HEALTH SYSTEM WATCH · health sector. 2 In France, a quasi-basic right was created in 2000 by...

HEALTH SYSTEM WATCH 2/2002 1

II/Summer 2002

HEALTH SYSTEM WATCH Supplement of the journal Soziale Sicherheit

Health System Watch is produced by the Institute for Advanced Studies/Institut für Höhere Studien

(IHS) - IHS HealthEcon and edited by the Hauptverband der österreichischen

Sozialversicherungsträger (Federation of Austrian Social Security Institutions)

Resource consumption in the EU: Allocation is more than financing – payment mechanisms

in Social Health Insurance Countries

Focus: Physicians and cities: a close link

Maria M. Hofmarcher, Christine Lietz, Monika Riedel*

Resource consumption In order to finance the health system in the best possible way, both economic and fairness aspects have to be taken into consideration. However, the way of financing alone does not indicate whether the allocation (i.e. the distribution of funds) is efficient or not. How funds are distributed and used is determined by the demand for health services as well as the supply, which in turn depends on the level of a society’s development. In developed countries, the major part of resources is spent on the following three sectors: hospitals, care provided by generalists or specialists, and medicines. In many cases up to 50 per cent of the total health budget is spent on hospital care. Costs, efficiency and quality are considerably influenced by the mechanisms of paying the individual health service providers.

Physicians and cities In Austria, the physician density, and in particular the density of physicians, who have a contract with the social health insurance, is low compared to Germany and France. Even Vienna has a lower physician density than Hamburg, Berlin, Lyon and Paris. What these five cities do have in common is the fact that their ratio of physicians per inhabitant is higher than that of the rest of the respective country. In Austria this difference is greater than in Germany, with Vienna having 72% more physicians per inhabitant than the rest of the country. In the two French cities - Lyon and Paris - the gap is even more pronounced: Paris, for example, has two-and-a-half times more physicians than the rest of France. In cities, also the health insurance’s per-capita spending for medical services is higher than in the country. In this case, however, the difference is not as big as with the density of physicians.

* With special thanks to Gerald Röhrling for his assistance and Martina Szucsich for translation


Resource consumption in the EU: Allocation is more than financing - payment mechanisms in Social Health Insurance countries

Mixed financing as a rule without exceptions In none of the developed countries public financing taps only one single source. In countries with

social security systems the major part of public expenditure on health is financed by contributions,

the rest by taxes. To what extent each of these two financing sources come into play varies from

country to country: While in France the main part (95%) of public spending on health is financed by

health insurance contributions, in Austria it is only 66%. Germany is in between with 90%.

Health insurance contributions can be considered as a general tax that has been specially adapted

to the financing of health care and corresponds to a fixed percentage of a beneficiary's income, the

amount being limited by an upper level. The contributions' amount as well as the defined services

are determined on the basis of certain laws, which substantiate a social contract providing services

in terms of non-cash benefits and/or money for all those who necessitate them, independently of

their incomes.

It is difficult to compare the individual contribution rates since they differ considerably from each

other, even within public health insurance companies. While in Austria people employed have to pay

approximately 7% (blue collar workers: 7.6%, white collar workers: 6.9%, civil servants: 7.1%), in

Germany they pay on the average 14% for public health insurance. In France, people employed pay

13.55%. In Austria, employers and employees to equal parts share the contribution. In France,

employers pay 12.8%, employees 0.75%. Unlike in Austria and Germany, where contributions are

paid up to a monthly gross income of € 3.226,67 (Austria) and € 3.375 (Germany), respectively, there

is no income ceiling.

Be it taxes or contributions....

Contrary to Social Health Insurance (SHI) countries tax financed health care systems depend on the

overall amount of tax revenues collected by the state. . This means the health care system is

constantly competing for public funds1.

Health insurance contributions - levied as a certain percentage of the income - have the properties of

an income tax. Nevertheless they are used only for specified services and are in most cases levied

and administered by self-governing bodies that have their own balance and budget rules.

Contributions and services therefore cannot be changed by simple government measures. A

1 A five-year investment plan of the British National Health Care System (NHS) provides for raising the health budget by 40 million Pounds (65 billion Euro) in order to lift health care spending to the European average level. In the preceding discussions some rather extraordinary suggestions were made, like the transfer of funds from the defense budget and the ministry of internal affairs to the health budget. (The plan is now to finance health care by raising national insurance by 1%.) Cf. Moore, W.: NHS to receive an extra £40bn over next five years, BMJ 2002;324:993 (27 April) and Appleby J., Boyle S.: Blair's billions: where will he find the money for the NHS?, BMJ 2000;320:865-867 (25 March).


legislative process, requiring certain rules of decision-making among the interest groups, precedes

every single adjustment of contribution rates or services. Contributions can seem more attractive

than uncommitted taxes if the impression can be created among the people that their money is spent

and administered to their benefit by non-government organisations.

Yet, contribution-based financing is mostly linked to the occupational status substantiating an

entitlement. Thus, unlike with systems that are financed by taxes there is no basic right to health

care provision in SHI-countries 2.

... economic consequences of financing on competitiveness are likely ...

Income and consumption taxes are the usual sources for financing public duties. The amount of

taxes available depends however on short - and long-term economic growth cycles. In times of

recession, tax revenues may dec rease and the competition for public funds increase. Profits in

general are more sensitive to an economic downturn than wages. The economic effect health

systems that are financed by taxes may generate depends considerably on what kind of tax is used.

Economic theory is based on the assumption that high taxes decrease labour supply by diminishing

the income available. Empirical evidence, on the other hand, indicates that the income elasticity of

labour supply (at least with men) is low3. High labour costs in turn may diminish a country's

competitive ability on the international level and slow down investments and growth. With the

growing globalisation of the economy, such considerations are becoming ever more important.

An important social aspect of taxation is the question of who carries the tax burden. A tax system is

considered vertically just if people with higher incomes have to pay more. Horizontal justice would

mean that persons suffering from certain disadvantages (e.g. health problems) pay lower taxes than

those without these disadvantages. Vertical justice tends to be higher in systems that are financed by

progressive income taxes including profit taxation. Only in such comprehensive tax systems it can be

guaranteed that taxes rise with rising income. Horizontal justice is generally given if tax contributions

are made by a broad basis, including the whole population. It may however suffer if revenues are

solely drawn from consumption taxes. For instance, the value-added tax on drugs, affects only those

who suffer from health problems. In addition to that, consumption taxes like the value-added tax

might endanger vertical justice since persons with lower incomes spend a larger share for

consumption goods, whereas persons with higher incomes have a higher propensity to save.

