How do the economic losses of E.R. and outpatient medicine look like in relation to the demand from minor medical cases in German-speaking countries?

Explained using the model of hypochondria & cyberchondria and a corresponding representative experiment.


The question of high quality, always available, cost-covering and constantly developing medical care is a concern for a large part of modern western economies. Depending on our overall History there was also a social change during the second republic in Austria, which, among other things, also included the obligation of the state regarding responsibility towards its own population in the context of medical care, and thus shaped our socio-medical home view to the figurehead that it is today. But adequate medical care, and in this case emergency medicine, is not necessarily a matter of course; A lot had to happen before we could be as proud of our system as we are today.


Our constantly evolving economy must now devote itself to the problems of our time; The population is growing, life expectancy is increasing and the possibilities of medical care are becoming more and more sophisticated: According to this, terms and facts such as “the intergenerational contract” or “occupational medicine” are given a new dimension in the need for discussion; Referring to this work, Austria is also faced with the dilemma of “overloaded emergency rooms”, i.e. the insufficient existence of treatment capacities, the existence of long waiting times in the outpatient departments themselves, and possibly even problem areas in the general rescue & supply chain of the social partners. In this work one would like to deal with this problem, analyse different perspectives, summarize knowledge through targeted research – interviews & small experiments and put potential solution strategies into discussion.

 

Medical Situation In Austria

The functioning and the task of a welfare state are determined by consensus and the balance of power within a society; while in the United States of America, for example, private self-responsibility is the focus, whilst especially in the second republic, for example under the administration of Bruno Kreisky, the idea of ​​collective responsibility, the welfare state that we know and appreciate today, emerged. In this case, word is in particular about the intergenerational contract, corresponding to the financing of one’s own retirement provision by the next generation, the education and upbringing mandate of the federal government, i.e. the growing up of the coming generations, the building and maintenance of infrastructure, not only in a material sense, but also, and most importantly in the context of this work, the healthcare of the population. The federal government’s expenditure on concerns in the health sector and also in nursing care corresponds to 11% of  our GDP [gross domestic product]; Austria therefore belongs to the lower end of the European top field. In addition, it should be noted that around three-quarters of all expenditures for health care come from the public sector. In this case, a publicly financed social system brought about by the taxpayer facilitates a favorable social balance.

This corresponds to right of the Hippocratic Oath; Even if this 2000 year old legacy is no longer legally effective today, the Geneva Vow, the declaration of the World Medical Association, elaborates on this quite a bit. With the quoted statement: “The health and well-being of my patient will be my top priority. (…) I will not allow age, illness or disability, belief, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social status or any other factor to intervene between my duties and my patient . “; is still considered to be the fundamental right of every patient and also has priority in most social systems.

 

Overload of ambulances and emergency rooms

 

“Overloaded emergency ambulances are generally a problem; Over the years I can simply remember that before Christmas – New Year’s Eve – New Year’s – Three Kings there was always a very tense feeling, because you know that the doctor’s offices are very poorly occupied, and therefore the clinics are overflowing; (…) some patients also come to the hospital because they do not want to process the referrals from a general practitioner or pediatrician and simply hope that everything will be taken care of in the hospital. [Children’s emergency ambulance; University Hospital AKH Vienna] Experience report by Judith Schuran, a qualified nurse with triage training from the University Hospital Vienna General Hospital, in an interview on May 21, 2021.

 

In 2016 alone, “8,551,135” people were treated in Austria’s emergency rooms; which theoretically corresponds to a one to one [1:1] ratio of the total population. As mentioned before, this also depends on the time of day and the season; Especially when in the afternoon the civil servant traffic in various outpatient clinics ends in the whole country and therefore most patients have to be transfered to the twenty-four hour general and emergency room. In very severe cases it can even lead to a ward block [blockage of the emergency room], with the result that no further patient can be admitted and treated; In this case, emergency services would have to use the nearest hospital. At the moment, this is still a rare complication, but such events have already occurred in Austria, for example on November 21, 2017 at the St. Pölten University Hospital. Not far, this also leads to a financial loss for the hospital operator;

 

“Contrary to popular belief, insurance does not simply cover the costs when a patient is treated in an emergency room or outpatient department. Instead, state gov. and insurance companies share the costs (…) This increase in costs is particularly problematic for hospital operators. Because in a majority of the federal states (Austria) a flat rate is paid for outpatient treatment, the services actually provided are not rewarded. “

Stefanie Braunisch; Gabriel Hellmann; Stefan Gavac; “Overrun and underfunded” [Editorial Addendum] (2018); https://www.addendum.org/ambulanzen/ueberlaufen-und-unterfinanziert/; Last access: 01.06.2021

 

For example, in 2016, “€66,178,970.00” was spent in the state of Vorarlberg for outpatient treatment, while in fact only “€46,256,965.94” was paid for by the state, federal government and insurance companies. In Vienna this minus ratio is as much as ~ 470 million in the same year. The financing, which among other things had to be earned again through other sources of income, such as inpatients.

