6.1. Analysis of recent reforms

The following section focuses on health reforms since 2012. A short narrative overview of previous health reforms (2005–2011) is given in section 2.2.2. More details are also provided in the Austrian HiT reports 2006 (Hofmarcher & Rack, 2006) and 2013 (Hofmarcher & Quentin, 2013).

Table6.1 provides an overview of health reforms and policy measures implemented since 2012. Three major policy developments at federal and Länder level stand out as they introduced significant changes for the functioning of the Austrian health system: the first was the development of the Austrian Health Targets (Gesundheitsziele Österreich) that represent the guiding framework for Austrian public health policy in general and for the ongoing health reform process in particular. The other two were linked to the establishment of a new target-based health governance system, which was formalized through two Federal Target-Based Governance Agreements in 2012 and 2017. Most other reform activities included in Table6.1, such as the adoption of the revised Austrian Structural Plan for Healthcare in 2017, trace back to the first Federal Target-Based Governance Agreement of 2012 (see section 6.1.3). Activities in line with the second Federal Target-Based Governance Agreement (see section 6.1.4) are currently being devised. They are therefore not included in Table6.1 as, for most cases, concrete implementation and – if necessary – subsequent enactment remain to be specified in detail.

Table6.1

6.1.1. Endorsement of Austrian Health Targets based on a Health in All Policies approach

A broad participatory approach led to the adoption of Austrian Health Targets

In 2011, the Federal Health Commission and the Austrian Council of Ministers initiated the development of Austrian Health Targets (https://gesundheitsziele-oesterreich.at/). The objective was to increase the healthy life expectancy of the Austrian population by an average of two years by 2032. An important motivation for the initiative was that healthy life expectancy in Austria was – and still is – below the EU average (see section 1.4). Population health and health inequity are strongly linked to living and working conditions as well as lifestyles. Therefore, the development of the Austrian Health Targets followed recommendations of WHO and the EU, and adopted a Health in All Policies (HiAP) approach.

Stakeholders of all relevant political and societal areas were invited to participate in the elaboration of the Austrian Health Targets. Between October 2011 and March 2012, a committee comprising representatives of nearly 40 institutions drafted a proposal of 10 Health Targets. The committee included public authorities at the federal, Länder and municipal level; social insurance funds; Social Partners; health care professionals; health and social care institutions; advocacy groups for patients, children/adolescents, elderly and socioeconomically disadvantaged people; and academic experts. In addition, about 4500 citizens expressed their views in an online consultation. The final targets were adopted by the Federal Health Commission and the Austrian Council of Ministers in summer 2012 after feedback from all the involved institutions, civil society and experts had been incorporated (BMGF, 2017e; BMGF, 2017f).

The 10 Austrian Health Targets (see Box6.1) are based on a number of guiding principles. In line with the aforementioned Health in All Policies approach, these include, for example, orientation towards health determinants and promotion of equal opportunities. They serve as a general guiding framework for Austria’s public health policy, including also for health reforms as part of the new target-based health governance system.

Box6.1

The monitoring process includes indicators for specific sub-targets

A comprehensive monitoring process accompanies and evaluates the implementation of the Austrian Health Targets. Since January 2013, cross-sectoral working groups have operationalized health targets 1, 2, 3, 6, 8 and 9. This has led to the development of target specific strategies and to the definition of indicators at three levels: 1) health targets, 2) sub-targets, 3) actions (Winkler et al., 2014).

The monitoring of the Austrian Health Targets feeds into other health reforms and strategies such as the Target-Based Health Governance Reform (see below), the Health Promotion Strategy (see section 5.1.2) and the Child and Youth Health Strategy (see section 2.6.4). To date, reports have been completed for seven health targets. The monitoring process of four health targets revealed that the majority of actions were implemented (more than 90% of 133 defined actions).

In general, the health targets are thought to have been relatively successful in shaping high-level strategies and decisions (i.e. Federal Health Commission, Council of Ministers, Target-Based Health Governance Reforms 2013 and 2017). Furthermore, they have been integrated in corresponding processes at state level. To date, Carinthia, Upper Austria, Salzburg, Styria, Tirol and Vienna have published their own sets of targets (BMGF, 2016i).

6.1.2. A new target-based health governance system to improve coordination and cooperation

The fragmentation of responsibilities for financing and provision of services between the federal government, the Länder and the SHI funds is a characteristic feature of the Austrian health system (see section 2.3). Since the early 2000s, many challenges, such as the relatively high level of expenditure growth and the lack of care coordination, have been increasingly attributed to this fragmentation of responsibilities. When deficits of SHI funds and financial pressures at the Länder level increased in the aftermath of the financial crisis, this provided the impetus for a reform aiming to overcome the traditional fragmentation.