Horizontal justice is even more threatened if fund raising is decentralised too much: wealthier regions

are able to contribute more than poor regions. As a consequence the central state often has to take

complicated adjustment measures, which might reduce the transparency of allocating funds to the

health sector.

2 In France, a quasi-basic right was created in 2000 by introducing a comprehensive right to health care provision; cf. Yukata I., Jacobzone S, Lenain P.: The Changing Health System in France, OECD Working Papers No. 269, 2000. 3 Cf. e.g.. Leibfritz W., Thornton J., Bibbee A.: Taxation and Economic Performance, OECD 1997, Economics Department Working Papers No.176


... and will finally depend on the balance of power in practice

In general employees carry the major burden of contribution payments in the medium run even if

employers share the rates, the latter in fact being able to shift the burden onto wages. The

magnitude of this shift depends on the labour market conditions and, above all, on the power of trade

unions. Even if a complete shift of the employers‘ contributions is not possible, part of it is likely to be

passed onto prices, which can in turn impair the competitiveness. It is difficult to assess these effects

on economies growth dynamics. Nevertheless it is often argued that social security systems are to a

certain extent automatic stabilisers that help to compensate for a decrease in demand during times

of recession and thus to slow down the economic downturn4.

Allocation is more than financing The sole way how funds are collected and administered does not give any information about the

efficiency of the allocation (i.e. the distribution of funds). The distribution and use of funds is mainly

determined by demand and to a certain extent also by the supply of health services provision, which

in turn is determined by the level of a society's development.

Figure 1: Expenditure on health according to the main functions, 1998 or most recent year

available

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SHI = Social Health Insurance Countries Hospital care: Belgium, Switzerland 1997; Austria: fund hospitals; health care spending according to official ESVG 95 method Physician services: Belgium: only public spending Drugs: Belgium 1997 Sources: WHO Health for all database, January 2002; OECD Health Data, August 2001; BMAGS; Statistik Austria; IHS HealthEcon 2002.

4 Vgl. Nowotny, E., Scheer, C., Walther, H.: Der öffentliche Sektor: Einführung in die Finanzwirtschaft (3., neubearb. und erw. Aufl.), Springer-Verlag, Berlin, 1996


Figure 2: Health care spending in % of the GDP, 1998 or most recent year available

3,55,3

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SHI = Social Health Insurance Countries Hospital care: Belgium, Israel 1997; Austria: fund hospitals; Israel: Hospitals and research Physician services: Belgium: only public spending; Israel: private physicians (29,4%) and dental care (70,6%), 1997 Drugs: Israel: budget spending for drugs, 1997 Sources: OECD Health Data, June. 2001; Israel: Central Bureau of Statistics; IHS HealthEcon 2002.

In all health systems hospital care, physician services and drug consumption utilize the major share

of resources. In some cases up to 50% of health care spending is used for hospital care (cf. table 1),

which in all countries utilizes most resources5. This is why cost containment measures in health

policies focus on this sector not only in Austria, but also on an international level. The availability of

data and information in this sector is comparably sound. Despite considerable efforts not even the

experienced international organisations like the OECD have succeeded in comprehensively

documenting the consumption of resources in the sectors of general practitioners and specialists.

For 1999, the spending for generalist and specialist care are recorded for only six EU countries,

including Austria (cf. annexed table A1). As for public health, including health promotion and

prevention, the availability of data is even less satisfactory6.

Social health insurance countries show signs of ageing...

Countries with social security systems particularly focus on the curative sector. Public health as a

strategy of strengthening prevention and health promotion, on the other hand, is poorly developed,

which is a problem considering today’s demand for interventions to reduce premature morbidity and

mortality. Moreover, the compilation and processing of epidemiological and biostatistical data is not

only dissatisfactory, but in some cases like e.g. in Austria also split up between regions.

5 Since the Austrian health expenditures are likely to be underestimated, the share spent on hospitals (48%) is probably overestimated. Cf. Pichler, E., Walter, E.: Finanzierung des österreichischen Gesundheitswesens, Industriewissenschaftliches Institut, Vienna, March 2002. 6 The handbook of the System of Health Accounts developed by the OECD assumes a calculation of these expenditures. Up to now, Germany, the Netherlands and Switzerland are the only European countries that have implemented this system.


Public health in Austria is rooted in the Sanitation law of the Empire (Reichssanitätsgesetz) of 18707,

which is still valid today, defining the major tasks of sanitary surveillance and epidemics hygiene. A

modern public health system has to meet additional requirements such as health monitoring, health

promotion for the total population and, above all, for socially disadvantaged groups. The Austrian

system is at present on its way to become compatible with these tasks.

In France, the health reform of 1996 is considered a step towards public health, creating the

possibility to form managed care networks, so-called "réseaux". In these networks, a group of health

care providers work to provide and co-ordinate the care and health promotion for a certain group of

patients (who generally suffer from the same disease, like e.g. diabetes). Due to the possibility of

negotiating with social health insurance funds, the law enables the network to offer and reimburse for

services that normally do not fall under the social security service catalogue. Such services might be

patient information or nutritional counselling. However, only few people have made use of this

possibility so far8.

... and are closely connected with the private sector

One of the major characteristics of SHI-countries is the private provision of medical services.

Physicians offer services against payment of fees fixed by law or the administration, their amount

usually being the result of negotiations between health insurance companies and health care

providing organisations. The results of these negotiations are always contracts establishing a

public/private partnership between the private provider and the public payer. In this context, the

contracts have to be designed to guarantee both a reasonable remuneration of physicians and an

optimum of care provided for patients. One of the major problems in this context is the so-called

asymmetrical information9: Due to their lack of specialised knowledge, patients and health insurance

companies only have a limited possibility to examine what the physicians do. This means it cannot

be verified whether a physician takes the proper efforts or not. Therefore, physicians´ payments may

be higher than the corresponding services provided as profit-oriented physicians have an incentive to

restrict their efforts10.

