Advertisement
Comparative-Effectiveness Research/HTA| Volume 23, ISSUE 9, P1142-1148, September 2020

Download started.

Ok

Are Unit Costs the Same? A Case Study Comparing Different Valuation Methods for Unit Cost Calculation of General Practitioner Consultations

Open AccessPublished:July 27, 2020DOI:https://doi.org/10.1016/j.jval.2020.06.001

      Highlights

      • No internationally accepted gold standard for unit cost calculation exists. Different analytical methods have been applied in the United Kingdom, The Netherlands, and Germany as part of their national unit cost programs.
      • Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates.
      • The study drew on Austrian data for calculating the unit cost of general practitioner consultations. Based on 6 different methodological approaches, large variations (+173%) in unit cost estimates were observed.
      • More reflection on data sources and unit costing methodology should be devoted in health economic evaluations to achieve more valid and comparable cost estimates.
      • Future research should support the development of internationally and inter-sectorally harmonized unit costing methods.

      Abstract

      Objectives

      To inform allocation decisions in any healthcare system, robust cost data are indispensable. Nevertheless, recommendations on the most appropriate valuation approaches vary or are nonexistent, and no internationally accepted gold standard exists. This costing analysis exercise aims to assess the impact and implications of different calculation methods and sources based on the unit cost of general practitioner (GP) consultations in Austria.

      Methods

      Six costing methods for unit cost calculation were explored, following 3 Austrian methodological approaches (AT-1, AT-2, AT-3) and 3 approaches applied in 3 other European countries (Germany, The Netherlands, United Kingdom). Drawing on Austrian data, mean unit costs per GP consultation were calculated in euros for 2015.

      Results

      Mean unit costs ranged from €15.6 to €42.6 based on the German top-down costing approach (DE) and the Austrian Physicians’ Chamber’s price recommendations (AT-3), respectively. The mean unit cost was estimated at €18.9 based on Austrian economic evaluations (AT-1) and €17.9 based on health insurance payment tariffs (AT-2). The Dutch top-down (NL) and the UK bottom-up approaches (UK) yielded higher estimates (NL: €25.3, UK: €29.8). Overall variation reached 173%.

      Conclusions

      Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates. It shows large variations with potential impact on the conclusions in an economic evaluation. Although different methodological choices may be justified by the adopted study perspective, different costing approaches introduce variation in cross-study/cross-country cost estimates, leading to decreased confidence in data quality in economic evaluations.

      Keywords

      Introduction

      To inform allocation decisions in healthcare systems, reliable and valid cost data based on methodologically sound unit cost information are indispensable. Unit costs are commonly defined as the value of all resources required to produce a service, divided by the level of activity the service generates.

      Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.

