Ambulatory care reforms fail to face the facts?

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 11

Abstract

Proposed ambulatory care centres aim to better balance utilization and integration of inpatient and outpatient care. EU rulings required the government to align inconsistent market authorization for ambulatory care providers. But the proposal does not tackle fragmented jurisdiction and diverse payment schemes across providers. Only physicians may become shareholders and they are prohibited from employing other doctors, raising doubts about the usefulness and cost-effectiveness of the policy.

Recent developments

This policy proposal follows-up on a 2007 initiative, where a proposal to establish ambulatory care centres was turned down after facing fierce opposition particularly from doctors (Eichwalder, Hofmarcher: 11/2008). While the 2007 policy proposal largely reflected central government attempts to better balance hospital care utilization with ambulatory care provision, the current draft legislation additionally aims to incorporate claims from the EU level and other policy developments in Austria.

• First, in March 2009 the European Court of Justice (ECJ) declared current procedures for certifying health care providers to operate their establishments as being inconsistent with EU laws especially regarding the right of establishment and the freedom of free service movement (see section on Influence in policy making and legislation).
• Second and simultaneously, agreements were made between doctors and health insurance funds to establish group practices in the form of limited liability companies. These talks were held in the course of setting-up the Austrian Health Fund where in Winter 2009 health insurance funds pledged to contain costs in the order of 1.7 billion Euros between 2010 and 2013 (see Hofmarcher: 14/2009).  
• Third, the government programme for the period 2008-2013 made it a priority to improve patient access to services in the ambulatory care sector. This is framed as an overall objective to increase the effectiveness and efficiency of integrated care services in the Austrian health system. In order to improve both quality and efficiency, a new form of delivery should be created based on needed care.

The creation of ambulatory care centres aims to:

• shift utilization from inpatient care to outpatient care outside hospitals
• strengthen the organizational capacity in the outpatient care sector
• enhance the quality of health care with improved coordination and access to care
• balance utilization between hospital outpatient departments (Spitalsambulanzen) and ambulatory care outside hospitals

To achieve this comprehensive set of goals the draft legislation for the creation of ambulatory care centres tries to reconcile the following principles on the European level as well as on the Austrian federal and "Länder" (federal states) level:

• the right of establishment (Niederlassungsfreiheit)
• the freedom of acquisition (Erwerbsfreiheit)
• the freedom of free service movement (Dienstleistungsfreiheit) and
• to ensure financial sustainability of the social health insurance funds.

In addition to privately practicing doctors contracted to deliver services in solo-practices, the current regulatory framework permits cooperation between physicians by the creation of both joint practices ("Ordinations-/Apparategemeinschaft") and group practices ("Gruppenpraxen") only as open corporations (see for details Eichwalder, Hofmarcher: 11/2008). The associates must be authorized physicians or dentists and they are typically subject to unrestricted liability. The new draft legislation calls for a fundamental restructuring of group practices to become an additional pillar for ambulatory care. It is proposed that ambulatory care centres:

• Are limited liability companies with specified shares for physicians so that the company is responsible for all claims against a shareholder (the physician).
• Increase access to outpatient care through extended office hours and expanded services outside hospital outpatient care.
• Become one-stop-shops with multiple practitioners allowing for shorter waiting times and greater possibilities for home visits. They are assumed to coordinate service delivery of different health professionals.  
• Save costs through joint utilization of equipment as well as medical and non-medical personnel. Thus ambulatory care centres would ensure cost-effective and high quality medical care.

The need for action arose from requirements to harmonize rules for market authorization of ambulatory care providers through adapting respective legislation. Also, concerns are widespread about overcrowded hospital outpatient departments, which essentially should provide emergency care services only. In addition, the draft legislation proposes structural changes with respect to the monitoring of quality in the ambulatory care sector (see section on Adoption and Implementation).

In June 2010, the proposal passed the council of ministers ("Ministerrat") and will be discussed in the national assembly. The law is expected to be enacted in Fall 2010. 

