Thomas Czypionka

Efficiency, ownership, and financing of hospitals: The case of Austria

While standard economic theory posits that privately owned hospitals are more efficient than their public counterparts, no clear conclusion can yet be drawn for Austria in this regard. As previous Austrian efficiency studies rely on data from the 1990s only and are based on small hospital samples, the generalizability of these results is questionable. To examine the impact of ownership type on efficiency, we apply a Data Envelopment Analysis which extends the existing literature in two respects: first, it evaluates the efficiency of the Austrian acute care sector, using data on 128 public and private non-profit hospitals from the year 2010; second, it additionally focusses on the inpatient sector alone, thus increasing the comparability between hospitals. Overall, the results show that in Austria, private non-profit hospitals outperform public hospitals in terms of technical efficiency. A multiple regression analysis confirms the significant association between efficiency and ownership type. This conclusive result contrasts some international evidence and can most likely be attributed to differences in financial incentives for public and private non-profit hospitals in Austria. Therefore, by drawing on the example of the Austrian acute care hospital sector and existing literature on the German acute care hospital sector, we also discuss the impact of hospital financing systems and their incentives on efficiency. This paper thus also aims at providing a proof of principle, pointing out the importance of the respective market conditions when internationally comparing hospital efficiency by ownership type.

The SELFIE framework for integrated care for multi-morbidity: Development and description

BACKGROUND The rise of multi-morbidity constitutes a serious challenge in health and social care organisation that requires a shift from disease- towards person-centred integrated care. The aim of the current study was to develop a conceptual framework that can aid the development, implementation, description, and evaluation of integrated care programmes for multi-morbidity. METHODS A scoping review and expert discussions were used to identify and structure concepts for integrated care for multi-morbidity. A search of scientific and grey literature was conducted. DISCUSSION meetings were organised within the SELFIE research project with representatives of five stakeholder groups (5Ps): patients, partners, professionals, payers, and policy makers. RESULTS In the scientific literature 11,641 publications were identified, 92 were included for data extraction. A draft framework was constructed that was adapted after discussion with SELFIE partners from 8 EU countries and 5P representatives. The core of the framework is the holistic understanding of the person with multi-morbidity in his or her environment. Around the core, concepts were grouped into adapted WHO components of health systems: service delivery, leadership & governance, workforce, financing, technologies & medical products, and information & research. Within each component micro, meso, and macro levels are distinguished. CONCLUSION The framework structures relevant concepts in integrated care for multi-morbidity and can be applied by different stakeholders to guide development, implementation, description, and evaluation.

How European Nations Care for Their Elderly: A New Typology of Long-Term Care Systems

Table of Contents: Introduction; Evidence and analysis; Policy implications and recommendations; Research parameters;

Psychotherapie im Internet: Österreich

The paper presents a survey of internet users und suppliers of psychotherapy and counselling. The survey based on a search for relevant homepages was carried out as an online questionnaire. Psychotherapy as such is not on offer in the internet in Austria in compliance with the law, but information on psychotherapy practice, first contacts and short-term counsellling is provided mainly via e-mail. There are some significant differences between patients and psychotherapists who use the internet and those who do not. The demographic data of patients using the internet are similar to those of internet users generally. Psychotherapists providing services on the internet tend to be older and more experienced than the average psychotherapist in private practice.ZusammenfassungIn dieser Arbeit wird eine empirische Erhebung zu Angebot und Nutzung des Internet in Psychotherapie und Beratung in Österreich vorgestellt. In zwei Erhebungsschritten wurden die entsprechenden Homepages aufgesucht und dann eine Online-Befragung der Anbieter durchgeführt. Grundsätzlich wird in Österreich im Internet keine Psychotherapie, sondern Erstkontakt, Praxisinformation und kurze Beratung hauptsächlich über E-Mail angeboten. Die geografische Verteilung der Angebote unterscheidet sich von jener der niedergelassenen TherapeutInnen. Während sich die PatientInnen von Internet-NutzerInnen in den demografischen Merkmalen nicht unterscheiden, handelt es sich bei den TherapeutInnen häufig um etwas ältere und erfahrenere PsychologInnen, wodurch sich diese von den niedergelassenen PsychotherapeutInnen unterscheiden.