Former and recurring recommendations by national and international institutions had focused on streamlining the constitutional competences in the health sector. However, this was not feasible as a constitutional majority in both chambers of parliament could not be achieved.

In 2012, the federal government (Ministry of Health and the Ministry of Finance), the SHI funds and the Länder therefore jointly initiated a fundamental reform of the health system. The federal government, the SHI funds and the Länder cooperated to develop a new governance system, which could potentially achieve the overall aim of improved coordination in the health system while leaving the constitutional division of powers and responsibilities unchanged (Czypionka, 2015). The new governance system is based on a common vision for the future development of the health system, and relies on cooperation and coordination of the different stakeholders who are willing to set their own interests aside for the benefit of achieving jointly agreed goals or targets (both translate as Ziel in German).

The new governance system was institutionalized through the setting up of the B-ZK in 2013, where representatives of the federal government, the Länder and the SHI funds agree on common goals or targets for the health system (see also section 2.3.4). As a result, the B-ZK has become the supreme decision-making body of the Austrian health system. The legal basis for the target-based health governance system is civil contracts between the federal government, the Länder and the SHI funds (Zielsteuerungsverträge, Target-Based Governance Agreements) and agreements under Article 15a of the Federal Constitutional Law.

The Federal Target-Based Governance Agreement provides the basis for State Target-Based Governance Agreements (Landes-Zielsteuerungsverträge), which are approved by State Target-Based Governance Commissions (Landes-Zielsteuerungskommissionen). These agreements define details at the Länder level and operationalize the implementation of federal targets (see section 2.3.4).

The first Federal Target-Based Governance Agreement (Bundes-Zielsteuerungsvertrag) was concluded in 2013 outlining a reform agenda for a period of four years (2013–2016). In 2017, the B-ZK concluded the second Target-Based Governance Agreement, which defines goals for the ongoing five-year reform period (2017–2021). The next two subsections provide an overview over these two reform periods.

To comply with the principles of accountability, responsibility and transparency, strategic goals with specific objectives and target values were defined. A comprehensive monitoring process was implemented to evaluate the implementation of these targets. Biannual monitoring reports provide up to date information to all stakeholders and allow a public debate on the progress of the health reform agenda (GÖG, 2017c).

6.1.3. First health reform period (2013–2016)

The 2013 Federal Target-Based Governance Agreement specified 12 strategic goals grouped into four areas: 1) financial targets, 2) health care structures, 3) health care processes and 4) health care outcomes. The strategic goals were operationalized in 26 objectives, each specifying concrete measures (a total of 100 measures were defined), target values and deadlines (ZS-G, 2013).

Financial targets: cost containment

The most important strategic goal with regard to financing was the containment of rising public health care expenditure in order to ensure long-term sustainability of the health system. Financial targets were negotiated in line with the fiscal equalization laws, resulting in a budget cap for public health spending that was set to meet fiscal targets of the EU Maastricht criteria defined in the consolidation package (Stabilitätspakt) for the period 2012–2016 (Österreichischer Stabilitätspakt, 2012) (see section 2.8.1).

The budget cap was based on gradual containment of public health expenditure growth, aiming to bring it in line with the forecasted nominal GDP growth until 2016. As a result, the annual target growth rate was reduced in a stepwise manner from 5.2% (average between 1990 and 2010) to the projected annual average GDP growth rate of 3.6% per annum in 2016. The overall budget cap was broken down to the Länder and to SHI funds, with the Länder contributing 60% and SHI funds 40% to total cost containment. This breakdown of the financial targets for each Land and SHI fund were a result of political negotiations. For monitoring of state health expenditure, a new calculation method was introduced that builds on the OECD System of Health Accounts and allows a breakdown of expenditure at the Länder level.

Overall, financial targets were achieved at national level for all years (2013–2016), during which public health expenditure grew on average by only 3.6% per year. At the end of the period, public health expenditure in total remained almost €1000 million below the allowed budget cap (see Table6.2). However, attainment of financial targets varied across Länder and SHI funds, from over-fulfilment (e.g. company health insurance funds or the Insurance Fund for the Railway and Mining Industries) to non-attainment (e.g. the regional SHI fund of Vorarlberg throughout the period; the regional SHI funds of Tirol, Salzburg and Vienna for specific years).