 
No easy market access for ambulatory care centres

The establishment of ambulatory care centres is subject to a strict examination of need in order to restrict market entry. The authorization scheme takes into account the decision of the ECJ which called for the same standards for market access. Market authorization should be in accordance with the respective regional supply plan (Regionaler Strukturplan Gesundheit - RSG) in addition to regional and central bodies involved in the process. But so far the proposed process is only applicable to newly set up ambulatory care centres. Existing group practices are already subject to a "location plan" (Stellenplan), which is also a form of restricted market entry and is administered on the regional level by the Physicians´ chamber and health insurance funds. An examination of need is also not required for elective services which fall outside the scope of health insurance reimbursement (e.g. plastic and cosmetic surgery).

Does the envisaged payment scheme add another hurdle for entry of ambulatory care centres?

While currently ambulatory care providers, regardless of whether they are contracted or not, have limited obligations to opening hours, ambulatory care centres will be required to have extended office hours. In this context, payment schemes are proposed to be adapted from an exclusively fee-for-service model ("Einzelleistungshonorierung") to include some form of capitation payment scheme ("Pauschalmodelle"). If the practice has multiple specialists a fixed payment scheme (e.g. per episode of care) ("Fallpauschalen") is proposed. However, the draft makes no reference to improved cost-effectiveness through better balance of capacity in ambulatory care, which is an explicitly stated objective in the proposal. 

Ambulatory care is largely provided according to the benefit-in-kind principle ("Sachleistungsprinzip"), which gives priority to payment for services and not to payment in cash. Ambulatory care is mostly based on contractual relationships between health care providers such as self-employed physicians and health insurance funds. Insured persons can obtain benefits in-kind from:

• contracted doctors who are self-employed and mainly work in solo-practices
• hospital outpatient care departments
• outpatient clinics ("Ambulatorien") which are either integrated (Kasseneigene Ambulatorien) or run by private individuals who have a contract.

The establishment of an ambulatory care centre as a limited liability company is conditional on forming a contract with the Federation of Social Health Insurance. The entity will have a joint contract. However, individual contracts between physicians and the health insurance fund are also possible. This is novel in the Austrian context as collective contracting prevails. An attempt to make contracting more flexible in the context of the 2008 health reform efforts failed (see Hofmarcher: 11/2008). Further, payment should be facilitated by electronic reporting and documentation of performance.  Presently, efforts are under way to finalize a catalogue of outpatient services to use for doctors´ reimbursement in the future, especially for specialists. The envisaged payment model would also be novel in the context of reimbursement schemes currently in place. 

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The new model of ambulatory care delivery is rather innovative in the Austrian context. Up until now cooperation between physicians is only possible as group practices or joint practices as open corporations. The proposal offers in addition a new form of cooperation with the benefit of limited liability for physicians. It allows for all kinds of health professionals to be employed except for other physicians. Unlike the old proposal, not all health professionals can be shareholders, only physicians (Eichwalder, Hofmarcher: 11/2008). The main change for group practices as ambulatory care centres when compared to the status quo is that physicians have a limited liability which they did not have before.

Ambulatory care centres add an additional pillar of care delivery without taking advantage of multidisciplinary ownership, nor do they provide for carrier opportunities of doctors outside hospital. The degree of controversy likely remains high as many details are not yet apparent, (e.g. specifics regarding the payment model). While currently contracted providers may team-up by just notifying the respective bodies in charge, new ambulatory care centres will need to go through a complicated process of authorization which appears discouraging (see section on Adoption and Implementation). Because this procedure involves a large set of barriers, no structural or systemic impact is expected even though the possibility to set-up an ambulatory care centre in itself appears innovative. In addition, because of the redundancy of administration ("Verwaltungszweigleisigkeiten") in market authorization additional costs may arise.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Providers

• Payers

• Patients, Consumers

• Private Sector or Industry

• International Organisations

Stakeholder positions

Overall comments from stakeholders about this proposal are cautious and often dismissive. The lack of a clear definition of the criteria of need and ambiguous delineation of what constitute outpatient clinics versus ambulatory care centres are the most frequently cited reasons for disapproval. While many welcome the effort to develop ambulatory care centres and acknowledge the need for improved capacity in ambulatory care, the outlined implementation path is highly criticised. In summary the main issues are (in brackets: the institution that raises the respective concern):

