Vienna whirl
Roger St Pierre reviews the impressive levels of patient care available to Austrian citizens and their visitors
First published in ITIJ 115, August 2010
Roger St Pierre reviews the impressive levels of patient care available to Austrian citizens and their visitors
Blessed with a dramatically beautiful Alpine landscape, Austria is a year-round destination, with hikers and mountaineers replacing skiers and snowboarders when the snow retreats. As one of Europe’s most attractive and historic capital cities, Vienna, with its excellent air, road and rail connections is also a major pull, especially for the short-breaks market.
Visitor trends have seen heavy increases from the recently acceded neighbouring Eastern Europe members of the European Union – both tourists and those seeking work – while, less expectedly, there’s been a 10-per-cent increase in visitors from India, with some 4,800 Indians having made the trip in 2008, a 10-per-cent increase over the 2007 figure. Germans regard their German-speaking neighbour as, in essence, a domestic destination, while the UK, France, the Benelux countries and Scandinavia are strong markets for Austrian tourism.
According to the tourist office in Vienna, while overall foreign arrivals have declined during the current recessionary times, this has been compensated for by a growth in stay-on-home-ground domestic tourism. With its modern systems and high-quality hospitals and clinics, Austria is not a problematic country for international assistance companies. Cost containment is aided by clear and, almost without exception, transparent and honest accounting.
Healthcare is top priority
The Republic of Austria is a federation of nine Bundesländer (cantons, or states), and the federal government takes the lead in both legislating on and operating the nation’s healthcare functions. As one of the world’s more prosperous nations, Austria has always put healthcare near the top of its public spending priorities and offers its citizens a high standard of care, with little differentiation between public and private sectors – unlike in many other countries.
“Training and equipment levels are exceptionally good, especially in the university hospitals,” observes Dr Michael Wirnsperger, the medical director of Tyrol Air Ambulance (TAA), adding, “All the latest technology is available to our doctors and surgeons.”
The country employs some 210,000 doctors and nurses across its state-run general practitioner (GP) network and its 254 public and private hospitals. The public hospitals are funded through social insurance and provincial authority healthcare budgets. There are also highly reputed university hospitals in Vienna, Innsbruck and Graz.
Austria has always faced serious challenges in taking emergency healthcare quickly to its own people and visiting tourists, especially in winter
The majority of private hospitals are run on a not-for-profit basis, often by nuns or other Christian groups, and these are renowned for their efficiency. This array of healthcare services serves a population of 8.3 million, some 3.6 million of whom are among the tax-paying workforce. This represents an impressive annual spend of US$25.1 billion, or a whopping 10.3 per cent of GDP.
Some two-thirds of the tab is picked up by the Sozialversicherung – a state-run insurance scheme that covers 98 per cent of the population, and guarantees citizens free public sector medical treatment for both illness and accidents. This is funded through compulsory contributions paid by both employees and their employers and levied at a rate according to income. Self-employed persons have to bear the full burden of contributions, while the unemployed covered by the unemployment scheme are exempt from payment.
However, around a third of people have supplementary private insurance cover to ensure higher and speedier service levels through private treatment in state hospitals or in the private sector itself. This enhanced service level covers such things as reduced waiting times, choice of surgeon, more comfortable rooms, choice of meals and unlimited visiting times. Costs are paid direct to the medical service provider, rather than via the patient.
As a matter of principle, private health insurance benefits are exempt from income tax.
Observes TAA’s founder and former chief executive, Jacob Ringler: “It is not easy to set up a private hospital as the government and the opposition parties are all fully committed to the public system, and the powers that be discourage the setting up of private medical institutions, which they regard as competing with state facilities. Those private hospitals that do exist have in general been in business for decades. The so-called day clinics are, in essence, extensions of general practices and have no contracts with social service and the e-card.”
Much of the public health budget over the past decade has been spent on a massive modernisation programme to bring the Austrian health system into the e-age. The Austrian e-card was rolled out in 2005. Austrians simply present their e-card to their GP, to clinics and to hospitals whenever they need treatment under the national health system. There are no charges and no forms to fill in – everything is computerised.
