likely to generate future economic, environmental and social benefits.
for more information see: PDF, in English

Individual responsibility in health care requires a coordinated symphony of wise regulations

Individual responsibility in the Austrian health care system primarily involves the collection of cost-sharing and self-payments. In 2012 about two-thirds of private spending was financed through self-payments; direct cost-sharing funded 12 percent; about a billion is applied by private health insurance.

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The level of private payments in Austria is high in international comparison. They fall in all areas of the health system and differ between the statutory health insurance funds both in the structure, as well as in the level. Recent initiatives rely on the assertion of a financial bonus for achieving certain health goals. Demand-side measures should be accompanied by incentives for providers and by regulations of the industry. The establishment of a progressive national prevention strategy in Austria is overdue.
for more information see: PDF, in German

The Austrian health reform 2013 is promising but requires continuous political ambition

The Austrian health system is much more complex and fragmented than in other OECD countries. In 2013 legislation was adopted to enhance efficiency through better balancing care provision across providers by promoting new primary care models and better coordination of care.

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Reform objectives should be achieved by cooperative and unified decision making across key stakeholders and by adherence to a budget cap that prescribes fiscal containment on the order of 3.4 billion Euros until 2016. This is priced into the envisaged savings of the current consolidation program. Efforts have been made to bridge the accountability divide by establishing agreements and administrative layers to govern the health system by objectives. Yet, more could have been achieved. For example, cross-stakeholder pooling of funds for better contracting governance and effective purchasing across care settings could have been introduced. This would have required addressing overcapacity and fragmentation within social security. At the same time, legal provisions for cooperative governance between Sickness Funds and the governments on the regional level should have been stipulated. The Austrian 2013 reform is interesting to other countries as it aims to ensure better-balanced care at a sustainable path by employing a public management approach to governance relations across key payers of care. HEALTH POLICY, DOI: http://dx.doi.org/10.1016/j.healthpol.2014.09.001: http://www.healthpolicyjrnl.com/article/S0168-8510(14)00231-0/fulltext

Accessible data for best practice comparative research in the area of health

The Health Data Navigator (HDN) was developed in 2013 within the FP 7 project EuroREACH which aimed at improving access to health care data through cross country comparisons.

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The Health Data Navigator provides a toolbox of guidance to researchers, policy makers and other stakeholders interested in cross-country research by (a) identifying information sources of aggregate, patient-level, disease-based data, (b) offering guidance on key data challenges such as data access, linkage and comparability and (c) highlighting gaps in existing data to encourage data collection in under-represented areas. The Health Data Navigator features an interactive compendium of health data and encourages exchange of best practices to improve comparative assessment of health system performance www.healthdatanavigator.eu, see also: The Health Data Navigator: Your toolkit for comparative performance analysis, A EuroREACH product, Ed. together with Peter Smith: http://www.healthdatanavigator.eu/HDN_Toolkit_Final.pdf

Enhanced monitoring of demographic change is high on the agenda

The Data Mapping Project is an activity of the Joint Programming Initiative (JPI) "More Years, Better Lives – The Challenges and Opportunities of Demographic Change". The project seeks to map the range of data sources on ageing at the European and national levels,

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examine whether there are major gaps in the available data infrastructure, as well as provide statistical agencies with user-driven feedback on standard data sources. Assessments as developed within the Health Data Navigator were applied to classify data sources. It will provide both scientists and policy-makers with a comprehensive overview of where to find appropriate data for cross-disciplinary approaches and evidence-based decision-making in an ageing context. The data project also helps to inform the development of the JPI’s Strategic Research Agenda, and any calls or research proposals that will follow from it, by identifying relevant sources, helping avoid repetition of work by individual projects, and ensuring that research proposals are well informed about possible data sources. Joint Programming is a new approach to foster collaboration and coordination in R&D in Europe. It is a member-state driven activity. The Joint Programming Initiative (JPI) "More Years, Better Lives - The Potential and Challenges of Demographic Change" seeks to enhance coordination and collaboration between European and national research programmes related to demographic change. Areas affected by demographic change cover a wide range of research fields and policy topics ranging from health to social welfare, education and learning, work and productivity to housing, urban and rural development and mobility. The JPI therefore follows a transnational, multi-disciplinary approach bringing together different research programmes and researchers from various disciplines in order to provide solutions for the upcoming challenges and to make use of the potential of societal change in Europe. Currently, 13 European countries are participating in the JPI “More Years, Better Lives“. For more information see: http://www.jpi-dataproject.eu

New tool to inform active and healthy ageing strategies

The Active Ageing index (AAi) research project has aimed at providing a new tool for policy makers to enable them to devise evidence-informed strategies in dealing with the challenges of population ageing and its impacts on society.

