Austrian health care approach directs ophthalmic patient care

While the ratio of ophthalmologists in the Austrian population is high, the field faces challenges including government-directed medical coverage, an expert says.

Susanne Binder

Well known in Europe as one of the most generous and consumer-friendly systems, health care in Austria is a predominantly public service with little private practice.

“In ophthalmology, at least 90% of doctors are ‘contract doctors’ within the National Health Service,” Susanne Binder, MD, scientific secretary of the Austrian Ophthalmological Society, said. “More than 50% work in hospitals, where the greatest part of diagnostic and surgical procedures is performed, while outpatient clinics provide only basic ophthalmic care services. There is no impediment to open private practices, but there is little or no market for private care.”

Unless a physician has a well-known reputation or an uncommon subspecialty, it is difficult to acquire enough patients to make the investment in a private practice worthwhile, Dr. Binder, an OSN Europe Edition Editorial Board Member, said.

“Most of the senior doctors working with me at the hospital have marginal activities outside the institution, something like half a day a week, mostly to offer their own patients some extra time for follow-up visits,” she said.

Under National Health Service (NHS) coverage, patients can choose where to go for consultation with a specialist. Unlike in other European countries, there is no filter between primary and specialist care, and patients do not need to consult a general practitioner first for a referral to a specialist.

Health insurance

Public health insurance in Austria covers a wide range of services, including all medical services in the primary sector, hospital and home care, drugs and other therapeutic products, rehabilitation, sickness and maternity benefits, prevention screenings, and travel and transport costs. Benefits can be obtained without limits and regardless of personal income.

Public insurance is obligatory, and every citizen with an income must pay a health care contribution. Supplementary health insurance is offered by private insurance companies. It covers the cost of premium-class accommodation in hospitals, offers the opportunity to choose a specific doctor, and shortens the waiting time for appointments in some cases.

“Treatment, however, is the same as for everyone else, based on the principle of universal right to optimal health care,” Dr. Binder said.

She estimated that about 10% of Austrian citizens pay for supplementary private insurance.

Uneven distribution

Currently, there are about 870 ophthalmologists in Austria, more than 400 of whom are located in Vienna.

“In a 9 million population, the ratio of ophthalmologists per population is quite high, but distribution is very uneven. Most of us are concentrated in the cities, and very few services and contracts for specialists are offered in countryside areas. The result is that we are overcrowded in some places and definitely lacking in other regions of the country. At least three provinces in Austria, Oberösterreich, Vorarlberg and Kärnten, do not have enough eye doctors,” Dr. Binder said.

Training as an ophthalmologist takes longer in Austria than in other European countries; specialty training is 5 years with a supplementary year for full surgical training.

“We need restructuring to optimize and shorten our training. The European Board of Ophthalmology strongly advocates a more uniform system of training in Europe, and we should also head in this direction,” Dr. Binder said.

The male-to-female ratio is growing in favor of women in the field, with women currently constituting 60% of the ophthalmology workforce. Dr. Binder said that there has always been a substantial presence of women ophthalmologists in nonsurgical practices outside hospitals in Austria and that the number of female surgeons is now on the rise. However, women are still in few leading positions.

“Only three [women] are head of department in the whole country,” Dr. Binder said.

Current challenges

The relationship with non-medical eye care providers, opticians in particular, is perceived as a major problem by ophthalmologists in Austria, according to Dr. Binder.

“There are unresolved conflicts over the opticians’ role and a lot of pressure from their professional associations to expand their scope of practice, encroaching on the practice of ophthalmologists. They now perform a lot of ophthalmic examinations, including [optical coherence tomography], and offer them for free, possibly recharging them in the price of spectacles,” Dr. Binder explained.

Concerns about patients’ safety and right to receive proper professional care are growing, and the approach adopted by the Austrian Ophthalmological Society is that of providing as much information as possible.

“Patients have a right to know the difference between medical and non-medical. Unfortunately, we are fighting also at [the] communication level with a [group that] is prepared to invest a huge amount of money in promoting themselves. Opticians spend about 10% of their income in [public relations] and advertising,” she explained.

Another challenge that Austrian ophthalmologists are currently facing is the lack of recognition by the government and politicians of the primary importance of eye health and eye health issues. Ophthalmology has never been considered a priority area for investment, and yet the human and social costs of vision loss are recognized worldwide to be higher than other disease categories, including diabetes, cancer and cardiovascular diseases.

“More than ever, with the aging of the population, we need a higher investment in screening programs, diagnostic equipment, human resources and treatment strategies,” Dr. Binder said.

For instance, hospital budgets are too tight to allow the use of Lucentis (ranibizumab, Genentech) for intravitreal injections in all the patients who need the anti-VEGF. In Dr. Binder’s opinion, Avastin (bevacizumab, Genentech) is an acceptable compromise, and her way around limitations is to use both agents, each in 50% of the patients, to cut down on costs.

“In this way, we are able to provide intravitreal anti-VEGF treatment to the increasing number of patients who need it, but we do it at our own risk because there is no government regulation that justifies the off-label use of drugs,” she said.

In the Netherlands, she said, the use of off-label drugs is government-approved when they are cheaper than authorized drugs.

“Our government sends mixed signals and inconsistent responses on this issue,” she said. “On one hand, we are unofficially encouraged to use Avastin because it’s cheaper; on the other hand, we are left alone in case of a lawsuit because there is an approved drug that we should use instead.”

Dr. Binder advocated a more open attitude toward forms of co-payment for premium and elective procedures.

“I can implant a multifocal or a toric lens under NHS coverage, or even perform refractive surgery in my hospital, but I must prove they are necessary for strictly medical reasons. The NHS puts a lot of pressure on us to not use premium lenses, while there is now a lot of pressure from patients in the opposite direction. The result is that 95% of our patients are implanted with conventional monofocal lenses. Shared care would be a good answer,” she said. – by Michela Cimberle

• Susanne Binder, MD, can be reached at Department of Ophthalmology, Ludwig Boltzmann Institute for Retinology and Biomicroscopic Laser Surgery, Rudolph Foundation Clinic, Juchgasse 25, 1030 Vienna, Austria; +43-17-11654607; fax: +43-17-11654609; email: susanne.binder@wienkav.at.
• Disclosure: Dr. Binder has no relevant financial disclosures.