• Lack of opportunities for multi-disciplinary collaboration across health care professions (provider organizations other than doctors´ chambers).
• Increase in administrative costs through a complicated market authorization led by the regional governor ("Länder", Ministry of Finance), lack of information about the actual location of the new organisation ("Länder"), and confusion about the contractual situation regarding prior authorization (Federal Chancellery). 
• Lack of information about the financial impact of the policy (Federal Audit Office), no efforts to consolidate the federal budget, a call to abandon the simple notifications for providers already certified in "location plans," and concern that ambulatory care centers will increase competitive pressure on existing outpatient care clinics (Chamber of Commerce). 
• Discrimination of outpatient clinics on the basis of the much stricter surveillance of sanitary regulation and investment for those entities when compared to ambulatory care centres ("Länder", Chamber of Commerce), a need for defined ratios of shareholders to employed doctors to delineate outpatient clinics from ambulatory care centres (Austrian Federation of Social Health Insurance Associations).
• Concerns about "cost shifting" onto health insurance funds when more patients are being treated outside hospitals as no provisions are included that adjust fragmented financing accordingly (Austrian Federation of Social Health Insurance Associations).
• Too much emphasis on the organizational model rather than on a coherent framework of better integrated care delivery in cooperation with hospital outpatient departments (Chamber of Labour).
• The "Freedom Party of Austria" (FPÖ) welcomes the possibilities of the new corporate structure but is strongly opposed to the draft. The needs of patients and doctors are not on an equal footing in the draft and there are too many bureaucratic barriers. A strict examination of need should be guaranteed to prevent big companies from pushing into the health care market and to make sure that economic interests do not come to the fore.
• Stakeholders of private outpatient care clinics are strongly opposed to the draft and feel it sets unequal standards for ambulatory care centres and outpatient clinics. Group practices should be subject to the same quality standards and official controls. Lack of development of private health institutions and health tourism are feared.
• On the other hand, the proposal is broadly welcomed by patient associations and by the working party of patient counselors.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
Chamber of Physician	very supportive		strongly opposed
Payers
Health Insurance Funds	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed
Private Sector or Industry
Chamber of Commerce	very supportive		strongly opposed
International Organisations
European Court of Justice	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

In 2007, an appeal was made to the European Court of Justice because a private entrepreneur was denied the establishment of a dental outpatient clinic in a federal state in Austria through a notification that this facility was not needed on the basis of the existing network of providers. The following decision from the ECJ revealed inconsistencies in issues of market entry of providers, coming from fragmented regulation regarding ambulatory care facilities where considerable overlaps in responsibilities exist.

First, outpatient clinics are considered hospitals and their establishment is in the hands of the federal states ("Länder") that implement the Federal Hospital Act (Krankenanstalten- und Kuranstaltengesetz) on the basis of provisions in the constitution. Thus, market authorisation for outpatient clinics is done on the level of the federal states ("Länder"). While regulations in this respect differ across all federal states, the central government secures some oversight via nation-wide provisions in capacity planning in the area of hospital care (see Hofmarcher: 15/2010).  

Second, regulation of market entry for the medical profession is mandated on the federal level and is described in the Ärztegesetz ("Doctors' Law"). In particular, this law protects physicians´ free exercise of their profession ("Berufsausübungsfreiheit"). The conditions for joint practices and group practices are laid down in the Doctors' Law. Consequently, the establishment of physician-run limited liability companies would also be included in this law.  While the network of contracted providers is developed on the basis of regional "location plans" the central government has no say in this respect. Further, "location plans" do not take into account other regional facilities or providers rendering outpatient care services. Only recently they were incorporated in federal planning in attempts to better balance capacity. However, even though the central government promotes nation-wide capacity plans, which should encompass all care sectors and should be developed on the regional level, progress in this respect lags behind the timeline (see Hofmarcher: 15/2010).

The decision of the European Court of Justice increases pressure to harmonize market authorization

In March 2009 the decision of the European Court of Justice (Case C-169/07, Case "Hartlauer HandelsgesmbH") was issued with respect to the appeal. In its decision the EJC determined that the different standards of examination of need between group practices and other outpatient clinics was unlawful and not compatible with the freedom of establishment. However, according to the ECJ an examination of need is acceptable in the area of health care where most member states aim at:

• maintaining access to balanced high-quality medical service
• securing financial sustainability of social health insurance through preventing cost increases.