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The index was calculated for the 27 European Union countries, with a focus on the current generation of older people and by using the latest data available. It covers diverse aspects of active and healthy ageing, by measuring older people’s untapped potential with respect to not just employment but also their unpaid familial, social and cultural contributions and independent, healthy and secure living broken down by gender. Sweden and Denmark, Ireland and the United Kingdom and the Netherlands rank top, whereas the majority of Eastern European countries and Greece are at the bottom. Women fare worse than men in most countries, identifying a need for social policy emphasis on reducing gender disparity in experiences of active and healthy ageing.

For more information see: http://www1.unece.org/stat/platform/display/AAI/Active+Ageing+Index+Home, see also: Zaidi, A. et al (2013) Measuring active ageing in Europe, submitted at European Journal of Social Policy.

Comprehensive analysis of the Austrian health care system

The Austrian Health System Review 2013 (HiT Austria) comprehensively discusses the organisation, financing and care provision in the Austria. Further it analysis recent reform initiatives and assess the performance of the health care system.

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The costs of the health-care system are well above the EU15 average, both in absolute terms and as a percentage of GDP. There are important structural imbalances in health- care provision, with an oversized hospital sector and insufficient resources available for ambulatory care and preventive medicine. This is coupled with stark regional differences in utilization, both in curative services (hospital beds and specialist physicians) and preventative services such as preventive health check-ups, outpatient rehabilitation, psychosocial and psychotherapeutic care and nursing. There are social inequalities in the use of medical services including preventive health check-ups, immunization or dentistry.

For more information see:
Austria: Health system review. Health Systems in Transition, 2013; 15(7): 1–291: http://www.euro.who.int/__data/assets/pdf_file/0017/233414/HiT-Austria.pdf
GOVERNED COORDINATION IN THE AUSTRIAN HEALTH SYSTEM: A REMEDY FOR FRAGMENTATION?: http://www.euro.who.int/__data/assets/pdf_file/0006/216843/Eurohealth_v19-n3.pdf
Austria: Health System Review. (together with Herta Rack) Health Systems in Transition, 2006; 8(3):1-247, http://www.euro.who.int/__data/assets/pdf_file/0009/96435/E89021.pdf

OECD review advises health reform agenda for Austria

The 2011 OECD Review Austria found that the highly regarded Austrian health system delivers good quality and easily accessible services, but is costly. Its governance and funding structure is highly fragmented and it makes too much use of inpatient care in hospitals. Entry and competition opportunities are de facto limited in most health markets. The system operates therefore on a supply-driven basis, and does not have clear mechanisms to optimize spending on a cost-benefit basis.

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Population lifestyles are also not supportive of good health outcomes and suffer important differences between social groups, raising risks for the future. This Working Paper reviews Austrian authorities’ responses to these challenges, and makes recommendations based on OECD countries’ experiences. The suggested priorities are: i) more clearly assigning the performance, financing and spending responsibilities in the system, ii) enforcing a national capacity plan for publicly-funded inpatient and outpatient care, iii) introducing performance-based payment mechanisms in all services, iv) promoting the transition to “integrated care” by better balancing preventive, outpatient, inpatient, rehabilitation and long-term care, v) emphasizing healthier lifestyles and monitoring progress against national health goals (such as targets for obesity and overweight rates), and vi) better clarifying the medium-term fiscal outlook and scenarios of the system.