      International research shows that depending on the methodological approaches, huge variations between unit cost estimates for healthcare services may arise.
      • Jacobs J.C.
      • Barnett P.G.
      Emergent challenges in determining costs for economic evaluations.
      • Clement (nee Shrive) F.M.
      • Ghali W.A.
      • Donaldson C.
      • Manns B.J.
      The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches.
      • Heerey A.
      • McGowan B.
      • Ryan M.
      • Barry M.
      Microcosting versus DRGs in the provision of cost estimates for use in pharmacoeconomic evaluation.
      • Shrestha R.K.
      • Sansom S.L.
      • Farnham P.G.
      Comparison of methods for estimating the cost of human immunodeficiency virus–testing interventions.
      Ultimately, this variation may affect the conclusions drawn from the economic evaluation. Yet existing guidelines provide little specific detail on appropriate costing sources and unit cost calculation methods.
      • Mayer S.
      • Kiss N.
      • Łaszewska A.
      • Simon J.
      Costing evidence for health care decision-making in Austria: a systematic review.
      Generally, it is accepted that depending on the specific service and its role in the economic evaluation, different costing methods and sources may be appropriate.
      • Mogyorosy Z.
      • Smith P.
      The main methodological issues in costing health care services: a literature review. CHE Research Paper 7.
      ,
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      From an economic perspective, unit costs should ideally capture the sacrifice made or the benefit forgone when a resource is consumed and hence not any more available for its best alternative use, that is, the opportunity cost,
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      ,
      • van Lier L.I.
      • Bosmans J.E.
      • van Hout H.P.J.
      • et al.
      Consensus-based cross-European recommendations for the identification, measurement and valuation of costs in health economic evaluations: a European Delphi study.
      also referred to as the economic cost.
      • Barnett P.G.
      An improved set of standards for finding cost for cost-effectiveness analysis.
      In a perfectly competitive, free market, this cost is reflected in the market price. The healthcare system, however, features few of the characteristics of a free market and is prone to market failure. Consequently, government interventions are considered necessary, for example, through price regulation.
      To make costing data for healthcare-related services more standardized and readily accessible, several countries have introduced national unit cost libraries, including the United Kindgom,
      New Economy
      Unit cost database.
      • Curtis L.
      • Burns A.
      Unit costs of health and social care 2015. Personal Social Services Research Unit.
      UK Department of Health
      NHS reference costs collection.
      The Netherlands
      • Oostenbrink J.B.
      • Koopmanschap M.A.
      • Rutten F.F.
      Standardisation of costs: the Dutch Manual for Costing in economic evaluations.
      • Hakkaart-van Roijen L.
      • Tan S.
      • Bouwmans C.
      Manual for cost research, methods and standard charges for economic evaluations in health care.
      • Tan S.S.
      • Bouwmans C.A.
      • Rutten F.F.
      • Hakkaart-van Roijen L.
      Update of the Dutch Manual for Costing in Economic Evaluations.
      • Oostenbrink J.
      • Bouwmans C.
      • Koopmanschap M.
      • Rutten F.V.
      Manual for cost research, methods and standard charges for economic evaluations in health care.
      and Germany.
      • Krauth C.
      • Hessel F.
      • Hansmeier T.
      • Wasem J.
      • Seitz R.
      • Schweikert B.
      Empirical standard costs for health economic evaluation in Germany -- a proposal by the working group methods in health economic evaluation [in German].
      • Krauth C.
      Methods of health economic evaluation for health services research [in German].
      Universität Hamburg: Netzwerk “Methoden der Messung der Inanspruchnahme von Gesundheitsleistungen und Kosten im Alter”: Modul B: Erstellung einer Datenbank für “unit costs” von Gesundheitsleistungen.
      The calculation of the listed unit costs follows a systematic methodology and is usually accompanied by a transparent description. In Austria, alternative sources for valuation including fees (tariffs/charges), tariff catalogs, and other administrative prices are recommended by the current pharmacoeconomic guideline (2006).
      • Walter E.
      • Zehetmayr S.
      Economic evaluation guidelines. Institut für Pharmaökonomische Forschung Vienna.
      Such data may capture the costs from the analytical perspective of the payer, that is, the expenses made to fund such service provision. These expenses, however, do not necessarily equal the economic costs that arise in the service provision, because fees might be based on political negotiations rather than actual cost estimates. The methodological handbook for Austrian Health Technology Assessment (2012) points out that some experts therefore find market prices based on services funded by private insurances a more appropriate cost source instead.
      Gesundheit Österreich GmbH, Bundesinstitut für Qualität im Gesundheitswesen: Methods handbook for Health Technology Assessment version 1.
      If appropriate unit costs are not readily available from existing sources, they can be calculated based on top-down or bottom-up approaches.
      • Olsson T.M.
      Comparing top-down and bottom-up costing approaches for economic evaluation within social welfare.
      In top-down costing, aggregate expenditures are assigned to individual services based on a defined metric. In bottom-up approaches, total costs are derived based on person-level service use information combined with costs.
      • Chapko M.K.
      • Liu C.F.
      • Perkins M.
      • Li Y.F.
      • Fortney J.C.
      • Maciejewski M.L.
      Equivalence of two healthcare costing methods: bottom-up and top-down.
      In its most precise form, that is, micro-costing, each component of resource use associated with the production of a service is estimated, valued, summed up, and then divided by the given unit of analysis (eg, per contact, per patient) to derive the unit cost.
      For Austria, a first unit cost library was set up by the Department of Health Economics (Center for Public Health) at the Medical University of Vienna in 2016 and has been regularly updated since.
      Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
      The Department of Health Economics Unit Cost Online Database is a publicly accessible compilation of unit costs (currently 2004-2019) retrieved from Austrian costing studies and economic evaluations identified in a systematic review of the peer-reviewed and gray literature.
      • Mayer S.
      • Kiss N.
      • Łaszewska A.
      • Simon J.
      Costing evidence for health care decision-making in Austria: a systematic review.
      Although the database is a very limited step toward the systematic publication of cost data, an average of around 70 external downloads yearly and a total of 250 downloads (as of October 2019) emphasize the need for and interest in the collection of (standardized) unit costs at national level.
      In Austrian health economic analyses, unit costs are commonly taken from various administrative sources. Little reflection is typically given to the costing approach and unit cost sources,
      • Mayer S.
      • Kiss N.
      • Laszewska A.
      • Simon J.
      Health economic costing methods and reporting in Austria.
      similarly to other European countries where standardized unit cost catalogs are not available.
      • Brodszky V.
      • Beretzky Z.
      • Baji P.
      • et al.
      Cost-of-illness studies in nine Central and Eastern European countries.
      Nevertheless, the impacts of the different sources and costing approaches on the unit cost estimates have not been comprehensively investigated so far.
      This article intends to determine whether different methodological approaches for unit cost calculation and publicly available unit cost sources are valid substitutes for each other, drawing on the example of general practitioner (GP) consultations in Austria. This example was chosen to reflect the frequency of information need as determined by the number of different unit cost estimates listed in the DHE Unit Cost Online Database. Overall, in Austria, 1 of 5 health economic analyses (n = 14, 19%) were found to rely on 1 or more GP visit-related unit costs.
      Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
      This article, therefore, addresses 2 research objectives. Firstly, the costing analysis exercise aims to increase awareness of relevant methodological issues to be considered in upcoming health economic studies and intends to inform future methodological discussions about different unit costing methods. Secondly, it aims to determine the unit cost of a single-practice GP consultation in Austria based on different Austrian and other European costing approaches to support future empirical economic evaluations and national decision making.

      Methods

      Institutional Background

      In Austria, 99% of the population is covered by the mandatory health insurance system. Affiliation with one (or more) health insurance funds is determined by the individual’s residence or type of profession. Until recently, 19 insurance funds were in place, that is, 9 regional health insurance funds, 4 occupational health insurance funds, and 6 company health insurance funds. At the time of writing this article, a healthcare reform is ongoing, combining the regional health insurance funds as well as the company insurance funds into one fund and merging the occupational funds into another one. This reform will be effective from 2020 onward.
      Ambulatory care in freestanding physician practices is provided by contracted and non-contracted GPs and specialists, who are self-employed and mostly operate in single practices. Contracted physicians are in a contractual relationship with 1 or more health insurance funds, whereas this does not apply to non-contracted physicians.
      • Czypionka T.
      • Röhrling G.
      • Mayer S.
      The relationship between outpatient department utilisation and non-hospital ambulatory care in Austria.
      ,
      • Gächter M.
      • Schwazer P.
      • Theurl E.
      • Winner H.
      Physician density in a two-tiered health care system.
      Reimbursement of contracted GPs is based on tariff catalogs, which at the time of writing were negotiated between the health insurance funds and the 9 regional chambers of physicians, respectively, and approved by the Main Association of the Austrian Social Security Institutions. Tariff catalogs of the different health insurance funds seem mostly comparable regarding the included and reimbursed core services; however, they differ regarding the tariff value for comparable tariff positions and the extent of patient copayments.
      Contracted and non-contracted physicians can be consulted by any insured person. For non-contracted physician consultations, however, a maximum of 80% of the official health insurance fund tariff may be claimed by the patient for reimbursement. Around 36.5% of Austrians have complementary private health insurance, which may potentially cover these expenses.
      • Bachner F.
      • Bobek J.
      • Habimana K.
      • et al.
      Austria: health system review.
      Non-contracted physicians may determine their prices freely, but the regional physicians’ chambers provide price recommendations for some services. Although these recommendations are nonbinding, they are also used in case of legal disagreements between physicians and patients to judge the appropriateness of the charged price.
      • Tirol Ärztekammer
      Practice-based physicians: non-contracted physicians.