In acknowledging these goals the ECJ decided nevertheless that objectives as stated are not pursued in a consistent and systematic manner. In particular, it was ruled that because group practices generally offer the same medical services as outpatient clinics, they should be subject to the same market conditions as there is hardly any noticeable difference to patients between a group practice and an outpatient clinic. In particular, the ECJ determined that criteria for need must be stated precisely, made clear in advance, and the current unequal authorization standards for national providers should be made consistent. These amendments are considered crucially important as through the supremacy of European Law, providers from other EU countries could previously set up independent clinics without any prior authorization.

Austria accommodates European rulings but in doing so is anxiously defensive

As a result of the ECJ decision, the Austrian Hospital Act and other laws had to be adapted correspondingly. The main challenge regarding this ruling was to ensure that current Austrian jurisdiction concerning fragmented market authorization of ambulatory care providers could be kept, while at the same time just standards had to be administered according to the European ruling. The prevailing distinction between ambulatory care centres and outpatient clinics primarily relates to issues of professional and political oversight, which remained un-debated. The main differences between ambulatory care centres and outpatient clinics are:

• Only physicians or dentists can become shareholders of ambulatory care centres. Any other natural or legal entity cannot be a shareholder.
• In ambulatory care centres physicians run their own practice and are free from oversight.
• Physicians cannot employ other physicians. However, other allied health personnel can be employed with up to five employees per physician or up to a total of 30 allied health personnel, without the need of a management structure.  
• If the practice has multiple specialists in a specific field patients must be guaranteed free choice of physician.
• Physicians working in ambulatory care centres must make the group practice the focus of their medical practice.
• Ambulatory care centres can only be run by licensed physicians.

In addition to fragmentation in entry regulation of ambulatory care providers, issues of corporate organisations of professionals are at stake and not resolved. For example, the Chamber of Physicians is the professional organization of physicians. Every physician is a member and pays a mandatory membership fee. A main function of the physicians´ chambers is to collectively contract with the social health insurance funds. They also maintain the register of physicians who are licensed to practice medicine in private practice. 

On the other hand, the Chamber of Commerce - representing all businesses including corporations and small businesses - acts on behalf of private outpatient clinics including private ambulatory care centres. However, the proposal states that ambulatory care centres and their shareholders (which can only be physicians) should only be members of the Physicians´ Chamber. Thus, the proposed registration of ambulatory care centres with the Physicians´ Chamber is largely driven by power plays between those interest groups rather than by coordinated efforts to improve ambulatory care. And policy makers lack charisma to effectively mediate in this respect.

Better federal oversight for quality assurance through the back door of ambulatory care centres?

The draft proposal provides for more regulation with respect to quality in ambulatory care. While outpatient clinics and outpatient hospital departments are subject to strict rulings in the context of the Federal Hospital Act and corresponding regional legislation, quality monitoring and public surveillance in private ambulatory care is largely in the hands of provider organisations, namely the Chamber of Physicians (see Hofmarcher: 14/2009). 

Proposed changes in this respect do not only concern ambulatory care centres but also contracted physicians. In this context it is proposed that the scientific advisory board of the Quality Institute, which is led by the Chamber of Physicians, should be re-established with greater federal oversight.

Legislative outcome

Hold

Actors and influence

Government
Ministry of Health	very strong		none
Providers
Chamber of Physician	very strong		none
Payers
Health Insurance Funds	very strong		none
Patients, Consumers
Patients	very strong		none
Private Sector or Industry
Chamber of Commerce	very strong		none
International Organisations
European Court of Justice	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The process of authorisation will be overseen by the provincial governor (Landeshauptmann), who is the direct liaison with the federal administration. The Federation of Social Health Insurance, the Chamber of Physicians and the Chamber of Commerce must also comment on market authorization decisions. Authorization is also subject to national capacity guidelines laid out in the nation-wide supply plan (Österreichischer Strukturplan Gesundheit - ÖSG) and corresponding regional supply plans (RSG). The Federal planning institute "Gesundheit Österreich GmbH" or other consultancy is required to assess market authorization decisions on the basis of regional capacity needs. In addition, an assessment of need will be done on the level of the regional health platform. The final decision ("Bescheid") mandates the degree of care provision ("Versorgungsauftrag") and the range of services ("Leistungsspektrum").