For more information see: Gönenç, R., M. M. Hofmarcher and A. Wörgötter (2011), “Reforming Austria's Highly Regarded but Costly Health System”, OECD Economics Department Working Papers, No. 895, OECD Publishing. http://dx.doi.org/10.1787/5kg51mbntk7j-en

Better health system performance requires a mix of measures to enhance patient-centred, coordinated care

The OECD study on improved health system performance through better care coordination identifies four key areas where reforms could potentially enhance the capacity of health- care systems to better coordinate care.

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Care coordination would be facilitated by better information transfer and wider use of ICT

First, better collection and dissemination of information on patients and provider performance appear to be a cornerstone for building improved care coordination and system governance for quality. Organisation of referrals and the appropriateness of care are facilitated if patient information is recent, accurate and provided on a timely basis. System governance and improvement of the quality of care also depend on having up-to-date indicators of provider performance. While Information and Communications Technology (ICT) appears to hold promise as a vehicle for this purpose, the penetration of information technology has remained weak to date in many countries. According to the questionnaire, very few countries consider that providers are often equipped with ICT and only about one-third frequently have patient files in electronic format. Some countries have introduced or are considering the introduction of national systems allowing transfer of patient files. However, nation wide systems of information transfer are costly to introduce and the potential benefits need to be balanced against high start-up and operating costs. In this context, the achievement of adequate (social) returns on investment needs to be assured.

The balance of resources going to ambulatory care may need to be reviewed

Second, with the progressive shift in care from inpatient to ambulatory-care settings, governments may need to consider whether the relative share of overall resources allocated to the ambulatory sector is in line with the new patterns of demand. As mentioned, ambulatory care needs seem likely to grow accentuated as populations age over coming decades.

New ambulatory care models need consideration

Third, and possibly more important, policy makers need to adapt better their ambulatory-care models to the new demands placed on them by chronic disease While there is some presumption that professionals at the primary-care level are best placed to take on this role, multidisciplinary teams involving medical and non-medical professionals may be better placed to provide more coherent care, particularly for patients with multiple pathologies. Systems dominated by providers operating in solo practice and paid for on a fee-for-service basis may be less well suited to meeting the care needs of the chronically ill. One specific avenue for consideration concerns scope-of-practice rules of non-medical practitioners. Questionnaire results suggest that most countries consider that these limit the capacity for care coordination. Widening the scope of their activities and, possibly, defining new classifications of medical workers specialising in care coordination tasks may improve the capacity to coordinate care while releasing medical professionals and consultants to concentrate on tasks of medical diagnosis and assessment.

Care coordination may benefit from greater health-system integration

Finally, the questionnaire results suggest that care coordination problems are most intense at the interfaces between health-care sectors and between providers. This suggests that coordination can be improved by bridging better the administrative and other barriers that impede easy transitions from one sector or provider to another. This issue may be particularly important for transitions into long-term care where problems appear to be the most intense. As noted, better systems for information transfer can aid the planning and organisation of services. Pooling resources between the health and social sectors for designated care coordinators who help patients and families at these transition points may be one model to bridge administrative barriers. But there may be also scope for integrated-care models that bring specialities and services under one roof and help make fragmented and complex systems more user friendly.

This report has attempted to identify care coordination practices and to isolate problems that currently impede better coordination. It has also examined current knowledge about targeted care coordination problems. The results broadly suggest that targeted programmes can have positive effects on quality. The evidence on cost savings is less consistent. But cost effectiveness may be improved by making care delivery more patient-centred. The study suggests that there is scope for improving performance in coordination by altering existing health-care systems through a policy mix ranging from better organized ambulatory care to patient-centred integration of health and long-term care. While the suggested areas for policy reflection are not new, they may now be taking on greater policy relevance as the importance of chronic disease increases.

For more information see: Improved Health System Performance through better Care Coordination (together with Howard Oxley and Elena Rusticelli), OECD Working Paper, DELSA/HEA/WD/HWP(2007)/6, http://www.oecd.org/health/health-systems/39791610.pdf, see also: Nolte E, Knai C, Hofmarcher M, Conklin A, Erler A, Elissen A, Flamm M, Fullerton B, Sönnichsen A, Vrijhoef HJ. Overcoming fragmentation in health care: chronic care in Austria, Germany and The Netherlands. Health Econ Policy Law. 2012 Jan;7(1):125-46. doi: 10.1017/S1744133111000338.