Overview of payment mechanisms Although the development of a country's health system can be explained by its specific history and

the normative principals of health and social policies, which are derived from it, the relative

magnitude of the individual fields of services does not considerably differ between developed

countries (cf. annexed tables A1-A3). Differences are, among other things, due to the individual

7 Sablik, K.: Das Gesetz zur Organisation des öffentlichen Sanitätsdienstes in Österreich von 1870, zur Entstehungs-geschichte des Reichssanitätsgesetzes vom 30. April 1870, communication by the Austrian sanitary administration, volume 71, 1970, issue 6-7. 8 Cf. Hofmarcher, M.M., Durand-Zelinsiki, I.: Contracting and Paying Providers in Social Health Insurance Countries in Western Europe, edited by: European Observatory on Health Care Systems 2002, (being published) 9 Vgl. McGurie Th. G.: Physician Agency, in Culyer A. J., Newhouse J. P. (Ed): Handbook of Health Economics, Volume 1A: 462-517, Elsevier 2000. 10 Gaynor M., Mark T.: Physician contracting with health plans: a survey of the literature, Carnegie Mellon University, Pittsburgh, Pennsylvania, June 1999.


payment mechanisms. Table 1 shows an overview of payment mechanisms in the fields of public

hospitals, generalist and specialist care as well as drugs for Austria, Germany and France.

Table 1: Payment mechanisms in Austria, Germany and France

Public hospitals Generalist and specialist

care

Drugs

Austria Per case flat rates (LKF

system), partly global budgets

Fee for service and lump

sums, physicians‘ fees

negotiated with individual

sickness funds

Degressive plan scheme

containing maximum mark-up

rates for wholesale and

pharmacy margins

France Global budgets fixed yearly

by the authorities, monthly

instalments to the hospitals

by the social health insurance

Fee for service, approx. for ¾

of physician’ centrally

determined, for ¼ fees are

determined by the market

National budgets for drugs,

two (degressive) mark-up

rates for wholesale and

pharmacy margins

Germany Per case flat rates, extra fees

(for special services and per

diem rates

A DRG system to be

introduced in 2003/2004

Global reimbursement

(amount determined by fee

for services and lump sums)

for all contract physicians of a

federal state; distribution

among physicians by point

system (EBM)

Since 1.1.2002 quality and

quantity-based target

agreements between health

insurers and physician

association; degressive

scheme containing maximum

mark-up rates for wholesale

and pharmacy margins Sources: European Observatory on Health Care Systems: Health Care Systems in Eight Countries: Trends and Challenges, April 2002 Rosian I., Habl C., Vogler S. Weigl M.: Arzneimittel, Steuerung der Märkte in der EU, ÖBIG, May 2001 Webpage AOK-Bundesverband: http://212.227.33.34/bundesverband Yukata I., et al, op.cit.; IHS HealthEcon 2002.

Different payment mechanisms...

The way health care providers are remunerated can considerably influence their behaviour. Empirical

studies have shown that payment mechanisms have a measurable influence on 11

- the form of treatment (e.g. medical vs. surgical treatment),

- the quality and quantity of medication,

- the number of treatments per physician visit or hospital day,

- the length of stay in hospital,

- the decision between out-patient or in-patient treatment of certain diseases,

- the naming of a disease and the severity degree physicians accord to it,

- the frequency of referrals to specialists and of laboratory tests.

11 Cf. Hsiao W.C., Roberts M.J., Berman P.A., Reich M.R.: Getting Health Reform Right, Harvard University, October 2000


Below, the six most frequently applied payment mechanisms in the health care sector are described.

In practice, these methods are mostly combined instead of using only one of them in order to live up

to the specific requirements of the individual health care system and sector.

- Fee for service remuneration:

the single consultations or treatments such as injections, measuring the blood pressure,

laboratory tests, X-ray examinations etc. are paid.

- Per-case flat rate:

A certain package of services is paid. In the case of hospitals, for example, the stay there is paid,

regardless of its length and the treatments performed.

- Per-diem rate e:

Per diem rates are predominantly applied in the hospital sector. A certain sum has to be paid per

hospital day.

- Per capita flat rate:

A fixed sum is paid per patient and time unit (e.g. one year, a quarter or one month) regardless of

the treatment performed.

- Wages:

Particularly in the hospital sector physicians often receive annual wages.

- Global budget:

This method is often applied for paying hospital services. Hospitals receive a budget – generally

for one year – and have to provide care for all patients of a certain catchment area.

... exercise different kinds of influence on the providers’ behaviour The various payment mechanisms not only offer different "rewards“, but also influence the decision

of who has to bear the financial risk. In the case of per-capita flat rates, for example, physicians are

faced with the financial risk created by the unpredictable health condition of their patients. If an

influenza epidemic breaks out, they have to provide more services while their fees remain the same.

In the case of fee for service remuneration, this risk is born by the patients or their insurers. Tables 2

and 3 show the incentives the various payment mechanisms used with physicians or hospitals can

trigger.


Table 2: Payment mechanisms for hospitals and their incentives

Payment

mechanism

Increasing the

number of

patients

Reducing the

number of

treatments per

reimbursement unit

Coding a disease

more severe than it

actually is

Choosing

healthier

patients

Fee for service

remuneration yes no yes no

Per case flat rate

(e.g. LKF) yes yes yes yes

Per-diem rate yes yes no no

Per-capita flat

rate yes yes no yes

Global budget no - - yes

Sources: Hsiao W.C., et al, op.cit., IHS HealthEcon 2002.

Table 3: Payment mechanisms for physicians and their incentives

Payment mechanism Increasing the

number of

patients

Reducing the

number of

treatments per

reimbursement unit

Coding a disease

more severe than it

actually is

Choosing

healthier

patients

Fee for service

remuneration yes no yes no

wages no - - yes

Wages + bonus for

number of patients yes - - yes

Per capita flat rate yes yes no yes

Sources: Hsiao W.C., et al, op.cit., IHS HealthEcon 2002.

If service provision is reimbursed on a fee for services basis, it is more attractive for physicians to

rate the disease in front of the patient or the insurer as more serious than it actually is, since a higher

degree of severity justifies more treatment episodes (which can be reimbursed separately). Unlike

most other payment mechanisms, this one constitutes no incentive for physicians to treat healthier

persons - on the contrary: patients who are more seriously ill need treatment more often and

therefore increase the physicians‘ income.

The system of per case flat rates is often applied in the hospital sector and consists in the payment

per hospital stay. It comprises a high risk for the hospitals since the amount reimbursed does not

depend on the severity of the case. This is why there is a tendency to reduce the number of

comprehensive and expensive treatments as far as possible and to choose healthier patients.