      Unit Costing Approaches

      To determine the potential variations owing to methodological differences in a unit cost, 6 methodological approaches (AT-1, AT-2, AT-3, DE, NL, UK) were explored in this costing analysis exercise of a GP consultation in Austria. All estimates are based on Austrian data. All calculations were further validated by the team of authors following consultation with the data provider where necessary. Calculations based on the 3 approaches applied in 3 other European countries (DE, NL, UK) were informed by the descriptions and explanations provided in the given unit cost libraries, methods handbooks, and electronic online tools.

      Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.

      ,
      Personal Social Services Research Unit
      Preventonomics Unit Cost Calculator (PUCC).
      Cost data including tariffs were obtained for the year 2015, or inflated to 2015 where necessary using the medical component of the consumer price index.
      Statistics Austria
      Health expenditure in Austria according to “System of Health Accounts”.
      Microsoft Excel was used for all calculations.
      Method AT-1 investigates the non–disease-specific GP unit cost information reported in published Austrian health economic evaluations. Relevant data were retrieved from the DHE Unit Cost Online Database
      Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
      (version 2.1) and in line with earlier studies,
      • Farag I.
      • Sherrington C.
      • Ferreira M.
      • Howard K.
      A systematic review of the unit costs of allied health and community services used by older people in Australia.
      ,
      • Graham B.
      • McGregor K.
      What does a GP consultation cost?.
      a mean unit cost was calculated.
      Method AT-2 resembles the basic approach of the Austrian Main Association of Social Security Institution’s internal meta tariff system (Metahonorarordnung).
      Gesundheit Österreich GmbH, Bundesinstitut für Qualität im Gesundheitswesen: Methods handbook for Health Technology Assessment version 1.
      The meta tariff system is a nonpublic database implemented in 1995. It is organized as unified service catalog and includes around 1600 service positions,
      Gesundheit Österreich GmbH, Bundesinstitut für Qualität im Gesundheitswesen: Methods handbook for Health Technology Assessment version 1.
      but generally does not include tariffs. It is based on the service positions included in the tariff catalogs of the 9 regional health insurance funds as well as the (nationwide valid) tariff catalogues of the 3 larger occupational health insurance funds.
      • Markaritzer K.
      New tariff system.
      To develop a costing approach similar to the setup of the meta tariff system and calculate an average GP tariff across health insurance funds, a variety of assumptions had to be made. This was necessary since the different tariff catalogs are not fully comparable in their structure, included services, definitions, reimbursement schemes, and periods.
      • Wilbacher I.
      • Schröder J.
      Combination of differen documentation systems.
      A weighted mean reflecting insured people across the 9 regional health insurance funds was calculated. This approach covers tariffs relevant for more than 3 quarters of the entitled Austrian population; however, it excludes 3 other health insurance funds that are covered in the official meta tariff system. This may result in an underestimation, because these 3 health insurance funds are considered to pay higher tariffs in general. At the same time, their reimbursement schemes cover 1 month rather than 1 quarter as for the regional health insurance funds, which would impede the overall comparability. Beside the publicly available information, relevant health insurance funds were contacted and asked for clarification where necessary.
      Method AT-3 is based on the (nonbinding) price recommendations by the regional physicians’ chambers for non-contracted physicians. A non-weighted mean of recommended GP consultation prices was calculated using available information published by 6 regional physicians’ chambers.
      Method DE follows the German top-down approach of GP unit cost calculation,
      • Krauth C.
      • Hessel F.
      • Hansmeier T.
      • Wasem J.
      • Seitz R.
      • Schweikert B.
      Empirical standard costs for health economic evaluation in Germany -- a proposal by the working group methods in health economic evaluation [in German].
      ,
      • Bock J.
      • Brettschneider C.
      • Seidl H.
      • et al.
      Calculation of standardised unit costs from a societal perspective for health economic evaluation [in German].
      adjusted for system differences between Germany and Austria. The sum of all reimbursed GP tariffs for year 2015 as published in the Austrian physicians’ cost statistics (Ärztekostenstatistik) was divided by the total annual number of registered GP consultations to calculate the average cost per consultation.
      Method NL is in line with the Dutch bottom-up calculation method for standard costs.
      • Oostenbrink J.B.
      • Koopmanschap M.A.
      • Rutten F.F.
      Standardisation of costs: the Dutch Manual for Costing in economic evaluations.
      ,
      • Hakkaart-van Roijen L.
      • Van der Linden N.
      • Bouwmans C.
      • Kanters T.
      • Tan S.
      Manual for cost research, methods and standard charges for economic evaluations in health care.
      The mean annual reimbursement per GP based on tariffs (physicians’ costs statistics, 2015) was used in a first step. This number was then divided by the average annual working time taken from a GP survey conducted in 2011 to 2012
      • Hoffmann K.
      • Wojczewski S.
      • George A.
      • Schäfer W.L.
      • Maier M.
      Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      and an additional source,
      • Pirich E.
      • Allen E.
      What may the price of health be? [in German].
      and adjusted for GP-reported patient-related time (81%)
      • Hoffmann K.
      • Wojczewski S.
      • George A.
      • Schäfer W.L.
      • Maier M.
      Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      to calculate the hourly cost of a direct patient contact. Based on an estimate of 9.1 minutes as average consultation time,
      • Hoffmann K.
      • Wojczewski S.
      • George A.
      • Schäfer W.L.
      • Maier M.
      Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      a mean unit cost per consultation was derived.
      Method UK is based on the UK micro-costing–like bottom-up approach.
      • Curtis L.
      • Burns A.
      Unit costs of health and social care 2015. Personal Social Services Research Unit.
      Firstly, average GP income (before tax) including additional revenues and running costs was calculated. Specifically, income before tax derived from the average GP remuneration from health insurance funds and additional revenues (+18%, based on an estimate by the Ministry of Finance and the Main Association of Social Security Institutions)
      • Waldner G.
      Trends in reimbursements of practice-based outpatient physicians in Austria, Germany and The Netherlands.
      were added. Running costs were calculated as a share of income before tax plus additional revenues (63.0% in 2015), based on assumptions made in earlier studies.
      • Waldner G.
      Trends in reimbursements of practice-based outpatient physicians in Austria, Germany and The Netherlands.
      In line with the Dutch approach, this sum was divided by the average annual working hours and adjusted by the percentage of direct, patient-related time.
      • Hoffmann K.
      • Wojczewski S.
      • George A.
      • Schäfer W.L.
      • Maier M.
      Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      The unit cost of a consultation was calculated based on the average patient contact duration.
      • Hoffmann K.
      • Wojczewski S.
      • George A.
      • Schäfer W.L.
      • Maier M.
      Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.