Extensive reporting of health reform initiatives in Austria between 2002-2010 within The Health Policy Monitor Network

The International Network Health Policy & Reform was initiated and developed by the Bertelsmann Stiftung (Foundation) in 2002.

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Bringing together health policy experts from 20 industrialized countries, over the years it became a widely acknowledged go-to place for adamant health policy analysis combined with outcome assessments and expert opinions, and a tool for cross-country knowledge transfer about what works and what doesn't in health policy. More than 1000 comprehensive reports can be looked up in the online database of the International Network Health Policy & Reform. Conducted in March 2003, the first survey covered the period September 2002 to February 2003. Until the merger with the National Lead Institutions Network in 2011, 16 survey rounds have been carried out.

For more information and Austrian reports visit Health Policy Monitor, 2002-2010: various papers: http://www.hpm.org/index.jsp.

The network is now part of the The Health Systems and Policy Monitor which is a platform that provides a detailed description of health systems and up to date information on reforms and changes that are particularly policy relevant, for more information see: http://www.hspm.org/mainpage.aspx

Health System Watch brought global perspectives to the Austrian health care system through comparative research

Health System Watch is a quarterly supplement to the monthly journal "Soziale Sicherheit". Health System Watch reviews recent data on health systems and health related topics covering European Union member countries as well as selected accession candidates. It was founded by Maria M. Hofmarcher and is written by members of IHS HealthEcon, a health research unit established by Maria M. Hofmarcher in 1999.

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The quarterly is produced in the context of a research cooperation with the Hauptverband der österreichischen Sozialversicherungsträger, where German printed copies of Health System Watch are available and cost EUR 16,- per year.

For more information see: Health System Watch – Quarterly, 1999-2005, Federation of Austrian Social Security Institutions; published in German up to now and in English 1999-2008.

The level of hospital efficiency in particular within groups of hospitals in Austria needs to be enhanced

Based on an analysis of the development of efficiency in acute care hospitals and rehabilitation clinics in Austria, the main objective of this study is to investigate the impact of ownership and patient related characteristics on this development.

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Applying standard Data Envelopment Analysis (DEA) techniques, we examine input-oriented efficiency in the period from 1997 to 2000. To do this, we define different categories of medical and non-medical personnel (in full-time equivalents), expenditure on current supplies and investment as input components in order to run four models with case rates, patient days, cases and cases plus patient days as the respective output components. Our findings suggest that both hospitals and rehabilitation clinics can economize on inputs; we identify an overall inefficiency level of ca. 20%. We then investigate the association of efficiency scores and characteristics related to ownership and patients using pooled multiple regression analysis. The analysis shows that descriptive statistics are not sufficient to explain inefficiency.

For more information see: Inefficiency in Austrian inpatient care: An attempt to identify ailing providers based on DEA results (together with Ch. Lietz, A. Schnabl), Central European Journal of Operations Research, Vol 13, December 2005, Issue 4

Are the 2013 health reform initiatives in Austria a true health reform?

Health reform 2013 in Austria is a renewed attempt to better balance care provision across providers by promoting new primary care models and better coordination of care supported by comprehensive central reporting and monitoring.

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Reform objectives should be achieved by cooperative and unified decision making across key stakeholders and by adherence to a budget cap that prescribes cost containment on the order of 3.4 billion Euros until 2016. This is priced into the envisaged savings of the current consolidation program. We believe that cost containment is feasible as public health spending growth is expected to remain at lower than pre-crisis levels in tandem with robust revenue growth since 2010. While considerable efforts have been made, to bridge the accountability divide in the health system, more could have been achieved despite an environment in which stakeholder relations within the constitution remain untouched. This could have resulted in cross-stakeholder pooling of funds for better contracting governance and effective purchasing across care settings, and would have required addressing overcapacity and fragmentation within social security, Hofmarcher, MM., H. Ostermann (2013); Better health services for less money through cooperative governance by objectives: The Austrian health reform 2013 wants it all, submitted at Health Policy.