Moreover, it is tried to reduce the length of stay in order to be able to increase the number of patients

and thus of reimbursed cases. If there are similarly defined cases (like e.g. mania without psychotic

symptoms and mania with psychotic symptoms, respectively) that are reimbursed differently, there is

a tendency to code those connected with a higher reimbursement.

Per-diem rates also predominantly occur in the hospital sector. They encourage prolonging the

length of stay, while avoiding expensive and complicated kinds of treatment, as well as the

enlargement of bed capacities in order to be able to keep more patients as long as possible.

Per capita flat rates favour a large number of patients. Since physicians and hospitals, respectively,

carry the fi nancial risk of the treatment of severe diseases, they have an incentive to pick healthier

patients in order to prevent expensive and labour-intensive treatment procedures.

Global budgets focus on motivating hospitals to apply the resources available as economically as

possible. With this form of payment hospitals bear however the financial risk of various uncertainties

such as the number of treatment episodes, costs of the individual treatment, length of stay per

patient, the number of patients etc. This is why hospitals under global budgets have an incentive to

keep case- and workload low.

Physicians who receive a fixed income face a low financial risk and therefore have no financial

motivation to keep the number of treatment episodes and patients low. What they are, on the other

hand, interested in is reducing their working burden and effort. Introducing a bonus or overtime

premium system can solve this dilemma.

The arguments stated above do not imply that physicians are only out for their own interests and try

to exploit the system as far as possible. It goes without saying that they are as well interested in the

well being of their patients. In order to guarantee the best possible payment scheme, health

insurance companies as payers have to consider the individual incentives that are generated by

different payment mechanisms. This is the more important as even the most altruistic physician

wants to earn a living.


Focus: Physicians and cities: A close link*

The market of medical care, particularly the one in Social Health Insurance (SHI) countries, is characteristically split up into three main participants: physicians (supply), patients (demand) and

health insurance companies (payers). In their role as experts, physicians influence the patients’ demand for health services, which they in turn provide. By doing so they pursue in most cases not only altruistic aims, but also a target income. In the relation between social health insurers and

patients there is an incentive for patient to over-use services since their marginal cost of consumption is zero. Due to this tendency as well as an international increase in the number of physicians, health insurers as payers have to implement certain measures to regulate the amount

and price of the health care provided. Otherwise, the number of services as well as costs would explode. A high physician density may lead to higher costs than desirable. . At the same time it may guarantee high quality of health care provided for the population.

In addition to the difficulty of determining the optimal physician density, the question of regional

distribution arises. A public health system has the duty to ensure that medical care is regionally balanced and available for the whole population. If on the other hand care is provided for the respective surroundings, a regional concentration of health care providers on urban centres might

however be favourable from an overall economic point of view.

Compared to the rest of Austria, Vienna has a relatively large number of contract physicians, particularly specialists. From the point of view of health policy it is of interest to find out whether such

a difference in physician density between cities and the country also exists in other European states.

For comparing Vienna‘s physician density on a European level, cities and countries, respectively, with similar characteristics as Vienna or Austria should be chosen. Germany and France are, like Austria, SHI-countries and provide comparably high living standards. Like Vienna, the cities Lyon

and Hamburg have a medical university, and, with a population of one and a half million, Hamburg is similar to Vienna in terms of population. Despite all this, big cities cannot be tarred with the same brush. While Vienna with its more than one million inhabitants is Austria’s only metropolis, Germany

has several cities with populations exceeding one million. In addition to that, the population of Vienna accounts for a fifth of the entire population of Austria, whereas the inhabitants of Hamburg make up only 2% of the German population. France, on the other hand, is more like Austria, Paris with its

slightly more than two million inhabitants being the only metropolis. Considering all these facts, it is reasonable to include not only Lyon and Hamburg, but also Berlin and Paris into the comparison.

What makes a physician is defined differently

Even if physician densities are compared with those of other SHI-countries like Germany and

France, institutional differences regarding health care provision have to be taken into account. In

Austria and Germany, e.g., health care provision is based on benefits in-kind. This means persons

covered by health insurance are entitled to medical treatment, which is made possible by contracts

* With special thanks to the Physicians’ Chamber for Vienna for permitting us to summarize findings in the research report: Felderer, B., M.M.Hofmarcher, Ch. Lietz, M. Riedel, Ärztedichte im urbanen Umfeld (Physician density in urban settings), Institute for Advanced Studies, Vienna März 2002.


between health insurers and health care providers. In France with its principle of cost reimbursement

the situation is different. Insured patients have to pay the physician’s fee which they are later (partly)

reimbursed for.

Unlike Germany and France, sickness fund patients in Austria are additionally provided with

physicians who do not hold a contract but may be seen by each enrolee at any time. Similar to

France, this means when consulting those physicians, patients can submit the receipt to the health

insurance and will be partly reimbursed for the physician’s fee. In Germany nearly all non-hospital

physicians are contracted, whereas in Austria only approximately two thirds of office-based

physicians have a contract with at least one insurance company. Ambulatory care provided by

outpatient departments of hospitals or outpatient clinics partly owned by the insurance companies

are further typically Austrian institutions. In 2000 approximately 15% of all ambulatory care cases

were treated in outpatient departments of hospitals and 2.4% in specialised outpatient clinics of

health insurance companies 12.

Austria has a relatively low physician density...

With 304 physicians per 100,000 inhabitants (considering all active physicians) Austria has a lower

physician density than Germany with 336 and France with 311 physicians per 100,000 inhabitants.

Austria’s density of agreed physicians (87 per 100,000 inhabitants) is clearly lower than the one in

Germany with a ratio of 153 (cf. figure 3). These striking differences in the number of contract

physicians can probably only partially be explained by the differences between the individual health

care systems described above.

In France contract physicians as we know them do not exist, since there are no contracts between

physicians and health insurance companies, as mentioned above. The ratios of physicians per

100,000 inhabitants indicated in figure 3 as 200 refer to office-based physicians. Comparing the

numbers with those of Austria and Germany is reasonable because in France patients can choose

their physician. This means the importance of office-based physicians in France in terms of care

provision is similar to that of contract physicians in Austria and Germany. Nevertheless, differences

between the systems of the individual countries must not be completely disregarded in such a

comparison13.

