Healthcare system under pressure: What needs to be clarified now

What is needed now: Honest communication and better management

Health economist Pruckner is now calling for something that rarely happens in political discussions: Honest communication. The message: The healthcare system can no longer be organized and financed in this form. Prof. Pruckner: “The political leaders know exactly what has led to this situation. We economists have been telling them for years where the problems lie, and the demographics have been predicted for 20 years. Society is ageing and it is logical that more services are needed in old age. As a result, expenditure is rising, and that doesn’t even include technological progress. What is needed now is honest communication: expectations can no longer be met.”

The consequence of this development will probably be: “There are already moderate co-payments in a number of areas, and this will probably be the case to a greater extent in the future.” Now the question arises as to what additional costs would be incurred by whom. In times of a lack of money – as in many other areas – it leads to a question of distribution.

What needs to be done to get the cost explosion in the healthcare system under control? According to Pruckner, there is no simple solution, but there are clear proposals from the scientific community. One of them: Better navigation of the healthcare system by GPs. Pruckner: “Today, people are not being treated where they benefit most. This is really expensive, doesn’t help much medically and is sometimes even counterproductive for patients.” In other words, better navigation would improve patient treatment and save money at the same time.

Another important step: Better treatment at the interfaces. This refers to the interfaces between the responsibilities of the federal and state governments. The private practice sector (general practitioners and specialists) is managed and financed separately from the inpatient sector. Pruckner explains this using an example: “On Friday afternoons, the private practice sector is often unavailable, so the only option is the hospital – and this also changes responsibility. And we need to improve this treatment at the interfaces.”

According to Pruckner, this requires funding “from a single source” – and cash flows that consistently follow the objectives. This is particularly necessary when it comes to outpatient care: “If everyone wants fewer people to be treated in hospital, then the euros must also follow this goal: In other words, more investment in the outpatient sector. However, this is exactly what is often not happening today.”

“Funding from a single source” does not mean that in future either the federal government, the federal states or the social insurance system will be the sole controllers. Rather, it is realistic that all parties involved remain on board – but steer together. The decisive advantage: Responsibility could then no longer simply be shifted to another pot.

Why navigation in the system is becoming a key issue

What does “better patient navigation” mean in detail? The two biggest levers lie in behavior: In the use of medical services and in better health literacy. “The question is how to give people the knowledge to help them enter old age in a healthier way. What content is needed to make people aware of the necessity of a service, such as a preventive check-up,” explains the health economist. He sees the general practitioner in the role of first point of contact: “We need to give patients much better support.”

GPs know their patients and their health history, and they know the medical services on the market. Pruckner: “Although we observe that many patients end up in the wrong places, we don’t go into enough detail why this is the case. People often simply don’t know where they are in good hands with their problems. We are often too quick to assume that people go to outpatient clinics because it doesn’t cost them anything. It is often the case that they simply don’t know any better than to turn to outpatient clinics. GPs can provide support and the necessary guidance in the healthcare system.” This is the disadvantage of an open medical system: without orientation, the end consumer is lost.

According to Pruckner, the social insurance institutions are currently running their first pilot projects to help chronically ill people who have been on sick leave for a long time: “The social insurance institutions are now starting to talk to people. They ask what they need,” says Pruckner. This gives patients better advice on what further steps are possible.

Health literacy & access to care

Let’s move on to the study on inequalities in the Upper Austrian healthcare system – which can also be applied very well to whole Austria. According to Gerald Pruckner, access to medical services is not “dramatically unequal” thanks to the nationwide health insurance system. This is because: “We have an insurance level of 99% and a fundamentally open healthcare system with free access to services,” says Pruckner. However, this does not mean that access to medical services is the same for everyone. The central question of the study was therefore: What is inequality and why does it exist?

What we already know is that inequality is partly caused by socio-economic factors. Life expectancy and health differ according to gender, education, income, occupation and other socio-economic factors. “Inequality is partly due to the fact that people with different characteristics behave differently,” explains Pruckner. People use services differently and manage their health differently. For example, women live on average four years longer than men, people with a higher level of education live longer and are in better health than people with a lower level of education. This is because they know the risks better, are more likely to take preventive care, eat healthier and take action earlier.

Women with a lower level of education make less use of preventive medical check-ups. Unsurprisingly, older people spend more on healthcare than younger people, but here too, the use of medical services varies according to income, education and age – as well as place of residence and region.

Apart from these socioeconomic reasons, there is also unequal access to medical facilities, for example when medical services are unevenly distributed across regions. Pruckner: “Austria is losing doctors” – and thus addresses a supply-side problem. There is no inequality here; the decline in the number of general practitioners, for example, affects everyone equally. “Access is deteriorating for everyone, and positions in general medicine are no longer so easy to fill. We are already seeing this inequality to some extent among specialists. We address this issue in our study using the example of gynecologists: The availability of services varies from region to region, and there are more practices available in areas where wealthier people live than in areas where workers and people with lower levels of education and income live. This is particularly true in rural areas. Distances are simply greater in peripheral areas, while in urban areas—i.e., in cities—access is unsurprisingly easier,” explains Pruckner.

Pruckner’s opinion: Yes, the study shows differences in access to benefits. However, these are not as great as some would expect. Overall, according to Pruckner, inequality is a mixture of the two phenomena of health literacy and access. The question arises as to the right adjustments: “If women with poorer education do not undergo certain examinations, what should be the response of the healthcare system?” The answer to this question is not necessarily “another practice” – the causes lie deeper. Rather, we need other ways to reach these people – in terms of addressing them and making them suitable for everyday life.

Conclusion: More communication & orientation, clear funding streams are needed

The issue of inequalities in access to healthcare is important – but it is not the dominant problem. Disparities arise primarily where there is a lack of health literacy and people are not well enough oriented in the system. It is therefore crucial not only to open more practices – as is often suggested politically – but to build a system that reliably guides patients again: With strong regional primary care as the first point of contact, clear responsibilities at the interfaces and funding that is consistently geared towards the agreed objectives.

Gerald Pruckner warns of the political side effects if we do not tackle these reforms: “If people get the impression that they have paid in for a long time and are now being left alone, dissatisfaction will grow – and at some point this can no longer be moderated away.”

Click here for the study “Inequality in the Upper Austrian healthcare system”