Autonomous medical universities are uncommon in the international university scene. Nevertheless, many presidents of US universities with a medical school would be happy to be rid of this constantly money-demanding and resource-consuming institution [23]. In Europe, there are only two historically grown examples, the Karolinska Institute in Stockholm and the Hannover Medical School, both highly respected institutions with international reputation and both had and have an ideal structure for university medicine, from which Austria was and still is far away: the hospital belongs to the university. This version was not wanted by the responsible body financing public universities, namely the Austrian Federal Government because (i) of the high costs required for a hospital of the highest level of care, and (ii) inpatient healthcare in Austria in the first place is a responsibility of the federal states and not of the federation itself. The political decision, after a long discussion, to separate the medical faculties from their traditional university body in the form of medical universities was ultimately based on three reasons:

1.

The size of the medical faculties and their share of total university costs. The size of the university medicine in Vienna, consisting of the preclinical institutes of the University of Vienna and the inpatient departments of the university-affiliated General Hospital, was and is unique in international comparison: on the one hand, the Vienna General Hospital as the largest hospital in Europe with 2206 beds and 1757 physicians as of 2003, all of them scientific staff members of the University of Vienna’s medical faculty and paid by the federal budget and on the other hand a total number of staff members of the University of Vienna’s medical faculty, including those of the preclinical area of 3198 [24]. Furthermore, up to 2005 there was unregulated access to medical studies with more than 2000 beginners every year, and only thereafter it was allowed by law to define a limited number of study places (with associated entrance test), namely 740, which is still extremely high from an international perspective. For comparison, the 155 US medical schools have on average of only 148 study places, and from all US medical schools together there actually are 21,000 medical graduates per year [25]. Standardized to the number of US inhabitants (= 333 million), this amounts to only one third of the 1735 medical graduates (year 2021/2022) from Austrian universities [26]! Table 1 shows the costs for the University of Vienna’s medical faculty in relation to the costs for the entire university for 2003, its last year before separation. It also shows the direct payments made by the Federal Government to the City of Vienna, as the maintaining body of the Vienna General Hospital, to cover the hospital’s needs arising from the common operation with research and teaching. The costs incurred by the Federal Government for university medicine in Vienna thus amounted to 58% of the costs incurred by the entire University of Vienna [27]. Similar criteria and ratios, with lower absolute figures, existed for the two other medical faculties at the university locations in Graz and Innsbruck.

2.

Continuity of the existing special legal conditions. Even before their separation, medical faculties had a special budgetary status within their universities as the university physicians had to be involved in the healthcare duties of the associated university hospital but also the budget for consumables and investment in a university hospital was largely tied up in the sense of joint operation of healthcare, research and teaching. For this reason, the budget of a medical faculty could not be subjected to the discretion of the rector of an autonomous university if the faculty would belong to it, and in the past, therefore, the medical faculties in Austria were allocated their own budget, separate from the other faculties of the university.

3.

University-affiliated hospitals in Austria are not legal entities per se. The first two reasons would not in themselves have been valid for the separation of a medical faculty from its university even if this university has full legal capacity (although the vast majority of the costs the university would have to allocate to its medical faculty, see Table 1, ended to speak in favor of a separation). In an international comparison, many universities either have outsourced their medical faculty, or at least its clinical part, into a subcorporation with the affiliated hospital (integration model) or form a close cooperation with the hospital if that has legal capacity per se (cooperation model) [28]. Thus, both partners must provide financial security for the joint operation of healthcare, research and teaching. Table 2 shows examples that already existed at that time.

Table 1 Federal expenditures (in million Euros) for university medicine in Vienna in 2003 (data from [24, 27])Table 2 Structure models for university-affiliated hospitals (only valid for universities as legal entities)

In Austria, none of the first three structural models shown in Table 2 were possible and still are not. Neither hospital affiliated to a public university in Austria, although hospitals of the highest level of care, was an independent legal entity, but belonged to a superordinate hospital holding company, namely the State Hospital of Graz to the Styrian Hospital Society (KAGES, Steiermärkische Krankenanstalten Gesellschaft), the State Hospital of Innsbruck to Tirol Kliniken, both limited liability companies, and the Vienna General Hospital had and still has, as most of the public Viennese hospitals, the City of Vienna itself as the maintaining body. None of the federal states and none of the aforementioned holding companies, already owned by the respective federal state, were willing to outsource its university hospital as an independent legal entity. Hence, every university with a medical faculty in Austria would have had no direct contractual partner, but always only a partially responsible partner, up to and including an entire federal state (the City of Vienna). It should also be added that universities and hospitals in Austria belong to different governmental authorities (universities to the federation, hospitals to the federal states) and are therefore financed differently, which is not the case in the other European countries. There is either, and largely, no federal structure or both universities and healthcare facilities are under the responsibility of the federal states, as is the case in Germany.

Moreover, at the time the medical faculties became autonomous in 2004, but also for many years afterwards, in Vienna until 2016, there was no cooperation contract at all between the Medical University and the maintaining body of the Vienna General Hospital, the City of Vienna. During those 12 years, only the legally prescribed federal payment to the City of Vienna and the other federal states for the additional needs of their hospital arising from the common operation with research and teaching was continued (see Table 1), but now allocated via the medical universities as a transitory item. The agreement concluded in 2016 between three partners, the Medical University, the City of Vienna and the Federal Government, stipulated, however, more intensive cooperation but is far away from an internationally established cooperation model or, let alone, integration model between a university and a legally independent hospital as is evident from Table 2. The Austrian Court of Audit, which audited the cooperation between the federation and the City of Vienna in 2012/2013 using the Vienna General Hospital as an example, merely suggested better cooperation [29] but most regrettably, no contribution to a sufficient cooperation model for medical universities in Austria with their university hospitals was made from this side either. Due to an apparently unrealizable internationally proven model of cooperation between university and hospital, the political decision at the time was that (i) the necessary budgetary sovereignty for university medicine could only be guaranteed with independent medical universities, and (ii) positioning in a loose cooperation with a hospital holding company only or—still aggravating—with a federal state as the City of Vienna, whose interests in research and teaching are expected to be limited and where many day to day decisions have to be made, was easier as a separate medical university than as part of a full university.