 

The Cause?

The causes for the overload of emergency rooms are diverse and depend particular on the prevailing social system. Of course, this is followed by the offer close to the home, the financing, the exhaustion of resources and, in particular, the presence of specialist staff with an awareness of publicly accessible health. However, the point of the incapable patient in the system is exceedingly relevant for this work; “In Austria, patients can assign themselves – around the clock. There is no orientation or guidance of the patient through the system. ”; Since this is of particular relevance in the social medical experiment explained below, with reference to the connection between hypochondria and cyberchondria.

In this case, it must first be explained what hypochondria, and in particular cyberchondria, stands for. Basically, a hypochondriac is a patient who takes an attitude towards his own health that is incomprehensible to outsiders; Assess ones own symptoms incorrectly and exaggeratedly in the given case. In this somatoform disorder, there is constant concern about one’s own health, whether it is to develop serious illnesses or to have already had them; These symptoms are not imagined, but insignificant ailments which are overestimated and misinterpreted, for example, as a symptom of a serious illness. The symptom picture of “cyberchondria” supplements the existence of the hypochondriac with the flood of knowledge through the World Wide Web; “Googling” symptoms and the resulting misdiagnosis of simple health conditions.

 

Experiment

On the platform “Netdoktor.de” [resp. “Netdoktor.at” Austria] medical advice is provided with reference to editorial medical journalism. Legally secured by the imprint: “The information must under no circumstances be viewed as a substitute for professional advice or treatment by trained and recognized doctors. The content of NetDoktor.de cannot and must not be used to independently make diagnoses or start treatments. © Copyright 2021 NetDoktor.de – All rights reserved – NetDoktor.de is a trademark ”; An application for the digital symptom check is offered at https://www.netdoktor.de/symptom-checker/. In the following experiment, using a META example or a fictitious patient -X-, with the help of statistical data analysis of the most common health insurance assignments in the German-speaking area, a potential input in that application is faked. On the basis of the standardized health insurance illness assignments mentioned, a potential catalog of symptom schemes was evaluated in a moderated brainstorming session; The test person, Alexandra Schmied, truthfully and without being biased, added the following experiment [More to read in the scientific work, see download link]

 

Experiment Results

In the general assessment it can be confirmed that each of the 30 taken diagnoses could match the indicated symptoms. However, it should be noted that a statistical and socio-medical probability must be included, because an accurate anamnesis, referring to age, gender, symptoms, previous illnesses and family history, is essential for an initial assessment. After summarizing this experiment, it is clear that the majority of the diagnoses were too imprecise or, in the case of a diagnosis made by “artificial intelligence”, with reference to the triviality of the query, the diagnoses were “too precise”. In figure 1.1, referring to the circle diagram, a percentage overhang of diagnostics in the area of ​​emergency medicine can be seen; These include diseases that require acute medical care, such as pulmonary embolism or life-threatening diseases, which are not an “emergency” at the moment but must be treated, see example coronary heart disease, as well as diseases that are among all Circumstances require rapid diagnosis and treatment.

 

 

This can be compared with figure 1.2, in which the distribution ratio between clearly demonstrable diseases and imprecise and unprovable diagnoses is explained. Added to this, 19 out of 30 diagnoses could be assigned to the area “need for further medical diagnostics”. Therefore, according to the recommendation of the “symptom checker”, a “specialist” must be consulted for almost two thirds of all diagnoses relating to conventional and insignificant health situations.

 

This now opens up the question of whether the potential test subject “X” received more information or even more uncertainties through the digital symptom check-up. The next question is how a potential patient “X”, would react to such diagnoses, regardless of the Netdoktor.de “Symptom Checker”. Above all, the facts must be clarified to what extent a test person is allowed to take responsibility for himself / herself in the context of human medicine. “For many people, information on the Internet about clinical pictures and symptoms can be helpful. (…) In people who already have a tendency to fear illnesses, however, the tendency to hypochondria increases. Through online research, they become more and more convinced that they are seriously ill. Even if the illness found on Google only occurs very rarely, those affected are convinced that they are ill with it.” So what would happen if the emergency service was called, or the test subject drove straight to the emergency room, respectively consulted  specialist?