12 On the difficulty of comparing cases or case figures of the individual settings, cf. Hofmarcher, M.M., Riedel, M.: Health System Watch IV, Winter 2001/2002: Gesundheitszustand in der EU: Die EU wächst zusammen. Schwerpunktthema: Arztpraxis oder Spitalsambulanz: Ein Fall ist nicht ein Fall. 13 The number of office-based and registered physicians in France is the same per definition. In Germany, office-based and registered physicians are two different groups, but, as mentioned above, only few office-based physicians without contract exist. Therefore both groups have the same physician density (153).


Figure 3: Physician density in Austria, Germany and France

304

171

87

336

153 153

311

200 200

0

50

100

150

200

250

300

350

400

active physicians office-based physicians contract physicians

phys

icia

ns p

er 1

00,0

00 in

habi

tant

s

Austria Germany France

Sources: Austria: ÖBIG, Association of Austrian insurance companies, Statistik Austria Germany: KBV, Federal Chamber of Physicians France: STATISS (DRASS, DREES) Reference year: 1999; IHS HealthEcon 2002.

... which also applies to Vienna

In Vienna there are less active physicians per capita than in Hamburg, Berlin, Lyon and Paris. As far

as contract physicians, particularly specialists, are concerned, Vienna clearly lags behind Hamburg

and Berlin. The two French cities have a higher physician density than the other cities, with Paris

showing particularly high ratios (cf. figure 4)

Figure 4: Physician density in Vienna, Hamburg, Berlin, Lyon and Paris

457

250

117

483

208 187

482

204 194

539

364 364

770

434 434

0

100

200

300

400

500

600

700

800

900


phys

icia

ns p

er 1

00,0

00 in

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s

Vienna Hamburg Berlin Lyon Paris

Sources: Austria: ÖBIG, Association of Austrian Insurance Companies, Statistik Austria Germany: KBV, Federal Chamber of Physicians France: STATISS (DRASS, DREES), DDASS du Rhône Reference year: 1999; IHS HealthEcon 2002.


Cities have a considerable physician surplus ...

In all five cities the physician density is clearly higher than in the surrounding area or the rest of the

country, respectively. Paris ranks first in terms of physician density with over two-and-a-half times

more active physicians per capita than France. Lyon ranks second, Vienna third immediately after

the two French cities, but clearly in front of Hamburg and Berlin. Vienna has 72% more active

physicians per capita than the rest of Austria, in Hamburg and Berlin the number is approximately

45% higher than for entire Germany. Regarding agreed physicians, the gap is less profound, but with

47% more physicians per capita in Vienna still obvious (Hamburg: 23%, Berlin: 29%) (cf. figure 5).

The fact that it is Vienna and Paris that have particularly high physician densities is probably a kind

of "metropolis effect“: Both cities are singular in terms of number of inhabitants within the two

countries.

Figure 5: Comparison of physician densities in cities and the country

172% 164%147%145% 137%

123%146%

135% 128%

174% 183% 183%

262%

227% 227%

0%

50%

100%

150%

200%

250%

300%

actice physicians office-based physicians contract physicians

ratio

Vienna / Austria (without Vienna) Hamburg / Germany (without Hamburg)

Berlin / Germany (without Berlin) Lyon / France (without Lyon)Paris / France (without Paris)

Sources: Austria: ÖBIG, Association of Austrian Insurance Companies (Verband der Versicherungsuntern. Österreichs), Statistik Austria Germany: KBV, Federal Chamber of Physicians France: STATISS (DRASS, DREES), DDASS du Rhône Reference year: 1999; IHS HealthEcon 2002

... even when considering the care provided to surrounding areas The assumption that cities have higher physician densities because they also provide care for their

surroundings can be examined by comparing the surroundings with the entire state. The assumption

proves absolutely true if the physician density of the city and its surroundings is exactly the same as

that of the rest of the country14. In the case of Austria, the physician density of Vienna, Lower Austria

14 This implies that a city provides care only for its own surroundings. The inhabitants of the province of Vorarlberg, e.g., are not supposed to consult a specialist in Vienna. This care provision for the surroundings however seems to play a minor role among office-based physicians.


and Burgenland, the two provinces being defined as catchment area of Vienna, would have to

correspond to the density of western Austria (which is Austria without Vienna, Lower Austria and

Burgenland).

As shown in figure 6, the cities’ higher physician densities can hardly be explained exclusively by

providing care for the surrounding regions. Vienna and its surrounding provinces Lower Austria and

Burgenland have 30% more active physicians and 22% more contract physicians per capita than the

rest of Austria. For Paris and its surroundings the situation is similar. In German cities and their

surroundings the gap is less pronounced, but still obvious. All this shows that despite a rather

generous definition of the surroundings – the provinces Lower Austria and Burgenland being quite a

large catchment area for Vienna - the cities‘ higher physician densities are unproportionally high.

Figure 6: Care provision for the surroundings: Comparison of physician densities in the

surroundings and the country

130%

143%

122%125%135%

124% 124%

108%

114%118% 110%112%117%109%109%

0,000

0,200

0,400

0,600

0,800

1,000

1,200

1,400

1,600


ratio

Vienna+Lower A.+Burgenland / (rest of) Austria Hamburg+Schl.-Holst. / (rest of) GermanyBerlin+Brandenburg / (rest of) Germany Rhône (incl.Lyon) / (rest of) FranceÎle-de-France (incl.Paris) / (rest of) France

Sources: Austria: ÖBIG, Association of Austrian Insurance Companies, Statistik Austria Germany: KBV, Federal Chamber of Physicians France: STATISS (DRASS, DREES), DDASS du Rhône Reference year: 1999; IHS HealthEcon 2002

Other possible reasons for the disparities between cities and the country

Disparities between the physician densities of cities and the country depend to a large extent on the

individual physician‘s choice of location. This can in turn be influenced by different motivations and

circumstances: A high demand for medical care caused by a higher number of potential patients in a

certain location justifies a higher physician density. Generally it may be assumed, that the better the

medical infrastructure (comprising e.g. a teaching hospital, continuous education programmes etc.),

the greater the motivation to choose a certain location.


A further factor physicians consider when choosing a certain location is the personal quality of life.

Physicians in rural areas often have to care for a relatively large catchment area, whereas physicians

in cities can share stand-by and emergency services with their colleagues and other providers. In

France, for example, the coast region and large cities have high physician densities, whereas some

rural regions are nearly underprovided for.