      Results

      Table 1 provides an overview of the calculated (mean) GP unit costs (year 2015) based on the 3 Austrian methodological approaches and the 3 methodological approaches applied in 3 other European countries using Austrian data. The different unit cost estimates range between €15.6 and €42.6, amounting to a variation of 173%.
      Table 1Unit cost of a GP visit in Austria based on 3 Austrian methodological approaches and 3 approaches applied in 3 other European countries (2015).
      MethodInput estimates (in euro for year 2015) and their sourcesUnit cost (in euro for year 2015)
      • 1.
        AT-1
      • -
        €27.70 (€25.00, 2010; original source unclear)
        • Schroettner J.
        • Lassnig A.
        Simulation model for cost estimation of integrated care concepts of heart failure patients.
      • -
        €20.43 (€15.99, 2003; original source Wiener Gebietskrankenkasse [WGKK])
        • Howard P.
        • Knight C.
        A clinical-and cost-effectiveness comparison of venlafaxine and selective serotonin reuptake inhibitors (SSRIs) in the management of patients with major depressive disorder from the perspective of an Austrian sickness fund.
      • -
        €20.11 (€16.74, 2005; original source expert advice)
        • Canonica G.W.
        • Poulsen P.B.
        • Vestenbaek U.
        Cost-effectiveness of GRAZAX for prevention of grass pollen induced rhinoconjunctivitis in Southern Europe.
      • -
        €20.05 (€18.10, 2010; original source Vienna Health Insurance Fund)
        • Moertl D.
        • Steiner S.
        • Coyle D.
        • Berger R.
        Cost-utility analysis of NT-proBNP-guided multidisciplinary care in chronic heart failure.
      • -
        €16.48 (€13.72, 2005; original source Metahonorarordnung des Hauptverbandes der österreichischen Sozialversicherungsträger, Metahonorarordnungs-Leistungsart: 0102)
        • Stoppacher A.
        Cost-effectiveness analysis of influenca vaccination in Austria. Medizinische Universität Graz.
      • -
        €15.58 (€15.00, €11.00-19.00, 2013; original source Anfrage beim Hauptverband der österreichischen Sozialversicherung)
        • Fischer S.
        • Tüchler H.
        • Piso B.
        Outpatient cardiac rehabilitation programme: economic evaluation. LBI-HTA Projektbericht.
      • -
        €11.75 (€10.00, 2007; original source Hauptverband der österreichischen Sozialversicherungsträger, 2007, Honorarordnungsdatenbank - Einzelauswertung)
        • Zechmeister I.
        • Blasio B.F.
        • Garnett G.
        • Neilson A.R.
        • Siebert U.
        Cost-effectiveness analysis of human papillomavirus-vaccination programs to prevent cervical cancer in Austria.
      18.9
      • 2.
        AT-2
      17.9
      • 3.
        AT-3
      42.6
      • 4.
        DE
      • -
        €1 059 586 588.00 total annual turnover for contracted GPs from tariffs

        Physicians’ cost statistics [Ärztekostenstatistik 2015]. Data access Austrian Public Health Institute. https://goeg.at/. Accessed May 2020.

      • -
        67 911 797 registered consultations

        Physicians’ cost statistics [Ärztekostenstatistik 2015]. Data access Austrian Public Health Institute. https://goeg.at/. Accessed May 2020.

      15.6
      • 5.
        NL
      • -
        €257 056.00 total annual turnover per GP from tariffs

        Physicians’ cost statistics [Ärztekostenstatistik 2015]. Data access Austrian Public Health Institute. https://goeg.at/. Accessed May 2020.

      • -
        1903 (42 weeks ∗ 45.3 hours per week) annual working time
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
        ,
        • Pirich E.
        • Allen E.
        What may the price of health be? [in German].
      • -
        81% direct, patient-related time
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      • -
        9.1 consultation time per visit
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      25.3
      • 6.
        UK
      • -
        €303 326.08 (income before tax and additional revenues
        • Cheung K.L.
        • Evers S.
        • De Vries H.
        • et al.
        Most important barriers and facilitators of HTA usage in decision-making in Europe.
        including 60% running costs), average per GP
      • -
        1903 (42 weeks ∗ 45.3 hours per week) annual working time
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
        ,
        • Pirich E.
        • Allen E.
        What may the price of health be? [in German].
      • -
        81% direct, patient-related time
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      • -
        9.1 consultation time per visit
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
      29.8
      Note. Source: Own compilation. All values are presented for 2015 and were adjusted for inflation using the medical component of the consumer price index where necessary.
      Statistics Austria
      Health expenditure in Austria according to “System of Health Accounts”.
      GP indicates general practitioner.

      Austrian Methodological Approaches

      A total of 16 GP consultation–related unit costs were identified in the DHE Unit Cost Online Database (method AT-1). Of these, 7 unit costs referred to non–disease-specific consultations in a physician practice and were assessed further. In one case, the specific source of the unit cost was unclear, while in another case, it was merely described as expert advice. In 2 studies, the tariff catalog of the Viennese health insurance fund was used as unit cost source. In 3 studies, information was taken from the Main Association of Social Security Institutions. The mean unit cost per (first) consultation was estimated at €18.9 with reported unit costs ranging between €11.7 and €27.7.
      Based on data retrieved from the health insurance fund tariff catalogs for the first patient contact and relevant calculations yielding estimates between €9.8 and €28.7, the mean unit cost of a GP consultation in Austria was calculated at €17.9 (method AT-2).
      The recommended prices for non-contracted GP consultations amounted to €42.6 on average (minimum: €35.2, maximum: €50.4) (method AT-3).

      Methodological Approaches Applied in 3 Other European Countries

      Adopting the German costing methodology (method DE), the estimated unit cost per GP consultation was €15.6. Following the Dutch methodology (method NL), the average cost per GP consultation was estimated at €25.3. Based on the UK bottom-up micro-costing approach (method UK), the average unit cost was €29.8. This estimate could be reproduced with the UK Preventonomics Unit Cost Calculator.