Explaining differences in stakeholder take up of disease management programmes: A comparative analysis of policy implementation in Austria and Germany

PURPOSE Understanding why policies to improve care for people with chronic conditions fail to be implemented is a pressing issue in health system reform. We explore reasons for the relatively high uptake of disease management programmes (DMPs) in Germany, in contrast to low uptake in Austria. We focus on the motivation, information and power of key stakeholder groups (payers, physician associations, individual physicians and patients). METHODS We conducted a comparative stakeholder analysis using qualitative data from interviews (n=15 in Austria and n=26 in Germany), legal documents and media reports. RESULTS Stakeholders in Germany appeared to have systematically stronger motivation, exposure to more positive information about DMPs and better ability to implement DMPs than their counterparts in Austria. Policy in Austria focused on financial incentives to physicians only. In Germany, limited evidence about the quality improvement and cost savings potential of DMPs was mitigated by strong financial incentives to sickness funds but proved a fundamental obstacle in Austria. CONCLUSIONS Efforts to promote DMPs should seek to ensure the cooperation of payers and patients, not just physicians, using a mix of financial and non-financial instruments suited to the context. A singular focus on financially incentivising providers is unlikely to stimulate uptake of DMPs.

Defining good health and care from the perspective of persons with multimorbidity: Results from a qualitative study of focus groups in eight European countries

Objectives The prevalence of multimorbidity is increasing in many Western countries. Persons with multimorbidity often experience a lack of alignment in the care that multiple health and social care organisations provide. As a response, integrated care programmes are appearing. It is a challenge to evaluate these and to choose appropriate outcome measures. Focus groups were held with persons with multimorbidity in eight European countries to better understand what good health and a good care process mean to them and to identify what they find most important in each. Methods In 2016, eight focus groups were organised with persons with multimorbidity in: Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain and the UK (total n=58). Each focus group followed the same two-part procedure: (1) defining (A) good health and well-being and (B) a good care process, and (2) group discussion on prioritising the most important concepts derived from part one and from a list extracted from the literature. Inductive and deductive analyses were done. Results Overall, the participants in all focus groups concentrated more on the care process than on health. Persons with multimorbidity defined good health as being able to conduct and plan normal daily activities, having meaningful social relationships and accepting the current situation. Absence of shame, fear and/or stigma, being able to enjoy life and overall psychological well-being were also important facets of good health. Being approached holistically by care professionals was said to be vital to a good care process. Continuity of care and trusting professionals were also described as important. Across countries, little variation in health definitions were found, but variation in defining a good care process was seen. Conclusion A variety of health outcomes that entail well-being, social and psychological facets and especially experience with care outcomes should be included when evaluating integrated care programmes for persons with multimorbidity.

Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA)

BackgroundEvaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA).Methods and resultsThis paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops.DiscussionBy discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.