The cities‘ surplus is almost exclusively due to the surplus of specialists...

Vienna has twice as many specialists per capita than the rest of Austria. In Paris the number is even

three times, in Lyon two-and-a-half times as high as in France. Hamburg and Berlin each have one-

and-a-half times more specialists than Germany. The density of general practitioners, on the other

hand, is not that much higher than in the rest of the country. At least this is the case for Vienna,

Hamburg and Berlin (cf. figure 7).

Figure 7: Comparison of general practitioners and specialists in cities and the entire state

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

generalpractitioners

specialists generalpractitioners

specialists generalpractitioners

specialists


ratio

Vienna / Austria (without Vienna) Hamburg / Germany (without Hamburg)Berlin / Germany (without Berlin) Lyon / France (without Lyon)Paris / France (without Paris)

Sources: Austria: ÖBIG, Association of Austrian Insurance Companies, Statistik Austria Germany: KBV, Federal Chamber of Physicians France: STATISS (DRASS, DREES), DDASS du Rhône Referenc e year: 1999; IHS HealthEcon 2002

... and can be observed for all specialities

The higher specialist density in Vienna can be observed in almost all specialities. Except in the fields

of neurology and psychiatry, in Vienna there are at least two-and-a-half times more contracted

specialists per capita than in Austria. Vienna is particularly well equipped with contract specialists in

physical medicine, whose number is ten times higher than in the rest of Austria. The number of

contracted radiologists and orthopaedists is more than three times as high as the value for entire

Austria. In dentistry, which is most important in terms of quantity, Vienna has 70% more contracted

specialists than the rest of the country.


Is Vienna overprovided or Austria underprovided for?

Despite its surplus of physicians compared with the rest of Austria, Vienna has a lower physician

density than Hamburg and Berlin. This may suggest that Austria‘s rural regions are provided with

much less contracted specialists per capita than rural regions in Germany. The German Land

Schleswig-Holstein, for example, has a density of contract specialists that is almost three times as

high as that of Lower Austria and Burgenland.

Per capita spending for medical care is higher in cities... The health insurers‘ per-capita spending15 for cities is higher than their spending for the country. In

Vienna, per-capita spending is 17% higher than in the rest of Austria. With this value Vienna ranks

second after Paris with a 26% difference. In Hamburg, the expenditure is 11%, in Berlin 7% higher

than in the rest of Germany (cf. figure 8).

... but less pronounced than the physician surplus ... As for the health insurance companies‘ per-capita spending for medical services, the difference

between cities and the country is less pronounced than that of physician density. In Vienna, the

contract-physician density is 47% higher than in the country, whereas the health insurance’s per-

capita spending is “only“ 17% higher than in the rest of Austria (cf. figure 8).

Figure 8: Medical-care spending vs. physician density in cities and in the country

Vienna /Austria

Hamburg /Germany

Berlin /Germany

Paris /France

S1 S2

147%123% 128%

227%

117% 111% 106%126%

0,000

0,500

1,000

1,500

2,000

2,500

ratio

Sources spending: Austria: Annual reports of the regional health insurance companies (GKK), Statistisches Handbuch der österreichischen Sozialversicherung (statistical handbook of the Austrian social insurance); Germany: federal health monitoring; France: CREDES: Eco-Santé 2001 (demo version); Reference year: 1998; France: projection of the year 1990–1995 Sources density of registered physicians: Austria: ÖBIG; Germany: KBV; France: STATISS (DRASS, DREES); Reference year: 1999

15 The values indicated for Austria refer to the expenditure of the nine regional health insurance companies, which cover approx. 80% of insured Austrians. For Germany, the expenditure of the general local health insurance companies (AOKs) is indicated, the AOKs covering the majority (almost 40%) of Germans with national insurance. The values for France correspond to the expenditure of the „Régime Géneral“, the health insurance for employees, which covers approx. 80% of the population. Since the health insurance companies effect the expenditure, the per-capita calculations refer to the number of sickness fund enrolees (exclusive the dependents)


... which has its reasons

The higher density of specialists in big cities is indeed justified, particularly if there is a medical

university like in Vienna. In Austria, approximately one third of physicians who carry out research

work in teaching hospitals do this in Vienna, and more than half of medical students study there. The

proximity to research locations makes Vienna attractive both for physicians working in the field of

research and their colleagues who can benefit from further education facilities they find there.

Moreover, social bounds established during their studies and training period might facilitate the

exchange of professional experience. Furthermore, the university infrastructure offers an easier

access to state-of-the-art medical-technological equipment, for approximately one third of large

medical devices in Austria are located in Vienna.

All this combines to facilitate the physicians‘ work and to guarantee high quality of care to the benefit

of the patients. The disadvantage of a higher physician density is however the higher per-capita

spending of the health care system, which has been shown by empirical studies also in other

countries. To a certain extent, this phenomenon is also a consequence of the demand created by the

supply.


Table A1: Expenditure on hospital care spending in per cent of total expenditure on health Index EU15=100 1990 1995 1996 1997 1998 1999 1990 1995 1996

Austria*** 43,4 44,6 43,4 49,0 48,2 48,6 108 113 112 Belgium 32,8 33,3 34,4 34,6 n.av. n.av. 82 84 89 Denmark 56,7 55,0 55,3 54,7 54,3 53,9 141 139 143 Germany 34,7 34,7 34,1 33,6 34,0 n.av. 87 88 88 Finland 44,7 42,0 41,8 41,4 41,1 40,7 112 106 108 France 46,0 45,5 45,5 45,4 44,6 43,8 115 115 118 Greece 28,4 24,8 3) n.av. n.av. n.av. n.av. 71 63 n.av. Ireland** 52,4 53,3 52,0 52,3 50,1 n.av. 131 135 135 Italy 42,7 44,8 41,7 42,6 41,4 41,3 107 113 108 Luxembourg 26,4 31,3 32,4 36,0 30,7 29,8 66 79 84 Netherlands 50,5 50,6 51,1 52,8 52,8 52,7 126 128 132 Portugal** 29,5 33,6 35,7 n.av. n.av. n.av. 74 85 93 Sweden** 49,8 42,1 n.av. n.av. n.av. n.av. 124 106 n.av. Spain 44,1 45,2 44,8 n.av. n.av. n.av. 110 114 116 United Kingdom** 29,2 29,5 25,3 26,1 n.av. n.av. 73 74 66