      Discussion

      This is the first study comparing 6 different unit costing methodological approaches within the same context to investigate relevant variations and impacts on the resulting unit cost estimates using the average cost of a GP consultation in Austria as case study. Beside the undoubted national importance of the empirical results, the study also serves as a first methodological case example internationally. Large variations between the estimates driven by conceptual and methodological differences were identified. It is therefore not surprising if the limited acceptance and uptake of health economic evidence by policy makers is often driven by lack of confidence in data quality or robustness of the underlying value concepts.
      • Cheung K.L.
      • Evers S.
      • De Vries H.
      • et al.
      Most important barriers and facilitators of HTA usage in decision-making in Europe.
      ,
      • Feig C.
      • Cheung K.L.
      • Hiligsmann M.
      • Evers S.
      • Simon J.
      • Mayer S.
      Best-worst scaling to assess the most important barriers and facilitators for the use of health technology assessment in Austria.
      From a theoretical viewpoint, several aspects determine the appropriateness of different costing methodologies, including the purpose of the costing analysis exercise, the type and complexity of the health service, and requirements of generalizability and representativeness.
      • Mogyorosy Z.
      • Smith P.
      The main methodological issues in costing health care services: a literature review. CHE Research Paper 7.
      Furthermore, the adopted analytical viewpoint (eg, provider, third-party payer, patient, or societal perspective) defines which cost components are to be potentially included in an analysis (eg, healthcare costs, out-of-pocket expenses, costs arising in other sectors).
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      In addition, the analytical viewpoint determines which sources are appropriate to value the resource use.
      • Jacobs J.C.
      • Barnett P.G.
      Emergent challenges in determining costs for economic evaluations.
      ,
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      ,
      • Mayer S.
      • Kiss N.
      • Laszewska A.
      • Simon J.
      Health economic costing methods and reporting in Austria.
      This point is very clearly illustrated by the different methodological approaches explored in this case study. The unit costs listed in the DHE Unit Cost Online Database (method AT-1) were all used in economic evaluations conducted from the public payer or the societal perspective. In 1 case, GP unit costs were retrieved from the Main Association of the Social Security Institution, thus reflecting costs from the payers’ viewpoint but not necessarily economic costs in the opportunity cost sense.
      Sensor Marktforschung
      Attitudes towards the current primary health vcare system: group discussion with medical students.
      Although a tariff might not bill all relevant costs for the service, it may capture the most relevant information from the payer perspective.
      • Mogyorosy Z.
      • Smith P.
      The main methodological issues in costing health care services: a literature review. CHE Research Paper 7.
      ,
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      At the same time, since tariffs are eventually funded through the population’s social insurance contributions, it may be justified to accept them as proxies for actual costs also from the societal perspective.
      These considerations generally also apply to the estimate based on method AT-2, which was set up to adapt the Austrian meta tariff system. Note, though, that services funded by some occupational health insurance funds (eg, Civil Servants Insurance corporation) come with patient copayments (eg, 10% of the tariff). In economic evaluations from the societal perspective, this out-of-pocket cost would have to be considered on top of the reimbursed tariff to fully reflect societal costs, which in empirical studies seems rarely the case.
      • Mayer S.
      • Kiss N.
      • Łaszewska A.
      • Simon J.
      Costing evidence for health care decision-making in Austria: a systematic review.
      Several other methodological challenges are associated with method AT-2, specifically related to the complexity of the Austrian outpatient tariff catalogs. For example, many tariff catalogs include quantitative reimbursement limitations, and some services are reimbursed on a diminishing scale. The average tariff a GP eventually gets paid by a health insurance fund may therefore be different from the tariff listed in the catalog.
      Gesundheit Österreich GmbH, Bundesinstitut für Qualität im Gesundheitswesen: Methods handbook for Health Technology Assessment version 1.
      In practice, some GP consultations may also result in additionally reimbursed fee-for-service positions billed for extra services,
      • Jung R.
      Proportion of case fees in general medicine.
      which could not be considered in this costing analysis exercise. Estimates by Jung (2016) based on the 9 regional health insurance funds show that on average, 70% of GP revenues can be attributed to case fees and around 30% to individual services.
      • Jung R.
      Proportion of case fees in general medicine.
      Several limitations thus pertain to this unit cost estimate. This also shows in the unit costs previously reported in Austrian economic evaluations (method AT-1). Study authors often applied case fees per quarter and not reimbursements per consultation to value a single consultation.
      • Rainer M.
      • Mucke H.
      • Schlaefke S.
      Ginkgo biloba extract EGb 761 in the treatment of dementia: a pharmacoeconomic analysis of the Austrian setting.
      Therefore, these unit costs are a poor proxy for the cost of a second consultation, and their application in an economic evaluation would lead to an overestimation of GP costs.
      Generally, tariffs in the Austrian outpatient sector are seen as a result of political negotiations.
      Rechnungshof: Funding and costs of services in hospital outpatient departments and physician practices.
      New services were added to tariff catalogs based on economic cost calculations only in the last few years.
      Rechnungshof: Funding and costs of services in hospital outpatient departments and physician practices.
      Differences in tariffs for the initial consultation and follow-up consultation are part of an incentive system to avoid initial under provision or supplier-induced follow-up demand, and may be considered tools to allow reimbursement differentiated by patient needs.
      • Jung R.
      Proportion of case fees in general medicine.
      Overall, however, the application of tariffs as unit costs remains questionable, for example, when it comes to appropriate reflection of the physicians’ different skill levels or time needed for the consultation.
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      To date, however, there is no standardized documentation of diagnoses and therefore no effective regimen exists for quality assurance. It is thus difficult to assess the appropriateness of services and develop a quality-assurance driven tariff system.
      The recommended prices for non-contracted GP consultations (method AT-3) capture the privately insured payer viewpoint (ie, the patient and/or private health insurance perspective). Given that the market for private (non-contracted) GPs can be assumed to be fairly competitive,
      • Gächter M.
      • Schwazer P.
      • Theurl E.
      • Winner H.
      Physician density in a two-tiered health care system.
      it may be reasonable to assume that the price approximates the opportunity cost of the service.
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      It also reflects the societal cost in case the patient submits the invoice for reimbursement to their complementary private health insurance fund. Nevertheless, the services of non-contracted GPs may not be directly comparable with those provided by contracted GPs. Average prices of non-contracted GP services, for example, are reported to start from €120 per hour.
      • Pirich E.
      • Allen E.
      What may the price of health be? [in German].
      Non-contracted GPs generally treat lower number of patients but spend on average more time per consultation
      • Gächter M.
      • Schwazer P.
      • Theurl E.
      • Winner H.
      Physician density in a two-tiered health care system.
      and may also incur higher expenses for additional training.
      • Pirich E.
      • Allen E.
      What may the price of health be? [in German].
      Private prices are thus not directly comparable with the equivalent tariffs (method AT-2) and may be a biased proxy for public services.
      Method DE, following the German approach, takes on a public payer perspective and consequently a societal perspective
      • Piribauer F.
      • Thaler K.
      • Harris M.F.
      Covert checks by standardised patients of general practitioners’ delivery of new periodic health examinations: clustered cross-sectional study from a consumer organisation.
      excluding patient copayments. The same applies to method NL. The general approach of method UK is closest to the opportunity cost concept as it reflects the costs from a physician’s perspective based on average labor and capital inputs. It also roughly follows the suggested approach of the Viennese Physicians’ Chamber for setting service prices for non-contracted physicians.
      • Pirich E.
      • Allen E.
      What may the price of health be? [in German].
      ,
      • Stepanek P.
      Pricing for non-contracted physicians.
      In a recent Delphi study among European health economists, it was agreed that opportunity costs would be the preferred valuation approach
      • van Lier L.I.
      • Bosmans J.E.
      • van Hout H.P.J.
      • et al.
      Consensus-based cross-European recommendations for the identification, measurement and valuation of costs in health economic evaluations: a European Delphi study.
      with country-specific (nationally representative) standard costs being the recommended proxy measure. This recommendation is also in line with the societal perspective reflecting societal opportunity costs. Problems, however, arise when such unit costs are not available or when they are a closer reflection of costs from the healthcare perspective. This is also confirmed by this costing analysis exercise. For example, our case study highlights that among the unit costing approaches applied in 3 other European countries, the German and Dutch methods are closer proxies of the payer perspective. Nevertheless, one could argue that they also represent societal costs excluding out-of-pocket copayments where applicable. This shows that the adoption of one analytical perspective may indeed justify different unit costing approaches, thus introducing legitimate variation in unit cost estimates between different jurisdictions and studies.
      Methodological transparency and reflection, for example, based on more specific costing guidelines and detailed economic evaluation checklists regarding costing issues, may be a first step toward more sound unit cost estimates.
      • Barnett P.G.
      An improved set of standards for finding cost for cost-effectiveness analysis.
      At the same time, owing to, for example, the practical differences between service providers and accounting arrangements, the need for some flexibility in costing guidelines and hence unit cost estimates will remain inevitable.

      Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.

      ,
      • Oostenbrink J.B.
      • Koopmanschap M.A.
      • Rutten F.F.
      Standardisation of costs: the Dutch Manual for Costing in economic evaluations.
      From a pragmatic standpoint, the appropriate time and effort to be invested in the costing of a service also depends on its (quantitative and qualitative) importance for an analysis.
      • Mogyorosy Z.
      • Smith P.
      The main methodological issues in costing health care services: a literature review. CHE Research Paper 7.
      ,
      • Drummond M.F.
      • Sculpher M.J.
      • Torrance G.W.
      • O’Brien B.J.
      • Stoddart G.L.
      Methods for the Economic Evaluation of Health Care Programmes.
      ,
      • Barnett P.G.
      An improved set of standards for finding cost for cost-effectiveness analysis.
      Although there is an inherent trade-off between resource intensity and precision, it is agreed that services most affected by an intervention should be valued based on more exact methods.
      • Barnett P.G.
      An improved set of standards for finding cost for cost-effectiveness analysis.
      Simpler valuation methods may be adopted for services that are, for example, less important for a given economic evaluation. Overall, these insights were also one of the driving motivations for PECUNIA, a large European project aiming to develop more standardized, harmonized, and validated multi-sectoral and multinational methods, tools, and information for costing in economic evaluations.
      • Simon J.
      • König H.-H.
      • Brodszky V.
      • et al.
      on behalf of the PECUNIA Group. Inter-sectoral costs and benefits of mental care in Europe: European Research Project PECUNIA.

      Limitations

      This costing analysis exercise needs to be interpreted in light of its potential limitations. Firstly, to address feasibility, transparency, and reproducibility, calculations aimed to be based on publicly available data retrieved from, for example, websites, legal documents, and scientific papers as far as possible. Although this was a deliberate choice, such approach has an inherent limitation of not always being able to draw on the most up-to-date information and in some instances reproduction may require individual data requests. This is, however, not uncommon in any unit cost calculation attempts nor limits the validity of the key messages of our article. Secondly, various assumptions had to be made for some calculation methods owing to differences in the tariff catalog lists of the health insurance funds. Merging some of the health insurance funds and harmonizing practice-based physician services is part of the ongoing Austrian healthcare reform. Hopefully in the future, therefore, relevant calculations will require less efforts in Austria in general.

      Conclusion

      Although unit costs based on tariffs may be an adequate valuation source from the payer’s perspective, also they are appropriate sources from the societal perspective, especially if relevant out-of-pocket costs are considered additionally. If available and for the more competitive parts of the healthcare market (but not for the public services), unit costs based on prices for private physicians seem to be a good proxy for opportunity costs.
      Especially for important cost items included in a health economics analysis, more reflection on the data source and costing methodology is needed for unit cost calculations to achieve valid, comparable estimates that are also in line with the study’s overall costing perspective. Existing costing guidelines and quality checklists that fail to provide sufficient guidance should be updated. This will help to avoid unnecessary and unjustified variations between studies owing to differences in unit costing approaches. Nevertheless, for countries without available unit cost libraries such as Austria, a methodologically standardized primary costing study based on dedicated data collection seems imperative. This would substantially increase the quality of cost estimates in future health economic analyses and potentially improve the acceptability of such evidence in policy making.

      Acknowledgment

      This manuscript draws on fruitful discussions during the first International Unit Cost Workshop held in February 2016 at the Department of Health Economics at the Center of Public Health, Medical University of Vienna. We gratefully acknowledge the valuable inputs from all participants. Financial support by the Austrian Research Association (ÖFG) for this workshop was received. All views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of the workshop participants, the PECUNIA consortium, or the funding agency.