Table6.2

The Austrian Court of Auditors criticized the methodology by which financial targets were derived, focusing solely on expenditure and not revenues. This was particularly concerning in regard to SHI funds that had revenue growing in line with wages but not GDP. Moreover, the level of cost containment was considered insufficient to achieve real structural change (Austrian Court of Auditors, 2016a). At the same time, various stakeholders such as the Austrian Medical Chamber criticized that the financial targets posed constraints on the health system with negative consequences for service provision (ÖÄK, 2012).

Health system structures: strengthening primary health care and increasing efficiency

With regard to health system structures, the Federal Target-Based Governance Agreement defined three strategic goals. First, it aimed at shifting health care provision to the so-called “best point of service”. This was defined as the right place for providing the best treatment, at the right time, and at the lowest cost from a societal perspective (Vereinbarung gemäß Art. 15a B-VG Zielsteuerung-Gesundheit, 2017).

One particularly important sub-target aimed at contributing to the achievement of this goal was the strengthening of primary health care through the introduction of multi-professional and interdisciplinary primary health care units. These units should act as the first entry point to the health system and take on a central and coordinating function. A primary health care concept was adopted by the B-ZK in June 2014 (BMG, 2014a), which ultimately – after intense political struggle and substantial delays – led to the adoption of the 2017 Primary Health Care Act in the second reform period (see below).

The second goal focused on adjusting care provision to increase efficiency, for example, by reducing hospital admissions and average length of hospital stays, fostering day surgery and ambulatory care, and reducing parallel structures. For several of these points, very specific targets were defined, for instance a reduction of the hospital discharge rate in funds hospitals of 1.1% to 4% per year. For other points, targets mandated, for example, the adjustment of health care planning and the definition of new financing models.

The third goal aimed at adjusting basic and continuous education of all relevant health personnel in line with the care provision needs of the population. The goal was partly achieved. In 2015, postgraduate medical education was reformed (Medical Training Regulation, 2015) and the Nursing Act (2007) was amended in 2016 creating a new profession of assistant nurse with more competences (see Table6.1). The Primary Health Care Act (2017), which should set prerequisite for fulfilling this goal, was only passed in the second health reform period.

Table 6.1

Regular monitoring reports as part of the reform process show that several of these targets were met. For example during the first reform period (2013–2016), hospital bed days in funds hospitals could be reduced by 10% (target value: 1.8–2.2% per year) and hospital discharges by 8% (target value 1.1–4% per year) (see section 5.4). Despite these reductions, Austria still has the second highest hospital discharge rate in the EU. Reduction of the average length of stay and pre-surgical length of stay were not achieved despite decreasing trends (Bachner et al., 2017) (see also section 4.1.2).

With regard to the “best point of service” goal, the revision of the Austrian Structural Plan for Healthcare in 2017 (see Table6.1) was a major achievement. It includes the establishment of defined service baskets for every care level at the regional level, based on patients’ needs, aimed at providing treatment at the respective “best point of service”. The Plan also includes provisions for ambulatory (extramural) services, defining the types and numbers of physicians on the basis of local demand as well as functions and services to be provided per specialty, which is intended to contribute – among others – to shifting service provision away from inpatient care (see section 2.5).

Health care processes: fostering coordination, quality and standardization

In order to achieve better coordination of care across sectors, important objectives with regard to health care processes were the development of federal quality standards for selected areas of care, harmonized documentation of diagnoses and services across different ambulatory providers (i.e. hospitals and ambulatory physicians), and streamlining prescription processes and developing joint financing mechanisms to assure that patients receive medications at the “best point of service”. Another objective was the further development of e-health projects, such as the ELGA and its applications, for example e-medication. Furthermore, integrated care programmes should be developed for common or chronic diseases.

Some of these objectives were achieved. National quality standards and guidelines were developed and implemented (e.g. for hospital admissions, discharges and pre-surgical diagnostics). The implementation of ELGA was initiated in 2015 (see section 4.1.4) and a telephone helpline for patients was launched with some delay in 2017 (see section 2.9.1). However, several other objectives turned out to be too ambitious. Particularly, progress towards the development of new integrated care models was slow. Although 14 integrated care models were implemented, national stakeholders failed to agree on quality standards which would have been necessary for defining and monitoring related targets within the given time frame. In addition, stakeholders failed to agree on joint financing or procurement of medicines. Finally, the harmonized coding of diagnoses in different ambulatory care settings is still in the initial stages. By 2016, five pilot projects had been carried out. Based on the experiences of these projects, roll-out of cross-sectoral harmonized coding of diagnoses in the ambulatory (extramural) sector is planned by 2021 (section 3.7.1).

