Medical rehabilitation needs to be better aligned with patient needs

Medical rehabilitation is an important component of the Austrian healthcare system. In Austria, EUR 1.077 billion were spent on inpatient and outpatient medical rehabilitation procedures in 2022. Most of this (74 per cent) was financed by the Austrian Pension Insurance Institution (Pensionsversicherungsanstalt, PVA). In the period from 2003 to 2022, the number of procedures paid for by the PVA tripled. Since its last audit in the area of medical rehabilitation carried out in 2017 (link to report in German), the ACA has observed some progress; however, there is further potential for improvement. Medical rehabilitation services should be even better aligned with patient needs. This is one of the ACA’s recommendations that it made in its reports on “Medical Rehabilitation – Development and Control” ( „Medizinische Rehabilitation – Entwicklung und Steuerung“) and “Medical Rehabilitation – Organization and Implementation” („Medizinische Rehabilitation – Organisation und Umsetzung“). In addition, the legal framework leads to a situation in which the pension insurance excludes pensioners from receiving outpatient medical rehabilitation care, among other things. Furthermore, the ACA recommends that applications for medical rehabilitation care be submitted digitally in the future. It noted improvements, on the other hand, in medical rehabilitation care for children and young people. The audit period spanned the years from 2015 through 2022.

Therapies should become even more personalized

In 2016, the PVA started changing the framework conditions for medical rehabilitation services, placing the focus of rehabilitation services on participation in the social as well as professional environment and personalizing services to a greater extent. The ACA believes that services provided by rehabilitation facilities should be even better aligned with patient needs. For instance, at the time of the ACA’s audit, rehabilitation services were still largely standardized due to the uniform therapy duration of 1,800 minutes per patient, spread over three weeks, regardless of their specific needs. Changes were only made in three per cent of cases.

Applications should be made digitally

Even though the PVA and the Umbrella Association of Social Insurance Providers (Dachverband der Sozialversicherungsträger) planned to implement a digital application for stays for preventative care (cures) and rehabilitation services, the form that permits patients to apply for rehabilitation services and that has to be signed by a physician still has to be filled out on paper. This means that there is a risk that important information is missing from the application, making it more difficult to select the most appropriate facility, for example. The ACA recommends rapidly digitalizing and improving the application procedure for medical rehabilitation services.

Unclear responsibilities between pension and health insurance providers

Medical rehabilitation is governed by legal provisions on various levels: by social security law, by agreements between the social insurance providers and the service providers as well as by frameworks stipulated by provincial legislation.

The law also assigns medical rehabilitation services both to health and to pension insurance providers, with some overlap in competences. However, the objectives of rehabilitation services, the conditions under which the services are granted as well as the definition of the services differ from one provider to the other. The ACA recommends that the Federal Ministry of Social Affairs work towards clearly defining the responsibilities for pension and health insurance providers.

Legal situation less favourable for pensioners than for actively insured persons

The PVA does not provide pensioners with outpatient medical rehabilitation care nor with rehabilitation services in the case of mental disorders or lymphatic diseases. They are only entitled to inpatient rehabilitation care. There is no objective justification for this approach.

The ACA criticizes this legal situation that puts pensioners at a disadvantage. It recommends that the Federal Ministry of Social Affairs amend the rules applicable to pensioners within the framework of an overall strategy for rehabilitation care. This should improve access to medical rehabilitation care and reduce the need for old-age care.

Nationwide inpatient rehabilitation care for children and young people

Until 2017, hardly any facilities offered inpatient rehabilitation care for children and young people in Austria. With some delay, a regionally differentiated range of services has now been established. In total, there are six rehabilitation facilities for children and young people. The newest one started operations in the spring of 2023. However, the share of rehabilitation needs in the field of mental health was almost twice as large as anticipated in 2010, when the process of establishing nationwide inpatient rehabilitation facilities for children and young people was initiated. In 2022, about two thirds, i.e. 1,687 applications, were made in the field of metal health.

The ACA critically notes that the umbrella association did not evaluate the annual costs of child and youth rehabilitation. It recommends recording costs and involving all provinces as well as social insurance providers in this endeavour. It considers it urgently necessary to recalculate the demand within the scope of the Rehabilitation Plan 2025 (Rehabilitationsplan 2025). Thus, the umbrella association should commission an evaluation of the inpatient rehabilitation facilities for children and young people in a timely manner since the occupancy rate of hospital beds in rehabilitation wards for children and young people amounted to a maximum of 59 per cent in the years from 2018 to 2022. Reasons for this were the COVID-19 pandemic, but also, among other things, difficulties faced by parents when needing to accompany their children during medical rehabilitation.

Rates set without calculations

The Umbrella Association of Social Insurance Providers, the Pension Insurance Institution (PVA) and the Austrian Health Insurance Fund (ÖGK) are in charge of medical rehabilitation services. The PVA takes the fundamental decisions about their organization and implementation since it is responsible for the lion’s share of rehabilitation procedures. At the time of the audit, there were 94 private establishments under contract for medical rehabilitation services and 17 PVA facilities.

The PVA manages a complex system of more than 200 framework and bilateral contracts because it distinguishes between several indications – i.e. the type of disease, e.g. cardiovascular diseases, location as well as type of service provided (inpatient and outpatient care). These rates are classified by indication and are the same for all contractual partners, regardless of the actual costs incurred by the respective facility.

In the ACA’s opinion, only a calculation will show whether the rates are appropriate or not. Its recommendation: the PVA should carry out appropriate calculations, among other things, to ensure that the social insurance providers’ rates lead to efficient and economic results. At the time of the audit, the PVA had only made calculations in the field of oncology. There was no system of calculations for all indications.

In view of the higher costs of the PVA-owned facilities, the relatively low utilization of distinguishing features and considerable investment needs, the structure of PVA facilities needs to be examined.