Article Abstract Online ISSN: 1099-176X    Print ISSN: 1091-4358 The Journal of Mental Health Policy and Economics Volume 5, Issue 3, 2002. Pages: 121-129 Published Online: 9 Feb 2003 Copyright © 2002 ICMPE.

*Correspondence to: Ingrid Zechmeister, MA, Department of Social  Policy, Vienna University of Economics and Business Administration, Reithlegasse 16, A- 1190 Wien, Austria
Tel.:  +43-699-1954 1246
Fax:  +43-1-31336 5879   
E-mail: ingrid.zechmeister@wu-wien.ac.at

Source of Funding:  None declared

Abstract

Recent mental health care reform plans in Austria focus on establishing community-based and decentralised mental health care. One of the main challenges in implementing these plans is the re-allocation of resources. Financing mental health care in Austria is characterised by a mix of federal and provincial responsibilities, heterogeneity in service provision, as well as diverse funding arrangements. The authors hypothesise that the existing structure of mental health care financing, with its incentives and disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Applying an analytical framework based on the principal-agent theory, the study shows how incentives are determined by existing constellations and characteristics of actors involved in mental health care financing. Overall, these incentives support hospital-centred and supply-oriented mental health care. If a community and needs-based mental health care system is to be established the financing structures have to be adapted respectively.

Background: In Austria, financing health care -and even more so mental health care- is characterized by a mix of federal and provincial responsibilities, lack of uniformity in service provision and service providers, and diverse funding arrangements. The division between financing structures for health care and social care makes the situation even more complex. This state of affairs results in various, partly counterproductive and sometimes paradoxical financial incentives and disincentives for the providers, recipients and financiers of mental health services. In several provinces of Austria, recent reform plans in mental health care have focused strongly on establishing community-based and patient-oriented mental health care. One of the main challenges in implementing this new policy is the re-allocation of resources. Aims of the Study: The authors hypothesize that the existing structure of mental health care financing, with its incentives and   disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Analyzing the characteristics of the overall mental health care financing system in one Austrian province, Lower Austria, will provide a better understanding of actor-relationships and inherent incentives and highlight implications for the process of deinstitutionalization. Method: The authors used an analytical framework based on the principal-agent theory, empirical evidence, and information on financial, organizational and legal structures to identify the characteristics of actor-relationships and the position of single actors within the system. Results: The article shows how incentives are linked to existing constellations of actors involved in mental health care financing and identifies significant power relations. As a consequence, incentives and disincentives within the financing system result in hospital- centered and supply-oriented mental health care in Lower Austria. Discussion: The current system of financing mental health care provides an obstacle to the provision of patient-oriented and community-based mental care. This is due to existing constellations and power relations among the actors where, most importantly, patients are the weakest party in the patient-payer-provider triangle. Balancing power relations will be a significant prerequisite for alternative financing systems. Implications for Health Policies and Further Research: If a community and needs-based mental health care system is to be established in Austria, the financing structures have to be changed accordingly. Applying a principal-agent framework is useful for identifying key aspects in mental health care financing in relation to the provision of services. Further research is needed to help develop alternative financing mechanisms that support community-based and patient-oriented mental health care systems.

Received 6 June 2002; accepted 9 December 2002

Copyright © 2002 ICMPE