 

Ambulance / emergency service [example Viennese professional rescue]
Ordinance of the Vienna City Council regarding the setting of fees in accordance with §§ 28 Paragraph 3 and 29 Paragraph 4 of the Vienna Rescue and Ambulance Transport Act – WRKG
 
 
 
 
~694,00€
electrocardiogram
>38,00€
Blood analysis / ex. Complete blood count
>14,00€
Ultrasound examination of the abdomen and kidneys
>147,00€
Cardiac ultrasound examination [echocardiography]
>135,00€
total
~1082,00€
Source: Salzburg Medical Association editorial office; All-round care … health check-up (2021); https://www.aeksbg.at/gesundheitsaktion/rundumvorsorge#:~:text=Gro%C3%9Fes%20Blutbild%20%E2%82%AC%2014%2C%2D%2D; Last access: June 9th, 2021

 

In this simplified example the cost and performance calculation, referring to the treatment of trivial symptoms, such as chest pain / vertigo / nausea / tachycardia and similar, can be used to describe the invoice an outpatient department or emergency department has to face. It should be emphasized that this is an example and that the costs can change with each case of illness; Depending on the situation and the symptoms present, other diagnostic methods can be performed. For example, an additional CT examination would result in additional expenses by a factor of > 150.00 € whilst an MRT examination would start at around 220.00 €. The generated minus of the ambulances and emergency rooms is partly borne by the budget of the federal government, or for example in the state of Burgenland, it is no longer paid out as a deficit, since the provided flat rate would not be enough either way. Twenty years after the development of the “performance-oriented financing”, a matching payment catalog for outpatient services was made available in order to be able to guarantee more transparency in billing.

 

A Solution?

Both the Federal Curia of employed doctors and the interview partner Judith Schuran [Nurse / AKH Vienna] confessed to the clearing of the general population regarding self-assessment of ones own health situation and the available local offer. Among other things, it is stated that there is no clear orientation for the patient through the system. This includes the “referral system”, i.e. the step-by-step sequence of doctor visits, and the fact that there is a free choice of doctors in Austria and, accordingly, various outpatient clinics and emergency rooms can be visited without consultation. This is followed by the fact that there may also be a need for clarification on the part of the patient himself, which affects both orientation in the system itself and self-assessment in the event of illness. On top of that, as it turned out after this interview with Judith Schuran, there is also a further approach; There are approaches to establish in-house general practitioners belonging to the hospital, for the treatment of non-acute illnesses:

“(…) a new system has now been established at the children’s clinic [AKH Vienna], where a pediatrician is on duty at weekends (…), and I have to honestly admit that after initial difficulties, where parents refused to go to this doctor because they absolutely wanted to see hospital staff, this system is now working extremely well! “, Judith Schuran [Nurse / AKH Vienna]

Accordingly, such a system also promises to relieve the emergency department, since a general practitioner can be consulted for medical care regardless of the day of the week and the time. This system is currently used in Vienna by the University Hospital Vienna General Hospital and additional primary care centers such as in the Clinic Donaustadt [SMZ-Ost; Social Medicine Center East.].

 

Discussion & Findings

The overload of emergency rooms, ambulances, resident doctors and hospitals is an omnipresent problem. This problem includes, among other things, patients who do not have a sufficient self-assessment of their own state of health, the lack of offers close to their home, the opening times of ordinations and outpatient clinics that are no longer adequate for today, and resource management with reference to financial support from the state.

Circumstances such as “fear of illnesses” do not positively counteract this problem. Accordingly, highly specialized medical expertise in tabloid journalism can encourage the creation and growth of misunderstandings, myths and false statements in a pathological reality. Lay knowledge about medicine and other specialist knowledge can lead to a misinterpretation of one’s own state of health; Symptoms could be misinterpreted and accordingly lead to inadequate or even wrong decisions and actions. This fact can also be described in this extreme under the terms hypochondria, if one takes an incomprehensible attitude towards one’s own health, and the corresponding counterpart of cyberchondria.

The resulting combination and the action of exogenous circumstances, for example the failure of the intergenerational contract due to higher life expectancy and rent disbursements that do not correspond to the amount of the deposit, inevitably lead to an overload of the social medical care system. For this, various reasons and, based on them, potential solutions are discussed. Potential solution approaches include factors that, under possible circumstances, promote better management of the system, promote education with regard to self-assessment in health issues, and answer questions about medical services that are close to home and available on a timely basis. Examples of potential solutions can be found here in the University Hospital Vienna General Hospital, where a general medical outpatient clinic was established, which is more flexible in terms of time, is available for trivial medical questions at the aforementioned interface [ex. Children’s clinic; Interview], or possible health centers and day care centers that can take over the extensive areas of general medical care and diagnostics; See the example of the Donaustadt primary care center [SMZ-Ost].

In order to continue to be able to guarantee high quality medical care in a time of demographic change and growth [see example generation contract, etc.] it is recommended to devote oneself to the ravages of time and to set the course before the system collapses!

 


Download Full Version [german]

https://21ws.net/wp-content/uploads/erf_uploads/2021/08/WissenschaftlichesArbeiten_SS2021_TiborSpath.pdf

Scientific work prepared for: New Design University, Private University St.Pölten [A]


Author & Intellectual Property (C) of Tibor Spath / August 2021


 

(C) 21ws.net

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