      References

      1. Bonin E-M, Beecham J. Preventonomics Unit Cost Calculator v1.5 Guidance Document. Personal Social Service Research Unit, London. https://www.pssru.ac.uk/project-pages/unit-costs/pucc/. Accessed June 8, 2017.

        • Jacobs J.C.
        • Barnett P.G.
        Emergent challenges in determining costs for economic evaluations.
        Pharmacoeconomics. 2017; 35: 129-139
        • Clement (nee Shrive) F.M.
        • Ghali W.A.
        • Donaldson C.
        • Manns B.J.
        The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches.
        Health Econ. 2009; 18: 377-388
        • Heerey A.
        • McGowan B.
        • Ryan M.
        • Barry M.
        Microcosting versus DRGs in the provision of cost estimates for use in pharmacoeconomic evaluation.
        Expert Rev Pharmacoecon Outcomes Res. 2002; 2: 29-33
        • Shrestha R.K.
        • Sansom S.L.
        • Farnham P.G.
        Comparison of methods for estimating the cost of human immunodeficiency virus–testing interventions.
        J Public Health Manag Pract. 2012; 18: 259-267
        • Mayer S.
        • Kiss N.
        • Łaszewska A.
        • Simon J.
        Costing evidence for health care decision-making in Austria: a systematic review.
        PLoS One. 2017; 12e0183116
        • Mogyorosy Z.
        • Smith P.
        The main methodological issues in costing health care services: a literature review. CHE Research Paper 7.
        • Drummond M.F.
        • Sculpher M.J.
        • Torrance G.W.
        • O’Brien B.J.
        • Stoddart G.L.
        Methods for the Economic Evaluation of Health Care Programmes.
        Oxford University Press, Oxford, UK2005
        • van Lier L.I.
        • Bosmans J.E.
        • van Hout H.P.J.
        • et al.
        Consensus-based cross-European recommendations for the identification, measurement and valuation of costs in health economic evaluations: a European Delphi study.
        Eur J Health Econ. 2017; 19: 993-1108
        • Barnett P.G.
        An improved set of standards for finding cost for cost-effectiveness analysis.
        Med Care. 2009; 47: S82-S88
        • New Economy
        Unit cost database.
        • Curtis L.
        • Burns A.
        Unit costs of health and social care 2015. Personal Social Services Research Unit.
        • UK Department of Health
        NHS reference costs collection.
        • Oostenbrink J.B.
        • Koopmanschap M.A.
        • Rutten F.F.
        Standardisation of costs: the Dutch Manual for Costing in economic evaluations.
        Pharmacoeconomics. 2002; 20: 443-454
        • Hakkaart-van Roijen L.
        • Tan S.
        • Bouwmans C.
        Manual for cost research, methods and standard charges for economic evaluations in health care.
        ([in German]) Erasmus Universiteit Rotterdam, Netherlands2010
        • Tan S.S.
        • Bouwmans C.A.
        • Rutten F.F.
        • Hakkaart-van Roijen L.
        Update of the Dutch Manual for Costing in Economic Evaluations.
        Int J Technol Assess Health Care. 2012; 28: 152-158
        • Oostenbrink J.
        • Bouwmans C.
        • Koopmanschap M.
        • Rutten F.V.
        Manual for cost research, methods and standard charges for economic evaluations in health care.
        2004
        • Krauth C.
        • Hessel F.
        • Hansmeier T.
        • Wasem J.
        • Seitz R.
        • Schweikert B.
        Empirical standard costs for health economic evaluation in Germany -- a proposal by the working group methods in health economic evaluation [in German].
        Gesundheitswesen. 2005; 67: 736-746
        • Krauth C.
        Methods of health economic evaluation for health services research [in German].
        Gesundheitsökonomie Qualitätsmanagement. 2010; 15: 251-259
      2. Universität Hamburg: Netzwerk “Methoden der Messung der Inanspruchnahme von Gesundheitsleistungen und Kosten im Alter”: Modul B: Erstellung einer Datenbank für “unit costs” von Gesundheitsleistungen.
        • Walter E.
        • Zehetmayr S.
        Economic evaluation guidelines. Institut für Pharmaökonomische Forschung Vienna.
      3. Gesundheit Österreich GmbH, Bundesinstitut für Qualität im Gesundheitswesen: Methods handbook for Health Technology Assessment version 1.
        (Accessed)
        https://jasmin.goeg.at/121/
        Date: 2012
        Date accessed: January 19, 2017
        • Olsson T.M.
        Comparing top-down and bottom-up costing approaches for economic evaluation within social welfare.
        Eur J Health Econ. 2011; 12: 445-453
        • Chapko M.K.
        • Liu C.F.
        • Perkins M.
        • Li Y.F.
        • Fortney J.C.
        • Maciejewski M.L.
        Equivalence of two healthcare costing methods: bottom-up and top-down.
        Health Econ. 2009; 18: 1188-1201
      4. Department of Health Economics (DHE), Center for Public Health, Medical University of Vienna: DHE Unit Cost Online Database: Cost Collection from Existing Studies.
        (Version 2.1/2017)
        • Mayer S.
        • Kiss N.
        • Laszewska A.
        • Simon J.
        Health economic costing methods and reporting in Austria.
        Value Health. 2016; 19: A363
        • Brodszky V.
        • Beretzky Z.
        • Baji P.
        • et al.
        Cost-of-illness studies in nine Central and Eastern European countries.
        Eur J Health Econ. 2019; 20: 155-172
        • Czypionka T.
        • Röhrling G.
        • Mayer S.
        The relationship between outpatient department utilisation and non-hospital ambulatory care in Austria.
        Eur J Public Health. 2016; 1: 20-25
        • Gächter M.
        • Schwazer P.
        • Theurl E.
        • Winner H.
        Physician density in a two-tiered health care system.
        Health Policy. 2012; 106: 257-268
        • Bachner F.
        • Bobek J.
        • Habimana K.
        • et al.
        Austria: health system review.
        Health Syst Transit. 2018; 20: 1-254
        • Tirol Ärztekammer
        Practice-based physicians: non-contracted physicians.
        http://www.aektirol.at/wahlarzte
        Date accessed: January 19, 2017
        • Personal Social Services Research Unit
        Preventonomics Unit Cost Calculator (PUCC).
        • Statistics Austria
        Health expenditure in Austria according to “System of Health Accounts”.
        • Farag I.
        • Sherrington C.
        • Ferreira M.
        • Howard K.