SELFIE, a novel Horizon2020 project on integrated care for multi-morbidity

Introduction: SELFIE is a new EU-Horizon2020 funded project, which started on September 1st 2015 and is entitled “Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performance”. SELFIE stands out from other EU-funded projects on integrated care by adopting a broad health economic approach. SELFIE will perform empirical research of promising integrated care models which specifically target individuals with multi-morbidity. It will conduct policy evaluations of financing/payments schemes with different incentives to support integration of care within and across the health care, long-term care and social care sectors. It will develop methods for price-setting, tools for performance monitoring, and strategies for implementation of integrated care in different healthcare systems and contexts including Central and Eastern European Countries. But the first stream of research in SELFIE consists of the development of a conceptual framework on integrated care for multi-morbidity, the identification of specific programs in developed countries, and qualitative research on these programs. Methods: To inform the conceptual framework, scientific literature was searched in online databases (i.e. Pubmed, Embase, Scopus, Web of Science, Cochrane, PsycInfo, and sociological & Social Services Abstracts via ProQuest) and combined with grey literature from OECD, WHO and EU. Studies and reports concerning frameworks/models, integrated care, and multi-morbidity were selected. These sources were also used to identify implemented integrated care programs in the EU. In later phases of SELFIE, these programs will be scored and rank-ordered on a number of criteria in order to select the most promising ones. The latter will be included in the qualitative and quantitative empirical evaluation using Multi-Criteria Decision Analyses (MCDA). MCDA assesses the performance of different integrated care programs on a number of criteria related to the Triple Aim of integrated care (i.e. patient experience, health/wellbeing and costs) and combines them with relative weights that Patients, their Partners, the Professionals, the Payers and the Policy makers (5 Ps) assign to the importance of the criteria. Weights will be obtained o.a. via Discrete Choice Experiments. As little is known about the dynamics, success factors and obstacles for ICC programs dealing with multi-morbidity, a research approach from the qualitative paradigm, the thick description, is used to gain more insight in their social fabric. Results: The literature search resulted in x unique studies of which y were included in our selection. At the time this abstract was written, information from the studies was being retrieved and the identification of implemented integrated care programs for multi-morbidity was in progress. At the conference we will present the first results, including the conceptual framework, the approach for the qualitative in-depth study of specific programs and the methods developed for the MCDA. The focus of the results will be on elements of integrated care particularly relevant for individuals with multi-morbidity. Examples of such elements are a holistic assessment of an individual’s needs, preferences, skills, life-style and illness-perceptions across the entire spectrum of diseases that the individual has, and person-centred care that accounts for overlap and interaction between clinical guidelines/protocols for different diseases and avoids polypharmacy. Discussion and conclusion: The ICIC-16 will be an ideal conference to present the SELFIE study for the first time to a large and broad audience and the results will be interesting to many attendees. The discussion will include the need to develop integrated care approaches for multi-morbidity, the elements that constitute integrated care suitable for people with multi-morbidity and the potential of using MCDA to facilitate a broad evaluation of integrated care. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634288. The content of this abstract reflects only the SELFIE groups’ views and the European Commission is not liable for any use that may be made of the information contained herein.

The relationship between outpatient department utilisation and non-hospital ambulatory care in Austria

Background: Coordinated health service utilisation in the ambulatory care sector is of major interest from a health policy perspective. This ecological study investigates the interplay between medical care utilisation in hospital outpatient departments and in freestanding physician practices by drawing on the example of the Austrian healthcare system, which is standing out due to three features: ambulatory care is provided by both free-standing public (contract) and private (non-contract) practitioners; medical specialists operate in free-standing physician practices and in hospital outpatient departments; essentially, no gatekeeping is in place. As the ongoing health care reform aims to strengthen the primary care sector, we investigate whether in the current system care in general practitioner and specialist physician practices is in a substitutive, complementary or independent relation with medical care in outpatient departments. Methods: Hypotheses were tested using ordinary least square regression analysis based on administrative data of all Austrian districts with a hospital department in 2010, including a proxy for actual utilisation rather than physician headcount. Results: Controlling for socio-demographic and geographic characteristics and inpatient activity, we find that a higher level of care provision by contract GPs is associated with lower use of hospital outpatient departments on the district level. In contrast, a higher level of care by non-contract specialists is related to a higher utilization in outpatient departments. Conclusion: While care by non-contract specialists seems to be in a complementary and potentially demand-inducing relation with outpatient departments, primary care by contract GPs appears to be capable of replacing care in outpatient departments.

Bedeutung und grundlegende Erfassung der Gesundheitswirtschaft

In einem ersten Schritt erscheint es zweckmasig, den Begriff Gesundheit bzw. Gesundheitswirtschaft zu erfassen und abzugrenzen. Mit einem Anteil von nunmehr 11 % des Bruttoinlandproduktes im Jahr 2010 laut dem System of Health Accounts (SHA, siehe Kap. 5.3.1) – rund 3/4 davon aus offentlicher Hand – wird in einer ersten Annaherung die Bedeutung der Gesundheitswirtschaft in der osterreichischen Okonomie deutlich. Das System of Health Accounts bildet eine Struktur von umfassenden, konsistenten und international vergleichbaren Gesundheitskonten. Es lasst sich als Sekundarstatistik auf Basis der VGR ausweisen. Das nachfolgende Kapitel soll vorweg eine weniger technische und dafur allgemeine und qualitativ weitgefasste Auslegung der Gesundheitswirtschaft liefern. Im weiteren Verlauf dieser Ausarbeitung wird der Begriff Gesundheit bzw. Gesundheitswirtschaft fortlaufend eingeengt bzw. konkretisiert (Kap. 5). Fur eine gegenstandliche Abbildung der Gutergruppen im GSK siehe Tab. 5.3 (S. 73) und Tab. 5.5 (S. 82).