The current aim is to rationalise the raft of highly fragmented and often incompatible computer systems operating in the different regions into a cohesive nationwide programme.
there is a wide variance in the standards provided by acute care hospitals, with the western part of the country better served than the east
Currently, Orange Austria and the Arbeiter-Samariter-Bund Österreich (Austrian Workers Samaritan Federation - ASBO) are running a pilot trial to create a system for monitoring blood sugar levels and blood pressure via mobile phone. This follows on from a collaboration between Orange Austria and Alcatel-Lucent, which saw the federation equipped with the Alcatel-Lucent TeleHealth Manager solution, an easy-to-operate, off-the-shelf e-health platform that combines intelligent end devices with the infrastructure required to provide remote monitoring and care nationwide for the federation’s members. The scheme is presently founded from ASBO funds. TeleHealth was introduced in Canada in mid-2008 and is now being made available in Europe, with Austria in the vanguard of its adoption.
Vital aeromedicine
As a land-locked Alpine country with a high point of 3,797 metres (12,460 ft), where only 32 per cent of the 83,872 sq km (32,383 sq mile) country is below an altitude of 500 metres (1,600 ft), Austria has always faced serious challenges in taking emergency healthcare quickly to its own people and visiting tourists, especially in winter when many roads to the ever-popular wintersports resorts are blocked with snow for weeks at a time and remote ski slopes are accident prone. That’s why this mid-European nation pioneered the air ambulance business. The first air ambulance jet took off from Innsbruck Airport back in 1976 but basic air rescue services had actually commenced four decades earlier when the predecessor of today’s private sector TAA was granted a licence to operate a single-engined, propeller-driven aircraft fitted with skids.
TAA is an entirely privately-owned company, with no public subsidies, and is part of the Welcome Air group. It currently has around 90 per cent of the air ambulance market in Austria, with its main competitors – FAI, European Air Ambulance and Jet Executive – all based in neighbouring Germany.
Medical Jet Service used to be TAA’s strongest competitor, but it went into liquidation last year and the other locally based companies tend to be much smaller operations, using rather small and prop-driven aircraft. “This is a small country and our main competition comes from companies based outside Austria’s borders, which makes it very difficult to ascertain the precise number of evacuations, but our own figure is currently 3,000 a year,” says Jakob Ringler.
TAA also operates the world’s first scheduled air ambulance service, shuttling ski accident victims from both Austria and the French Alps several times a week. These ‘wintersports plaster shuttles’ airlift ill or injured holidaymakers from some of the most remote areas of the service’s base country and other parts of the Alps back to such places as Germany, Scandinavia, Holland and Belgium. Last year, these scheduled flights airlifted 1,500 foreign visitors: 1,000 of them from Austria and 500 from France.
A private company founded back in 1976, OAFA (Austrian Air Ambulance) no longer operates its own aircraft but acts as a broker and also as an assistance company, serving its own insurance scheme. Says a company spokesman: “Given its mountainous terrain, this is a difficult country in which to operate. Each mission has its own particular demands – short-distance runways, high altitude airports, long-distance flights, restricted areas and determining the quickest possible access are just some of the challenges that have to be met by our team.”
There is no state-run air ambulance service as such, but the helicopter emergency medical service (HEMS) system of EMS helicopters, flying under the Christophorus branding, is state subsidised. This includes a total of 26 helicopters, all Eurocopter EC135s, with plenty of medical facilities onboard. They are spread across the country at 16 different bases, but in the winter months a further six bases are added around the mountains due to high demand. The helicopters are also equipped with life-saving rescue equipment, such as a hoist, so that they are able to get to even the most inaccessible patients in the mountains.
Most hospitals have English-speaking staff members, while the university hospital clinics have translators on hand for most major languages
HEMS coverage is exceptionally good, especially in wintersports areas, with a rescue helicopter never more than a 15-minute flight away, but evacuation is only available in daylight hours. On the other hand, the country’s emergency doctor network is available 24/7 and even serves patients in close-by areas of Switzerland from time to time. There has been some criticism in the past that there is an over-supply of HEMS aircraft in Austria during the peak winter sports season, although anyone that has been picked up injured from the side of a mountain by one would surely disagree.
Visitors’ rights
Foreign visitors are free to choose between public or private hospitals and such a decision will often rest simply on the instance of travel and waiting time involved, especially at high season times. For this reason, some, generally small, private medical facilities are springing up in tourist areas, offering all the specialisations such as trauma, orthopaedic surgery, spinal treatments and rehabilitation. Specialist public medical centres for such things as PTCA and stroke treatment are widely available across the country.
Major hospitals working with assistance providers include the Algemeines Krankenhaus der Stadt Wien, in the capital city of Vienna; the Landeskrankenhaus-Universitätskliniken and Christian Doppler Klinic- Universitätskliniken in Salzburg; the Landeskrankenhaus-Universitätskliniken, in Graz, the Algemeines Krankenhaus der Stadt Linz, in Linz, and, in the private sector, the Privatklinik Döbling GmBH, in Vienna and the Tagesklinik Kitzbühel in the ski resort of Kitzbühel.