EU15* 40,1 39,6 38,6 n.av. n.av. n.av. 100 100 100 EU12* 41,1 40,7 40,3 n.av. n.av. n.av. 102 103 105

Switzerland 49,5 50,7 50,9 50,8 50,3 n.av. 124 128 132 USA 44,9 43,1 42,7 42,1 41,3 40,5 112 109 111

Bulgaria 53,0 2) 59,0 n.av. n.av. n.av. n.av. 132 149 n.av. Estonia n.av. n.av. n.av. n.av. n.av. 35,4 n.av. n.av. n.av. Latvia 78,0 62,0 58,0 56,7 51,6 51,9 195 157 150 Lithuania n.av. n.av. n.av. n.av. 41,6 n.av. n.av. n.av. n.av. Malta n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. Poland** 34,8 1) 33,7 33,1 34,7 31,7 31,3 n.av. 85 86 Romania n.av. 59,0 58,0 63,0 n.av. n.av. n.av. 149 150 Slovakia 32,1 43,0 44,0 44,8 48,2 47,0 80 109 114 Slovenia 42,9 49,1 49,7 48,9 47,2 47,7 107 124 129 Czech Republic n.av. 29,6 33,8 35,6 35,4 35,1 n.av. 75 88 Turkey 33,4 28,7 28,2 28,8 29,3 n.av. 83 72 73 Hungary 59,7 54,8 53,1 n.av. n.av. n.av. 149 138 138 Cyprus n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av.

*Average weighted on the total health care spending **Only public spending *** Spending for fund hospitals 1)1991, 2)1992, 3)1994 Sources : WHO Health for all database, January 2002; OECD Health Data, August 2001 for Ireland, Portugal, Sweden, United Kingdom, USA and Poland; Health Care Systems in Transition (HiT) for Lithuania and Switzerland; Austria: Federal Ministry of Social Security and Generations, health care spending according to Statistik Austria, Jänner 2002; IHS HealthEcon 2002.


Table A2: Expenditure on pharmaceuticals in per cent of total expenditure on health Index EU15=100 1990 1995 1996 1997 1998 1999 1990 1995 1996 1997 1998

Austria 13,2 10,4 10,6 12,9 14,1 n.av. 81 64 65 78 84 Belgium 15,5 16,2 15,4 16,1 n.av. n.av. 95 100 94 97 n.av. Denmark 7,5 9,1 8,9 9,0 9,2 9,0 46 56 55 54 55 Germany 14,3 12,3 12,4 12,2 12,7 n.av. 88 76 76 74 76 Finland 9,4 14,0 14,4 14,8 14,6 15,1 58 86 88 89 87 France 20,0 21,0 21,0 21,3 21,9 22,8 123 129 129 129 130 Greece 14,5 17,3 17,9 17,2 14,7 13,5 89 107 110 104 87 Ireland 11,1 9,5 9,5 9,3 9,9 n.av. 68 59 58 56 59 Italy 21,2 20,9 21,1 21,4 21,9 22,1 130 129 129 129 130 Luxembourg 14,9 12,0 11,5 12,6 12,3 11,7 91 74 70 76 73 Netherlands 9,1 10,4 10,4 10,3 10,8 11,0 56 64 64 62 64 Portugal 24,9 25,2 26,3 26,9 25,8 n.av. 153 155 161 162 153 Sw eden 8,0 12,5 12,9 12,8 n.av. n.av. 49 77 79 77 n.av. Spain 17,8 19,6 20,0 20,7 n.av. n.av. 109 121 122 125 n.av. United Kingdom 13,6 15,4 15,7 16,3 n.av. n.av. 83 95 96 98 n.av.

EU15* 16,3 16,2 16,3 16,6 16,8 n.av. 100 100 100 100 100 EU12* 17,2 16,6 16,7 16,9 17,0 n.av. 105 102 102 102 101

Switzerland 8,2 7,7 7,6 7,7 7,6 n.av. 50 47 47 46 45 USA 9,2 8,9 9,2 9,6 10,1 11,0 56 55 56 58 60

Bulgaria 12,3 17,4 23,5 23,4 23,8 n.av. 75 107 144 141 141 Estonia n.av. n.av. 17,0 17,0 16,6 22,7 n.av. n.av. 104 103 99 Latvia n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. Lithuania n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. Malta 16,0 15,0 15,0 22,0 n.av. n.av. 98 92 92 133 n.av. Poland 12,6 15,6 8,9 n.av. n.av. n.av. 77 96 55 n.av. n.av. Romania 11,0 1) 17,0 19,0 17,0 20,0 n.av. 68 105 116 103 119 Slovakia 16,8 28,0 30,1 29,7 28,7 28,3 103 173 184 179 171 Slovenia 10,4 18,9 17,4 17,9 18,9 19,0 64 116 107 108 112 Czech Republic 21,0 25,6 25,5 25,3 25,5 27,0 129 158 156 153 152 Turkey 20,5 30,1 26,3 27,8 34,7 n.av. 126 186 161 168 207 Hungary 5,0 25,0 26,3 26,4 26,5 25,5 31 154 161 159 158 Cyprus n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av.

* Average weighted on the total health care spending 1)1992 Sources: WHO Health for all database, January 2002; OECD Health Data, August 2001 for the USA; Health Care Systems in Transition (HiT) for Bulgaria, Malta, Poland and Slovakia; IHS HealthEcon 2002.


Table A3: Expenditure on physician services in per cent of total expenditure on health 1990 1995 1996 1997 1998 1999

Austria 18,3 18,2 17,7 19,4 19,2 19,0 Belgium** 18,6 15,3 15,9 n.av. 12,8 12,8 Denmark 15,8 16,0 15,7 15,7 15,7 15,2 Germany 17,7 16,7 16,4 17,0 17,0 n.av. Finland 25,1 24,7 24,6 24,2 24,4 24,4 France 11,8 11,7 11,6 11,7 11,7 11,7 Greece 12,4 10,8 3) n.av. n.av. n.av. n.av. Ireland 15,1 2) n.av. n.av. n.av. n.av. n.av. Italy 19,7 21,8 3) n.av. n.av. n.av. n.av. Luxemburg 21,6 14,2 3) 12,6 13,2 12,2 n.av. Netherlands 9,1 8,1 3) 8,0 7,8 7,7 7,8 Portugal n.av. n.av. n.av. n.av. n.av. n.av. Sweden 14,4 12,4 3) n.av. n.av. n.av. n.av. Spain 16,2 1) 15,5 2) n.av. n.av. n.av. n.av. United Kingdom 14,9 14,8 3) n.av. n.av. n.av. n.av.