Health outcomes: improving quality of life and quality of care

The Federal Target-Based Governance Agreement included four strategic goals related to health outcomes: (1) increasing healthy life years and quality of life, (2) measuring and improving quality of care, (3) improving patient safety and health literacy, and (4) assuring a high level of population satisfaction with the health system. Several of the objectives related to these goals were achieved.

First, the Health Promotion Strategy was agreed on in 2014 based on the Austrian Health Targets with the aim to improve people’s life expectancy and quality of life. The strategy provides an impact-oriented framework for the period until 2022. It focuses on specific fields of action, for example early childhood interventions (Frühe Hilfen) (see section 2.6.4) and defines priorities, for example initiatives for health in schools, healthy environments and lifestyles, health literacy and social inclusion of the elderly with mental problems (see section 2.6.2) (BMGF, 2016d).

Second, the A-IQI were developed further and selected results were made available in regular public reports and on the web portal kliniksuche.at, launched in 2016 (see section 2.9.1). In this regard, quality measurement in the ambulatory (extramural) care sector (see section 2.8.2) and first initiatives to establish standardized diagnostic coding are important steps (see above). Third, a comprehensive outcome measurement framework for the health system was developed (see section 7.4.2). This includes measurement of risk factors and health status using various databases and surveys, for example on tobacco consumption, as well as data on inpatient mortality, patient satisfaction and life expectancy (Bachner et al., 2015).

Lessons learnt from the target-based health governance approach

Towards the end of the reform period, an internal evaluation of the reform process was initiated to provide input for the following reform period. The evaluation showed that about 62% of all targeted actions had been achieved by the end of 2016 (Bachner et al., 2017). In addition, a number of strengths and weaknesses of the reform process were highlighted.

• On the positive side, institutional capacity was raised by establishing new governance structures. Federal and State Target-Based Governance Commissions were made jointly responsible and accountable for target achievement. Further, better decision-making and communication processes were made possible under these structures. Also, shared responsibility led to an increased number of cross-sectoral projects (e.g. pilots of primary health care units, telephone helpline).
• On the negative side, many measures were not impact-oriented but focused on evaluation or drafting of new concepts. Despite enhanced collaboration, major intersectoral problems remained unresolved, such as the lack of joint procurement or financing of medicines across inpatient and ambulatory (extramural) sectors.

While a certain degree of detail may provide a sound roadmap for implementation, the targets and actions were technically too detailed (in total 106 targets and actions) and thus failed to attract sufficient political commitment.

Finally, the new governance system is characterized by a high degree of bureaucratic burden. Before decisions could be taken at the senior decision-making level of the B-ZK (see section 2.3.4), major results of working groups had to be discussed. In the case of lack of communication with subordinate levels, decisions were refused and passed back, making the whole process complex and lengthy. However, if decisions were once taken, commitment of the health reform partners to various reform activities was strong (see also Table6.1).

6.1.4. Second health reform period (2017–2021)

The second Federal Target-Based Governance Agreement for the period 2017 to 2021 was signed in 2017 and sets four strategic goals that are further specified in 11 objectives with concrete indicators and target values (see Table6.3). It builds on the experiences, priorities and guiding principles of the first health reform period. The legal basis for the second reform period is two new agreements under Article 15a of the Federal Constitution and the Health Reform Act (Vereinbarungsumsetzungsgesetz, 2017).

Table6.3

The new Target-Based Governance Agreement is more ambitious in terms of agreed actions and financial targets. Yet, the complexity and the number of strategic goals and objectives have been reduced and medium- or long-term tasks have been summarized. The reform partners also streamlined the complex governance structure by reducing the number of bodies and working groups involved. A standing high-level committee (Ständiger Koordinierungsausschuss) was set up as a body of the Federal Health Agency (BGA) with a preparatory function for the B-ZK and decision-making competences in defined areas (see section 2.3.4) (Vereinbarung gemäß Art. 15a B-VG Zielsteuerung-Gesundheit, 2017).

The new Agreement is also more impact-oriented as the achievement of objectives will be assessed using outcome indicators. In total, 22 indicators were defined including, among others, healthy life years, days of hospitalization per 100 000 inhabitants, the number of primary health care units, preoperative length of stay, and prevalence of polypharmacy (see Table6.3). The accompanying monitoring process will be less complex given the reduced number of indicators and restructured reporting. In addition, the new agreement also includes objectives at the Länder level and adjusted State Target-Based Governance Agreements (Landes-Zielsteuerungsverträge).

