European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Austria

3.4 Out of pocket payments

In 2015, OOP payments that include direct payments, user charges (cost-sharing) and informal payments constituted 17.9% of current expenditure on health (73.4% of private expenditure; see Table3.1) (Statistics Austria, 2017w). Over the last 10 years, absolute OOP spending increased by 36.4%, from €4610 million in 2006 to €6287 million in 2015, while its share of total health expenditure slightly decreased by 0.3 percentage points in the same period (OECD, 2017c; Statistics Austria, 2017w).

In 2015, the largest share of OOP payments was spent on ambulatory (extramural) curative and rehabilitative care (37.44%), especially for dental services (13.9% or €876 million) and on pharmaceuticals (21.4%), notably for OTC medicines (14% or €865 million). Also spending on LTC (14.6%) and therapeutic appliances (12%) are among the largest shares of total OOP spending (see Table3.7).

Direct payments for benefits not covered by SHI funds represented 15.8% of current health spending. Cost-sharing (user charges) for benefits partly covered by SHI funds was only 2.1% (or €754 million) of current health spending. It must be noted that the Austrian statistics presented in Table3.7 include cost-sharing of patients visiting non-contracted physicians under direct payments, although this would usually be considered as cost-sharing.

OOP payments do not seem to constitute a significant barrier for accessing health care in Austria, mainly because of the existence of numerous exemptions (e.g. for low-income patients) and a prescription fee cap. However, there is evidence of inequalities across the insured due to different cost-sharing levels of different SHI funds (Mossialos et al., 2006; Unterthurner, 2007). Recent policy debates concern the harmonization of cost-sharing requirements across SHI funds for a total of 23 services and products, in particular for therapeutic aids (such as wheelchairs) and tick-borne encephalitis vaccination (HVB, 2017a).

3.4.1 Cost-sharing (user charges)

In 2015, cost-sharing accounted for 12% of total OOP spending. Cost-sharing requirements vary between SHI funds. Specialist insurance funds under specialist insurance laws (including those of the self-employed and farmers) require cost-sharing across all types of ambulatory (extramural) medical care, while SHI funds under ASVG have fewer cost-sharing requirements.

Cost-sharing typically takes the form of co-payments for ambulatory (extramural) visits (including GPs and specialist physicians), inpatient stays, prescription pharmaceuticals, medical rehabilitation and therapy and visual aids. Table3.8 provides an overview of cost-sharing regulations for SHI funds under ASVG.

Although co-payments in general apply for all patients, exemptions exist for certain population groups, for example for patients with notifiable infectious diseases, persons in compulsory community service or asylum seekers under federal care, pensioners entitled to compensatory allowances, children or co-insured dependants up to the age of 15. These groups are exempted from prescription fees and a range of further co-payments. Exemptions from co-payments vary per type of service and across SHI funds.

Social insurance legislation lays down guidelines for what constitutes “requiring social protection” for the purposes of exemption from prescription fees. Exemption from prescription fees acts as a marker for a range of other exemptions. The proportion of insured individuals that are exempt from prescription fees varies significantly across SHI funds. Considering regional SHI funds, the share of the insured exempted from prescription fees was lowest in Burgenland (2%) and highest in Vienna (28%) in 2016 (Wildbacher, 2018). That includes, for instance, single people whose monthly net income in 2017 did not exceed €909.42 (for married couples: €1363.52). For individuals with a chronic illness who can demonstrate associated high costs, these income limits are raised to €1045.83 for single people and €1568.05 for married couples. Furthermore, for every dependent child living in the household, the income limit increases by €140.32 (values for 2018 under ASVG). In addition, there is a prescription fee cap of 2% of an individual’s annual net income since 2008 (see section 5.6.1).

Cost-sharing is primarily used as an instrument for cost containment and for directing patients towards GPs and ambulatory specialists. With the aim of relieving SHI funds, health care reforms between 2000 and 2005 increased cost-sharing for inpatient stays and visual aids (Steiner, 2016; Unterthurner, 2007).

3.4.2 Direct payments

Direct payments for medical goods and services not covered by SHI funds made up 88.0% (€5533 million) of total OOP payments in 2015 (see Table3.7). The largest share (37.8% of direct payments) was related to ambulatory (extramural) curative and rehabilitative care. This includes visits to GPs and specialist physicians without a contract with the SHI funds, but also direct payments for dental care (€754 million or 13.6%) (see section 5.12). Other important categories of direct payments include payments for nursing and residential care facilities (€918 million or 17% of direct payments), and OTC medicines (€865 million or 15.6 %) (Statistics Austria, 2017w).

3.4.3 Informal payments

Data on informal payments are not systematically collected and analysed in Austria. A study by the European Commission suggested that informal payments are related to waiting lists and dual practices. Dual practice relates to ambulatory (extramural) services provided by publicly employed hospital physicians in their private practices outside the hospital. Patients may pay for these services informally with the expectation of receiving better treatment (European Commission, 2013a). A Special Eurobarometer Report on Corruption (2017) found that 9% of survey respondents in Austria reported having provided their physician with an additional payment, a valuable gift or hospital donation to obtain faster treatment. This is clearly above the EU27 average of 5% and higher than in Bulgaria, Latvia and Poland (European Commission, 2017d).

A recent review on physician payment mechanisms suggests that the institutional design of special physician fees (for “special fee class” rooms in public hospitals; see section 3.5.1) and dual practices pave the ground for two-tier medicine in Austria (Sommersguter-Reichmann & Stepan, 2017). Two-tier medicine in this context mainly refers to prioritization of patients with VHI that are moved up or bypass public waiting lists. In an anonymous patient survey, 6.5% of respondents stated that they had been offered shortened waiting times in return for direct private payment and 7.4% were offered earlier treatment when visiting the physicians’ private practices (Czypionka et al., 2013).