EU15* n.av. n.av. n.av. n.av. n.av. n.av. EU12* n.av. n.av. n.av. n.av. n.av. n.av.

Switzerland 17,5 17,5 17,3 17,5 17,7 n.av. USA 23,1 22,7 22,5 22,4 22,6 22,7

Bulgaria n.av. n.av. n.av. n.av. n.av. n.av. Estonia n.av. n.av. n.av. n.av. n.av. n.av. Latvia n.av. n.av. n.av. n.av. n.av. n.av. Lithuania n.av. n.av. n.av. n.av. n.av. n.av. Malta n.av. n.av. n.av. n.av. n.av. n.av. Poland n.av. n.av. n.av. n.av. n.av. n.av. Romania n.av. n.av. n.av. n.av. n.av. n.av. Slovakia n.av. n.av. n.av. n.av. n.av. n.av. Slovenia n.av. n.av. n.av. n.av. n.av. n.av. Czech Republic n.av. n.av. n.av. 24,5 22,9 22,0 Turkey n.av. n.av. n.av. n.av. n.av. n.av. Hungary n.av. n.av. n.av. n.av. n.av. n.av. Cyprus n.av. n.av. n.av. n.av. n.av. n.av.

1)1991, 2)1992, 3)1994 * weighted on the total health care spending; **only public spending Source: OECD Health Data, August 2001; IHS HealthEcon 2002.


Table A4: Characteristic features of care provision, 1999 or most recent year available Admission rate in per

cent Average length of

stay in days Treated cases/bed FTE staff per bed Physicians per

1,000 inhabitants Dentists per

1,000 inhabitants Pharmacists per 1,000 inhabitants

Physician's visits per capita

Austria 27,7 a) ** 7,9 42,5 2,1 3,0 0,5 0,5 6,7 Belgium 19,8 c) 11,4 a) 38,1 b) 1,5 h) 4,1 0,7 a) 1,4 a) 7,9 Denmark 19,0 a) 7,3 a) 54,9 a) 3,5 b) 2,8 0,9 0,5 5,8 Germany 21,6 a) 12,0 a) 30,1 1,5 3,5 0,8 0,6 6,5 c)

Finland 27,3 10,5 30,8 d) 2,1 g) 3,1 0,9 1,5 4,3

France 22,8 d) 10,8 b) 48,9 1,1 3,2 0,7 1,0 6,5 c)

Greece 15,0 d) 8,6 b) 30,9 i) 1,4 e) 4,3 1,1 n.av. n.av.

Ireland 14,8 a) 7,6 46,6 3,1 2,3 0,5 0,8 n.av.

Italy 17,6 a) 8,0 a) 36,2 a) 2,2 a) 5,7 0,6 1,0 6,0

Luxemburg 19,4 e) 15,3 c) n.av. n.av. 2,5 0,6 0,7 a) 2,8 a)

Netherlands 9,6 a) 13,1 26,8 a) 2,5 b) 3,1 0,5 0,2 5,8

Portugal 12,0 a) 9,0 a) 37,8 a) 3,1 a) 3,2 0,4 b) 0,8 3,4 a)

Sweden 18,0 c) 7,5 c) 42,0 c) n.av. 3,1 1,5 a) 0,7 2,8 b)

Spain 11,4 c) 10,0 c) 35,5 c) 1,6 c) 3,1 b) 0,4 g) 0,7 n.av.

United Kingdom 15,1 a) 9,8 c) 60,2 a) 3,7 a) 1,6 f) 0,4 0,6 g) 5,4 a)

EU 15* 18,1 10,2 40,7 2,1 3,4 0,6 0,8 6,0 EU 12* 18,7 10,4 36,6 1,7 3,8 0,6 0,8 6,2

Switzerland 17,0 a) 14,0 a) 21,5 i) 2,0 g) 3,4 0,5 a) 0,6 a) 11,0 g)

USA 12,5 7,0 38,9 4,6 2,7 a) 0,6 a) 0,7 c) 5,8 c)

Bulgaria 15,8 11,9 21,1 n.av. 3,4 0,6 0,2 5,7

Estonia 19,6 9,9 28,2 n.av. 3,1 0,7 0,6 6,3

Latvia 22,1 11,8 25,4 n.av. 3,1 0,5 n.av. 7,0

Lithuania 24,5 11,3 28,1 n.av. 3,9 0,6 0,6 4,5

Malta 20,2 b) 4,6 b) n.av. n.av. 2,6 0,4 1,8 n.av. Poland 13,8 a) 9,3 26,1 n.av. 2,3 0,3 0,5 5,3 Romania 20,7 9,5 n.av. n.av. 1,9 0,2 0,1 8,0

Slovakia 19,4 10,4 26,0 n.av. 3,2 0,5 0,4 13,5

Slovenia 16,6 9,0 30,9 n.av. 2,2 0,6 0,3 6,8

Czech Republic 19,4 11,6 30,4 n.av. 3,1 0,6 0,5 12,3 Turkey 7,6 6,0 36,4 1,5 1,3 0,2 0,3 2,1 Hungary 25,4 9,2 33,5 1,3 3,6 0,6 0,5 21,1 Cyprus n.av. n.av. n.av. n.av. n.av. n.av. n.av. n.av.

Accession13* 14,1 8,4 31,3 n.av. 2,1 0,3 0,4 6,1 MOEL10* 18,1 9,9 27,3 n.av. 2,6 0,4 0,4 8,6

a) 1998; b) 1997; c) 1996; d) 1995; e) 1994; f) 1993; g) 1992; h) 1991; i)1990 *average weighted on the population 1999, **cases Sources: WHO health for all database, January 2002; OECD Health data, August 2001 for cases/bed, FTE staff and physician's visits and USA all codes Health Care Systems in Transition (HiT) for admission rate and average length of stay in Malta; M. Schneider, G. Cerniauskas, L. Murauskiene: Health Systems of Central and Eastern Europe for treated cases and physician's visits in BUL, EST, LAT, LIT, POL, ROM, SLK and SLO; IHS HealthEcon 2002.

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