The second Target-Based Governance Agreement maintains many priorities and reform efforts of the first reform period, which have, in fact, been on the political agenda for several decades.

As shown in Table6.3, the first strategic goal is to optimize resource allocation by reducing overutilization of inpatient care and by strengthening ambulatory care, in particular primary health care. Objective 1.1 on the set-up and development of primary health care models is based on the Primary Health Care Act adopted in 2017.

The Act was heavily criticized by the Austrian Medical Chamber for two main reasons. First, it did not provide the option to employ physicians in independent practices (see section 2.8.2) and it required contracted physicians to resign their existing SHI contracts to create a primary health care unit with other physicians under a new contract. A transition period for full implementation of new contracts was therefore introduced (see the General Social Insurance Act (ASVG)). Second, the Chamber feared the competition from larger-scale (for-profit) organizations entering the field of primary health care provision. For this reason, a multi-stage procedure was included in the law that prioritizes contracted physicians (see the Primary Health Care Act). The intense political debate substantially delayed the adoption of the Act until August 2017. The Primary Health Care Act provides the legal framework for the establishment of at least 75 primary health care units until 2021, which will be supported through specific programmes (e.g. start-up services). Primary health care units can be set up in the form of a centre or a network. They are required to consist of a multi-professional team of GPs and qualified nurses, complemented by paediatricians or specialists and other health and social professionals (e.g. physiotherapists or social workers). Primary health care units are required to offer a certain range of services, extended opening hours, home visits, competences in treating patients with special needs, and they have to ensure continuity of care. Each unit has to submit a care concept describing how its service provision and organizational structure respond to the health needs of the local population.

Moreover, the new Target-Based Governance Agreement also introduced an amendment to the ASVG requesting a new payment scheme for primary health care and ambulatory specialist care that incorporates lump sums and capitation payment, fee-for-service and pay-for-performance elements (see objective 3 in Table6.3).

Several objectives of the second Target-Based Governance Agreement aim at improving accessibility of ambulatory care. Objective 1.2 aims to expand the number of multidisciplinary teams in ambulatory specialist care (including hospital outpatient departments). Objective 4 demands the optimization of health services for children and adolescents, including targets for the expansion of multi-professional teams in psychiatric and psychosocial institutions and more early childhood interventions (Frühe Hilfen) (see section 2.6.4). These measures are combined with monitoring of opening hours and waiting times.

The second strategic goal aims at ensuring population satisfaction by optimizing care and treatment processes. This is to be achieved through five more specific objectives, which include the further development of e-health solutions (e.g. ELGA and its applications, mHealth, pHealth, survivorship passport), new integrated care programmes for common chronic diseases, enhanced cooperation across care settings and the introduction of standardized quality measurement in ambulatory care (see Table6.3).

Building on the implementation of ELGA in public hospitals in 2015, the renewed ELGA regulation (ELGA-Verordnungsnovelle 2017) mandates the stepwise roll-out of ELGA to ambulatory health care providers and pharmacies which should be terminated by mid-2019. Completion of the nationwide roll-out of ELGA is expected by 2021. Moreover, a new attempt has been launched to optimize use of medicines through joint procurement.

The third strategic goal aims at improving health literacy and strengthening health promotion. Activities are being coordinated by the Austrian health literacy platform, which was established in 2013 to bring together various actors from the federal and state level as well as from social insurance funds (see section 2.9.1). Also the public health portal www.gesundheit.gv.at (see section 4.1.4) has been further developed. As well as providing high-quality, peer-reviewed online information on health and health care, the portal contributes to improving the health literacy of the population. Furthermore, uniform criteria for HIAs will be developed to foster target-oriented public health interventions.

Finally, fiscal sustainability of the Austrian health system remains a priority in the fourth strategic goal. Stakeholders agreed to introduce more stringent financial targets, with caps on public health spending growth to be reduced gradually from 3.6% in 2017 to 3.2% or below in 2021 (Vereinbarung gemäß Art. 15a B-VG Zielsteuerung-Gesundheit, 2017). The second health reform period further aims to address the fragmented and dual financing system by introducing an earmarked pool of financial resources at the federal level for the financing of supra-regional health care services, which constitutes a first commitment towards joint financing and planning.