 

Table 1: Current and future market authorization in ambulatory care

Regulatory Instruments		Ambulatory care settings	Market authorization		Payment schemes*
			Current	Future	Current	Future
"Public laws" , e.g. Hospital acts	Social Security Act Nation-wide (ÖSG) and Regional capacity plans (RSG)	Outpatient departments in hospitals	Regional market authorization in the context of hospital plans		Flat rate per case plus subsidies from the hospital budget
		Outpatient clinics	Regional market authorization	Unified regional procedure with approval coming from central and state level bodies	Fixed Budget or fee-for-service
"Professional laws" , e.g. Ärztegesetz		Ambulatory care centres	----		----		Fee-for-service or capitation or both
		Contracted doctors	Regional "location plans"		Primary care: flat rate+fee-for-service Specialist: fee for service
Source:AuthorsCompilation  *Payment_models_differ_largely_across_Federal_States

  * Payment models differ largely across Federal States (Länder)

 
In the future market authorization for ambulatory care centres and for

Outpatient clinics will need to follow a defined set of criteria and must comply with regional capacity plans (RSG) regarding:

1. population density, metropolitan and rural issues and transport links in the community
2. utilization patterns and capacity utilization of existing providers who render benefits in kind or reimbursable services
3. the average work load of these existing providers and
4. technical advancements in medicine

It is proposed that the newly established ambulatory care centre is to visibly improve access to services especially in "underserved" areas. Hospital outpatient departments should especially be taken into account as ambulatory care centres are expected to substitute service provision from this setting through longer and flexible opening hours.   

Monitoring and evaluation

No monitoring or evaluation procedure has as of yet been described. 

Expected outcome

While the decision by the European Court of Justice on issues of market authorisation was eagerly awaited, the implementation of rulings proves difficult because of fragmented regulations for care provision. In attempts to accommodate both European standards and national peculiarities in regulating market authorization, the resulting draft proposal appears defensive especially in light of the stated objective to improve capacity in ambulatory care. Doubts on the effectiveness and particularly the cost-effectiveness of this policy must be raised:

First, ambulatory care centres face a double-barrier to market entry. Market authorization as envisaged will be hard to achieve by applicants because of a complex procedure involving regional and central bodies in addition to statutory stakeholders. Further, ambulatory care centres are to be paid either on a capitation or fee-for-service scheme while contracted solo-practitioners will be further paid largely on a fee-for-service basis. Fee-for-service remuneration and non-aligned payment schemes across key providers are considered to be detrimental for improved patient-centred care (e.g. Rittenhouse 2009, Swensen 2010). In addition, hospital outpatient departments are being paid yet with another scheme (see Table 1) generating incentives to adopt hospital case-rates for ambulatory care patients. Furthermore, the draft does not specify details regarding the new payment schemes for ambulatory care centres. It only refers to the need to prevent cost inflation likely occurring when fee-for-service schemes apply also to ambulatory care centres.

Second, the proposal lacks a clear vision as to how a coordinated architecture of health care sectors should be created to accommodate future health care needs, e.g. care provision for chronically ill people and to streamline existing capacity. For example, existing capacity in hospitals is increasingly used to treat ambulatory day care cases, which are paid with hospital case rates. While this may be a fair approach, these patients do not have a "medical home" and are classified as 0-day care cases or even 1-day care cases. While starting from a low level some years ago, the number of these patients has grown robustly in recent years and there are indications that these patients are often elderly and/ or patients with co-morbid conditions. If ambulatory care centres are increasingly taking in these patients, specific per-case payments on the basis of a respective catalogue (in preparation) should be applied capturing both the severity of the condition and the cost structure, which presumably would be different in ambulatory care centres compared to acute care hospitals.

Third, with the creation of ambulatory care centres it is hoped that out-of-hospital care provision will become more attractive to providers and provide a roof for currently "homeless" doctors. While labour demand in hospitals has been strong in recent years the growth of the number of ambulatory care doctors being awarded a contract was sluggish. This echoes diverging levels of activity with doctors outside hospital facing a rather constant case load with some exemptions. At the same time physician density has caught-up and is well above the OECD average largely reflecting high outflow of graduates from medical school where entry regulations have been weak until recently. Thus, waiting lists have built up for licensed doctors to be issued a contract ("network providers"). As a consequence many of these "homeless" licensed doctors now run a private practice. In order to secure the principle of free choice of doctors and the right of establishment for professionals, patients may see any provider and doctors are permitted to run private offices regardless of a contractual status.  If patients see those "out-of-network" doctors without a social insurance contract ("Wahlarzt") they pay a market price at the point of delivery and are reimbursed in retrospect 80 percent of the fee that would have been charged if the treatment had been delivered by a contracted physician. These co-payments form a substantial and growing part of private spending on health. In 2008 private spending for "Wahlärzte" was on the order of 540 million Euros or amounted to 10 percent of total private health expenditure (excluding private health insurance). 