Assistance companies working within the country report no major problems in their dealings with Austrian medical facilities apart from the very occasional incident of overcharging for skiing accident treatment. They also find that costs are around the average for EU countries. “Austrian hospitals operate a so-called points system for charging, with every item carefully accounted for and charged according to essentially standard and pre-set tariffs,” observes Dr Christian Steindl, managing director of IFRA Assistance.
Most hospitals have English-speaking staff members, while the university hospital clinics have translators on hand for most major languages. Austria has reciprocal agreements for the treatment of foreign patients from the EU, via the European Health Insurance Card, and form 9bO for visitors from outside the EU.
Major Austrian-based providers of private travel insurance include Wiener Städtische (Vienna Insurance), Uniqua, OAMTC (the Austrian Automobile Club), Generali and its Europäische Versicherung subsidiary, the Austrian Mountaineering Association (in co-operation with Uniqa), and some smaller companies. According to the Austrian Insurance Association, the overall insurance industry employs some 26,547 people and has a €16.2-billion premium volume from direct domestic business. The premium income in the health insurance sector for 2008 saw a 3.5-per-cent increase over the previous year, to €1,535.
Besides a major presence by the major international assistance companies like Europ Assistance and Elvia Mondial, Austria has its own assistance companies, the most important among which is the OAMTC. International SOS services Austria from across the border in Germany.
Apart from the obvious hazards of mountaineering, skiing, snowboarding and other adventure pursuits, travel insurance and assistance companies regard Austria as a low-risk destination, with a modest crime rate and rare instances of violent crime, though incidents involving the theft of personal property have been on the rise in recent times, with pick-pocketing and purse-snatching having become rife in heavily trafficked tourist areas like downtown Vienna and the busy major wintersports resorts.
Care co-ordination
In the private sector, there is a substantial level of cross-border healthcare purchasing between Vienna and the eastern part of the country and next-door neighbour Hungary, where costs are generally lower but treatment standards are very high. Many patients travel to Hungary for medical procedures, especially in areas of dental treatment, such as implants, which are not covered by the Austrian public healthcare system. For other procedures, if the costs incurred within Hungary do not fall within the reciprocal arrangements of the EU medical card system, Austrian patients may seek reimbursement through their Austrian insurance as Category I patients (some 42,000 cases a year). However, there are major legal, institutional and political barriers that inhibit both public and private providers from maximising the cost benefits from cross-border healthcare purchasing between the two countries.
EU visitors to Austria receive free emergency medical treatment provided the doctor or hospital outpatient department concerned is registered with one of the Gebietskrankenkasse regional health insurance offices. If private medical facilities are used then the patient must pay at the time of treatment but up to 80 per cent of the costs can be reimbursed by the Gebietskrankenkasse and the remaining 20 per cent may be reimbursable by the national health authorities in the patient’s home country or via the patient’s travel insurance.
A doctor’s referral certificate is needed in order to obtain non-urgent inpatient care, with a daily charge being made to the patient, whether national or foreign, for the first 28 days spent in hospital.
in the capital city of Vienna, where, uniquely in the country, the publicly owned hospitals are run by private sector companies, [such facilities] turned out to be the worse performing in the whole country
According to healthcare researcher Thomas Czypionka, of the Institute of Advanced Studies Vienna: “Worryingly, an intensive study of 133 acute care hospitals across the country that we carried out reveals that there is a wide variance in the standards provided by acute care hospitals, with the western part of the country better served than the east. Generally, the privately operated hospitals, most of which are not-for-profit operations, are better performing than the state ones, which are owned and operated by the provinces.
“However, in the capital city of Vienna, where, uniquely in the country, the publicly owned hospitals are run by private sector companies, [such facilities] turned out to be the worse performing in the whole country.
“Our in-depth analysis revealed that, in the light of the high costs of the hospital sector at present, there is considerable potential for efficiency improvements to ease the pressure on highly strained public healthcare budgets without reducing the levels of patient care.”
Industry insiders feel this factor could well lead to an increase of cross-border medical purchasing in both public and private sectors. The fact is that Austria’s total number of available hospital beds declined to 33,800 from 37,400 between 1999 and 2003 and this trend has continued in the years since, but it is also fact that political parties of all colours have expressed a continuing commitment to the public health system.