What is your mantra for success in the fight against diabetes

The mantra of saving in the health system must be fundamentally reconsidered

The coronavirus worries the world. Seldom before has health been such an important topic in public discussion. How Austrians are cared for has recently changed - at least structurally. The Austrian health system was rebuilt. This is discussed by Andreas Huss from the Austrian Health Insurance Fund and health economist Thomas Czypionka.

DEFAULT: As soon as you were born, the Austrian Health Insurance Fund is already heavily in debt. As the?

Andreas Huss: That is not right. The ÖGK started with 1.4 billion reserves of the regional health insurance funds and is therefore highly liquid.

DEFAULT: However, a deficit of 1.7 billion is expected by 2024.

Huss: This is a management preview that has been calculated extremely carefully. But that's better brewing coffee. Such long-term forecasts cannot be accurate. The reason why this number was so intensely discussed in the media is due to the unfortunate statement by the Federal Chancellor that there will be an additional billion in patient savings by 2023.

DEFAULT: Will we ever see this billion patients?

Thomas Czypionka: The income of the ÖGK depends on the economic development. There isn't much she can do about that. The coronavirus means higher healthcare spending and a decent damper on GDP and thus revenue. That doesn't make the funding situation of the health insurers any easier. One billion patients will certainly not be found through savings in administration. However, the patients benefit from the fact that many cost reimbursements have already been increased. That relieves them.

Huss: But we didn't need a merger for that. Since 2016, we have spent around 84 million euros annually to harmonize the services of the nine regional health insurance funds and the health insurances of the self-employed, farmers, civil servants and railway workers at the highest level in each case.

DEFAULT: What were those achievements?

Huss: For example, the Salzburger GKK previously paid 3320 euros for a wheelchair, the Viennese fund only 498 euros. Vienna patients now also receive higher subsidies for crowns and fixed dentures. In Carinthia, Styria and Vienna there have recently been no more cures or recreational stays for retirees. They are now being paid again. Now we also want to standardize the contractual services, for example for physiotherapy, occupational therapy and psychotherapy and speech therapy. This is not well organized in some federal states. That will be a huge effort. But again: we wouldn't have needed a merger for that.

Czypionka: We have shown in a study that the differences in performance focus on very specific people. For example, if you have a severe form of multiple sclerosis, you not only need a wheelchair, but also medication, therapy and other services. This requires a balance between all health insurers. The money should not be bunkered in silos, but rather distributed where it is needed.

DEFAULT: Where are the biggest differences today?

Huss: The civil service insurance receives 470 euros more in contributions per employed person than the ÖGK - even without the higher deductibles, which add up to around 50 euros. This is mainly due to the fact that their policyholders are better educated, earn more, are less sick and are not unemployed. As a result, the ÖGK loses up to 30 million euros per year due to bankruptcies and other premium write-offs. The BVAEB does not have that problem. It is not understandable that a civil servant receives much more benefits than an ÖGK insured person. In most federal states, they are even in the special class in hospitals. I am particularly annoyed that some patients get an MRI appointment much faster because the radiologist receives a higher fee from some health insurers than from the ÖGK. That is why we need a balance so that we can adjust the services.

DEFAULT: Do we have multi-class medicine?

Huss: We live in a system of the free market economy. As a result, people who have more money can also afford more. It would be naive to think that this would stop at medicine. It is our task every day to fight to ensure that this does not get out of hand. We already have two-class medicine when it comes to waiting times. In my estimation, nobody gets more expensive drugs or better medical treatment.

Czypionka: The officers also pay deductibles. So you have to understand that they don't just want to redistribute their money now.

DEFAULT: Should all health insurers introduce deductibles?

Czypionka: General deductibles are not recommended. You could prevent people from using necessary services. Deductibles only make sense if you want to steer. For example, if someone wants to go straight to a specialist even though they would be well looked after by the family doctor. However, doctors should not be given any incentives to give preference to individual patients. It is nonsense if the same handle is paid for differently by individual cash registers. This leads to a tendency to involuntarily prefer to treat patients for whom you get a third more fee and to take more time for them. Then we already have a bit of two-tier medicine.

DEFAULT: Do all health insurers need higher medical fees?

Huss: I am so much a realist that I know that in the next five years it will certainly not be possible to bring the fees into line with those of the BVAEB. The ÖGK simply doesn't have the money for it.

Czypionka: Doctors usually have a mix of fees. They can also make a living from it in socio-economically disadvantaged areas. But you would have to redistribute a bit between the individual subject areas. In some cases, incomes have diverged widely over the past 20 years. Pediatricians, for example, have been disadvantaged for a long time, and then we wonder why there aren't enough medical practices here.

Huss: General practitioners earn between 5,000 and 7,000 euros net per month. You don't get rich from it, but you can make a living from it. But I understand their frustration when they compare their fees with those of the specialists. In the future I would therefore like to see a clear promotion of general practitioners and paediatricians and a zero fee increase for laboratory physicians and radiologists. For me, general medicine is the supreme discipline. A good family doctor knows the whole person, his family and professional situation, his fears and worries. Specialists often only see one joint or one organ. The general practitioners often lack the self-confidence that they are actually the hub in care.

DEFAULT: Is the payment the reason for the shortage of statutory health insurance physicians?

Czypionka: For most specialist groups, it is not the money, but a change in attitudes towards the medical profession. Many young doctors prefer to look after fewer patients and therefore do not have a health insurance contract. This can lead to a negative spiral because the remaining contract doctors have more and more to do and then also throw their hats on.

Huss: Some doctors then put the ÖGK contract back and keep the "small cash registers". We can then only advertise the position for the health insurance company. It is less attractive and we therefore cannot find any applicants. At the round table with the minister, I made it clear that we have to regulate this by law. You can't pick raisins here and only choose the cash registers with the higher tariffs.

DEFAULT: What else does the cash reform bring?

Huss: It brings us some problems. In a federal system one cannot suddenly take out a partner and organize it centrally. The federal states and their medical associations are still organized regionally. It doesn't go together. The collection of contributions can be done centrally, but the organization of health care in Lungau does not work that way.

Czypionka: Real savings can only be achieved through better care. When it comes to chronic diseases, we have huge deficits and insane costs. For example, if diabetics were treated better, we could save a lot. The relief of doctors by nurses could also bring savings. But as long as the resident sector and the hospitals have separate pots of money, there are too few incentives for this.

DEFAULT: The medical association fears savings and is already rattling its chains.

Huss: I understand that some statements were provocative to the Medical Association and that they must now shoot back. We are having good discussions and I am sure that this will be over in the next few weeks. We agree that we want a uniform catalog of services throughout Austria and that we are gradually approaching the new overall contracts. We will continue to need different fees in the federal states, otherwise we won't get doctors in some areas at all. In some questions we just have to retain a certain regional flexibility.

DEFAULT: What traces will the coronavirus leave behind in healthcare?

Huss: Presumably the realization remains that the mantra of "saving in the system" has to be fundamentally reconsidered. In the current situation it becomes obvious that a society has to be well positioned in the health and social sector and not every field must be completely optimized to meet normal needs. It is important that there is a strong health system based on solidarity that is also equipped to deal with exceptional situations. (Andrea Fried, CURE, May 10, 2020)