Finally and in this context, in the current stage of implementation of the new law it is not possible to assess how many physicians will use the new limited liability structure to become their "roof-top." Rather, through the highly regulated market access, case growth in ambulatory care outside hospitals will likely remain low when compared to the hospital sector, especially since no payment model is in place to ensure an appropriate flow of funds to where patients are treated. Moreover, prohibiting other health care professionals except physicians from becoming shareholders of ambulatory care centres adds another barrier to improved patient-centered care. Finally, the proposal lags behind policy developments in Germany where ambulatory care centres (MVZ) may also employ other doctors. The potential of these centres has grown as employment of doctors rose considerably in recent years (Sachverständigenrat 2009). Thus, the draft legislation on ambulatory care centres appears to work against the goal of establishing a more balanced utilization of services, with better integration between inpatient and outpatient care. Care provision may even become more fragmented with additional administrative costs in addition to cost increases arising from non-aligned payment schemes with specialists still being predominately paid on the basis of fee-for-services.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

References

Sources of Information

• Dispensation: VfSlg 15.456/1999 - 10.03.1999, VfSlG 15.787/2000 - 18.03.2000, EuGH 10.03.2009, C-169/07
• Eichwalder, Stefan and Maria M. Hofmarcher. "Failure to improve care outside hospitals." Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/at/b11/2.
• Explanation - Bundesgesetz zur Stärkung der ambulanten öffentlichen Gesundheitsversorgung (BEGUT_COO_2026_100_2_593444).
• Gemeinschaftsrechtswidrigkeit der Bedarfsprüfung für selbstständige Ambulatorien (für Zahnheilkunden), RdM 2009/85.
• Hofmarcher, M.M., H. Rack (2006): Gesundheitssysteme im Wandel - Österreich, Medizinisch Wissenschaftliche Verlagsanstalt, Berlin.
• Hofmarcher, Maria M. "Excess capacity and Planning: Kain tortures Abel?". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/at/a15/2.
• Hofmarcher, Maria M. "Patient safety on the rise?" Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/at/b14/1.
• Hofmarcher, Maria M.. "Austrian Health Fund born". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/at/b14/2.
• Rittenhouse, D., et.al. (2009): Primary Care and Accountable Care - Two Essential Elements of Delivery-System Reform, N ENGL J MED 361; 24: 2001-2303.
• Sachverständigenrat der Konzertierte Aktion im Gesundheitswesen (2009): Koordination und Integration - Gesundheitsversorgung in einer Gesellschaft des längeren Lebens, Sondergutachten Berlin. http://www.svr-gesundheit.de/Startseite/Startseite.htm.
• Swensen, St. J. et al. (2010): Cottage Industry to Postindustrial Care - The Revolution in Health Care Delivery, N ENGL J MED 363, January.
• Press Releases

Author/s and/or contributors to this survey

Maria M. Hofmarcher, Bernadette Hawel

The authors are grateful to Leslie Tarver for providing excellent editorial support, and for many valuable comments received by various experts coming from:

Gesundheit Österreich GmbH

• Andreas Birner 
• Ines Grabner

Ärztekammer (Chamber of Physicians)

• Robert Hawliczek, Head of the Department of Radiooncology, Sozialmedizinisches Zentrum Ost-Donauspital, Speaker of managing doctors in the Chamber of Physicians

Hauptverband der österreichischen Sozialversicherungsträger (Federation of Austrian Social Insurance Institutions)

• Josef Probst, Deputy CEO

Wirtschaftskammer (Chamber of Commerce)

• Martin Gleitsmann, Head, Department of Social Policy and Health

 

 

Suggested citation for this online article

Maria M. Hofmarcher, Bernadette Hawel. "Ambulatory care reforms fail to face the facts?". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/at/a15/1