        A systematic review of the unit costs of allied health and community services used by older people in Australia.
        BMC Health Serv Res. 2013; 13: 69
        • Graham B.
        • McGregor K.
        What does a GP consultation cost?.
        Br J Gen Pract. 1997; 47: 170-172
        • Markaritzer K.
        New tariff system.
        Österreichische Ärztezeitung. 2009; 5
        • Wilbacher I.
        • Schröder J.
        Combination of differen documentation systems.
        • Bock J.
        • Brettschneider C.
        • Seidl H.
        • et al.
        Calculation of standardised unit costs from a societal perspective for health economic evaluation [in German].
        Gesundheitswesen. 2015; 77: 53-61
        • Hakkaart-van Roijen L.
        • Van der Linden N.
        • Bouwmans C.
        • Kanters T.
        • Tan S.
        Manual for cost research, methods and standard charges for economic evaluations in health care.
        Erasmus Universiteit Rotterdam, Netherlands2015
        • Hoffmann K.
        • Wojczewski S.
        • George A.
        • Schäfer W.L.
        • Maier M.
        Stressed and overworked? A cross-sectional study of the working situation of urban and rural general practitioners in Austria in the framework of the QUALICOPC project.
        Croat Med J. 2015; 56: 366-374
        • Pirich E.
        • Allen E.
        What may the price of health be? [in German].
        Doktor Wien. 2013; : 12
        • Waldner G.
        Trends in reimbursements of practice-based outpatient physicians in Austria, Germany and The Netherlands.
        Universität Linz in Zusammenarbeit mit der Oberösterreichischen Gebietskrankenkasse, Linz2001
        • Cheung K.L.
        • Evers S.
        • De Vries H.
        • et al.
        Most important barriers and facilitators of HTA usage in decision-making in Europe.
        Expert Rev Pharmacoecon Outcomes Res. 2018; 18: 297-304
        • Feig C.
        • Cheung K.L.
        • Hiligsmann M.
        • Evers S.
        • Simon J.
        • Mayer S.
        Best-worst scaling to assess the most important barriers and facilitators for the use of health technology assessment in Austria.
        Expert Rev Pharmacoecon Outcomes Res. 2018; 18: 223-232
        • Sensor Marktforschung
        Attitudes towards the current primary health vcare system: group discussion with medical students.
        • Jung R.
        Proportion of case fees in general medicine.
        Evidenzbasierte Wirtschaftliche Gesundheitsversorgung, Gesundheitsökonomie, Hauptverband der österreichischen Sozialversicherungsträger, Vienna2016
        • Rainer M.
        • Mucke H.
        • Schlaefke S.
        Ginkgo biloba extract EGb 761 in the treatment of dementia: a pharmacoeconomic analysis of the Austrian setting.
        Wiener Klinische Wochenschrift. 2013; 125: 8-15
      5. Rechnungshof: Funding and costs of services in hospital outpatient departments and physician practices.
        • Piribauer F.
        • Thaler K.
        • Harris M.F.
        Covert checks by standardised patients of general practitioners’ delivery of new periodic health examinations: clustered cross-sectional study from a consumer organisation.
        BMJ Open. 2012; 2e000744
        • Stepanek P.
        Pricing for non-contracted physicians.
        • Simon J.
        • König H.-H.
        • Brodszky V.
        • et al.
        on behalf of the PECUNIA Group. Inter-sectoral costs and benefits of mental care in Europe: European Research Project PECUNIA.
        J Ment Health Policy Econ. 2019; 22: S32
        • Schroettner J.
        • Lassnig A.
        Simulation model for cost estimation of integrated care concepts of heart failure patients.
        Health Econ Rev. 2013; 3: 26
        • Howard P.
        • Knight C.
        A clinical-and cost-effectiveness comparison of venlafaxine and selective serotonin reuptake inhibitors (SSRIs) in the management of patients with major depressive disorder from the perspective of an Austrian sickness fund.
        J Med Econ. 2004; 7: 93-106
        • Canonica G.W.
        • Poulsen P.B.
        • Vestenbaek U.
        Cost-effectiveness of GRAZAX for prevention of grass pollen induced rhinoconjunctivitis in Southern Europe.
        Respir Med. 2007; 101: 1885-1894
        • Moertl D.
        • Steiner S.
        • Coyle D.
        • Berger R.
        Cost-utility analysis of NT-proBNP-guided multidisciplinary care in chronic heart failure.
        Int J Technol Assess Health Care. 2013; 29: 3-11
        • Stoppacher A.
        Cost-effectiveness analysis of influenca vaccination in Austria. Medizinische Universität Graz.
        • Fischer S.
        • Tüchler H.
        • Piso B.
        Outpatient cardiac rehabilitation programme: economic evaluation. LBI-HTA Projektbericht.
        in: Nr. 89. Ludwig Boltzmann Institut für Health Technology Assessment, Wien2016
        • Zechmeister I.
        • Blasio B.F.
        • Garnett G.
        • Neilson A.R.
        • Siebert U.
        Cost-effectiveness analysis of human papillomavirus-vaccination programs to prevent cervical cancer in Austria.
        Vaccine. 2009; 27: 5133-5141
        • Burgenländische Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Kärntner Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Niederösterreichische Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Oberösterreichische Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Salzburger Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Steiermärkische Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Tiroler Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Vorarlberger Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Wiener Gebietskrankenkasse
        Tariff catalogue [Honorarordnung].
        • Ärztekammer Burgenland
        Prices for non-contracted general practitioners and specialists.
        • Ärztekammer Niederösterreich
        Recommended prices for private services.
        • Ärztekammer Oberösterreich
        Prices for non-contracted general practitioners and specialists.
        • Ärztekammer Steiermark
        Recommended prices for private services.
        https://www.aekstmk.or.at/129
        Date accessed: June 7, 2017
        • Ärztekammer Tirol
        Prices for non-contracted physicians.
        • Ärztekammer Vorarlberg
        Recommended point value for private services.
      6. Physicians’ cost statistics [Ärztekostenstatistik 2015]. Data access Austrian Public Health Institute. https://goeg.at/. Accessed May 2020.