Prevention, hospital network, waiting lists, intramoenia, local medicine: the Covid cyclone has turned our lives upside down and forces us to rethink the very conception and priorities of Italian healthcare. But in what terms? "In many terms" warns Professor Rosella Levaggi, professor of Health Economics in the Department of Economics and Management of the University of Brescia and President of the Italian Society of Public Economy (SIEP).
Her interview is the continuation and development, from the point of view not of a doctor but of an expert in health economics, of the journey into Italian health care initiated on FIRSTonline by the previous interview of Professor Silvio Garattini, scientist and founder of the Mario Institute Negri of Milan, which will continue in the coming weeks with the intervention and opinion of other authoritative voices in the panorama of our health care. Here is the interview with Rosella Levaggi.
Professor Levaggi, has the pandemic changed the conception or at least the order of priorities of an adequate and efficient allocation of public resources in Italian healthcare? In what terms?
“In many terms. For example, as a recent OECD report also shows, many health systems suffered because they lacked capacity in terms of beds and excess equipment. Before the pandemic, having little spare capacity (excess beds) was considered an index of efficiency. Another very important aspect that the pandemic has highlighted is the central role of the public in coordinating interventions and the importance of local structures. Finally, the long-term problems that the pandemic may have caused: from the early diagnosis of oncological diseases to the control of chronic ones".
In a recent interview with FIRSTonline, Professor Silvio Garattini of the Mario Negri Institute in Milan has indicated in a more massive work of prevention, in overcoming the classism that distinguishes public health users into Serie A and Serie B on the basis of income and not on the basis of their rights and the abolition of intramoenia activities are the pillars of a possible revolution in Italian healthcare: what is your opinion on this?
“Prevention is certainly fundamental and we need to invest more in this aspect, not only by using more resources for healthcare, but also in terms of communication and also in terms of income distribution because a healthy lifestyle is not within everyone's reach . As far as series A and B users are concerned, in my opinion there are obviously problems on the part of the offer, but it is often also important to know how to ask and know who to contact. In this sense, health literacy interventions, especially on younger people, could be very useful. Certainly, in a country like Italy, differences in life expectancy such as those recently highlighted by the Save The Childern report are intolerable and work must be done to reduce this gap. As for the intramoenia, I think the problem is not the tool itself, but the way it is managed. If a hospital has excess capacity that it cannot use to treat NHS-funded patients due to budget constraints, intramoenia can help cover part of the fixed costs and free up resources; if, on the contrary, the instrument is used to reduce public activity, it is obviously not good”.
In the same interview with FIRSTonline, Professor Garattini argues that the Italian hospital network needs to be rationalised, abolishing hospitals that are too small because they are inefficient, and concentrating healthcare activities in large hospitals where the best medical skills can be gathered: what do you think?
“The question is very complex and also in this case the answer is not simple. Certainly microstructures with a limited number of patients and high costs are not sustainable. However, it must also be taken into account what the closure of a particular hospital implies, however small it may be. In non-metropolitan areas, facility closures can have major repercussions on care and access to services. The risk is that of creating what in English literature is defined as a "medical desert" which obviously harms the frail the most".
The endless patient waiting lists in public hospitals and laboratories are a shame for a country like Italy: Portugal seems to have found a solution by putting hospitals in competition and offering economic incentives to those who get rid of the lists first. Is this a feasible hypothesis also in Italy?
“The problem is: why is there a waiting list. If there is a list because more patients could be seen in a facility by doing more shifts/more overtime, the economic incentive works. If the waiting list exists because there is a ceiling on the number of services reimbursed, the incentive obviously doesn't work”.
Aggregation also seems to be a desirable path in local medicine by bringing together general practitioners, specialists and nurses in Case della Salute who can better meet the expectations of patients: is this an acceptable idea?
“For some chronic pathologies, for the care of frail elderly people, I think this tool could be very important both for coordinating the therapeutic path of these patients and also for having an overview of the patient. However, the project requires a considerable organizational effort and not all Regions may be able to manage it".
