Would the Italian healthcare system be able to manage additional resources?
Italian healthcare system: facts, numbers, announcements and problems. The speech by Massimo Balducci
It's not just now that the Italian healthcare system is leaking. Since the 1978 reform (law 833) the healthcare system has been one of Italy's major illnesses. Let's quickly try to see what are the crucial points that determine the dysfunctions before everyone's eyes.
First of all, let's realize that the Italian healthcare system is uniform across the entire territory. The differences between regions are only in the details. The healthcare system is the result of law 833 of 1978 , a period in which the original text of our Constitutional Charter was in force, according to which the Regions could legislate only within the framework of state laws. Now law 833 of 1978 is a framework law. It follows that the healthcare systems in Calabria and Lombardy are substantially the same (even if they offer different services). You have to search in the l. 833/1978 the causes of the dysfunctions and not dwelling on the symptoms (waiting lists and recourse to private medicine, disorganization etc.).
Now what are these causes? Here we will make a quick census of the causes of health dysfunctions and the paths to take to get out of the tunnel.
First of all, the institutional confusion between those who offer the service and those who use it. Suffice it to say that hospitals (defined as hospital facilities) have neither legal personality nor accounting autonomy. The same applies to districts/clinics. It follows that it is not possible to identify who is responsible for which service or to keep the costs of the services under control.
Law 833/1978 was developed in a period characterized by two aspects. On the one hand, the role of the hospital was changing: from a place where sick people who did not live in healthy homes were treated to a place where technical tools were available that could not be available in the patient's home. The cases of Paul VI and John Paul II are emblematic. The first had his prostate operated on in the Vatican, the second was always treated at the Gemelli Hospital.
Therefore the l. 833/1978 was affected by the prestige that the hospital was acquiring. The l. 833/1978 focuses all the provision in the hospital. The local doctor is considered a sort of sorter who does not treat the patient but directs him to the districts for diagnostics and then directs him to the hospital to be treated. The Local Health Unit has legal personality and accounting autonomy where those who provide the services, i.e. hospitals and clinics, do not have it. In this way the l. 833/1978 introduced a dichotomy unknown in the rest of Europe, that between hospital doctor and local doctor. Above the Alps, doctors work in the area and, for a few hours a week, in hospitals, which they see as an exceptional place to resort to.
The second aspect that characterizes the period in which our healthcare system matures is represented by a particularly hot political climate. We must not forget that 1978 is the year of the Moro kidnapping and murder . The l. 833/1978 is heavily affected by the prices that had to be paid to the PCI to guarantee its support for the government with the "no no confidence" mechanism. This means that the mechanism of the health system financed from above is affirmed and not the mechanism of counter-performance. The l. 833/1978 states a fundamental and indispensable principle, that is, the principle that the patient must only worry about treatment and not also about meeting the costs of the illness. Above the Alps, with a few exceptions, this guarantee is ensured through the "third party paying" mechanism. The healthcare facility does not receive funding from above but is remunerated according to the services it provides. This remuneration is not paid by the patient but by a third party, namely the "third party payer". This creates a conflict between those who provide the service and those who pay for it, activating mechanisms of mutual responsibility that are currently unknown in our healthcare system. Obviously the political climate of the period imposed a solution in which everything had to be guaranteed regardless of costs, a solution based on financing from above and not on the remuneration of the consideration.
From 1978 until the beginning of the 90s of the last century we had two parallel healthcare systems: a public one based on the territory in which the hospitals had adequate equipment but in which patient care was very hypothetical, a private one in which the The hotel service was of excellent quality but the service could not count on adequate equipment. With Legislative Decree 504 of 1992 (the De Lorenzo decree) the aim is to put private and public healthcare on the same level and to put them in competition. Legislative Decree 504/1992 requires that both public and private healthcare facilities be "accredited". However, the accreditation mechanism does not work for two reasons: first, public health facilities cannot in fact be accredited because they do not formally exist (they have neither legal personality nor accounting autonomy), second, there are no bodies capable of carrying out the assessments techniques necessary for accreditation. As a result, the private structure is accredited by the public structure (which is accredited with a self-certification) only as a support to the public structure. It is useless here to draw attention to the fact that, according to EU standards, those who accredit must in turn be authorized to accredit by a national body appointed for this purpose (in our case it is Accredia).
The result is, on the one hand, failure to comply with EU regulations on public markets and, on the other, widespread confusion such that many Regions are forced to give up insurance because, given the prevailing confusion, the insurance premiums requested would exceed the budget of the individual local health authorities.
I doubt that allocating additional resources to this mess would improve the situation. The ways forward are certainly not easy but must be traced as follows: (i) assignment of legal personality and accounting autonomy to hospitals and districts/clinics, (ii) creation of adequate bodies to accredit, (iii) accredit both the public and private structures, (iv) progressively move from the financing mechanism to that of the "third party payer".
On this last point it is worth making a couple of additional considerations.
In Norway, a country with exorbitant financial resources due to gas and oil deposits, the healthcare system (which enjoys super-abundant resources) is not based on the "third party payer" but on direct financing. Well here the waiting lists are very long. In Germany or the Netherlands, where the "third party paying" system is in force, waiting lists are not a problem. We are currently trying to increase the salaries of healthcare workers, leaving the possibility for healthcare workers to operate in a dual regime, partly as salaried workers and partly as freelancers (with the services provided under the intra moenia regime).
The possibility of offering health workers a clear alternative should be explored: either a salary or remuneration for performance. In this second case by imposing decent tariffs (to be negotiated with the orders). At the clinic of the Free University of Brussels I paid 35 euros for a visit to a prestigious professional (if you had been included in the Belgian healthcare system you would have recovered approximately 29 euros) while in Italy I pay 37 euros in copays. I do not mention the costs of private visits under intra moenia regime.
To anyone wishing to delve deeper into these issues, I would like to point out my recent publication A cat chasing its tail or public administration reforms – analyzes and suggestions, Milan, Guerini, 2023.
This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/sanita/il-sistema-sanitario-italiano-sarebbe-in-grado-di-gestire-risorse-aggiuntive/ on Wed, 04 Oct 2023 13:09:41 +0000.