Healthcare, goodbye waiting lists: the Portuguese model sets the standard

Once upon a time there was Portugal, a country which, like ours, does not have many resources to finance its National Health Service (per capita health expenditure: €2.150 vs. €2.446 in Italy) and which, like Italy, has for some time to solve the problem of too long waiting lists. Over the past twenty-two years, many measures have been taken in Portugal, many of them costly and ineffective, with the specific aim of reducing waiting lists. 

It all started in 1995, the year in which the PERLE - Programa Específico de Recuperação de Listas de Espera - was introduced, later renamed PPA - Programa de Promoção do Acesso in 1998. Both programs, aimed at reducing waiting lists, have not had any success, apart from initially reducing waiting times, which then returned exactly to their initial levels (unfortunately, the money spent was not recovered). In 2002 it was the turn of a new program called PECLEC – Programa Especial de Combate às Listas de Espera Cirúrgicas. For those unfamiliar with Portuguese, the title promises to "fight waiting lists" and has the incredibly ambitious goal of eliminating them in two years.  

Despite the aggressive resolutions, after 2002 waiting lists not only hadn't disappeared, but had reappeared longer than ever. It was then decided to adopt another path that shifted the objective from waiting lists to waiting times. In 2004, SIGIC – Sistema Integrado de Gestão de Inscritos para Cirurgia was born from this new perspective. This new approach makes use of a new ally for the first time: a powerful computerized system that collects all the data on waiting times, volumes of services and performances of public and private hospitals in a transparent and secure way (in terms of privacy).  

The basic principle of SIGIC is that if a patient is not operated on within the set time, he is entitled to a voucher with which he can be transferred to any other hospital (public or private in Portugal) and be operated on (always free of charge) within the times pre-established. The advantage for patients is obvious, once they have reached 70% of the maximum waiting time for their surgery in their referral hospital, they can ask to be transferred to another public or private facility and be operated on immediately.  

But what do hospitals gain by being efficient beyond a good reputation? The answer is simple: if a hospital operates on a patient belonging to it, this is reimbursed according to the corresponding DRG (medical procedure), but if a patient is not operated on within certain days (which vary depending on the procedure and the patient's condition ) the patient himself has the right to move and choose any other hospital through the information system that has a good performance and a shorter waiting time. The hospital that welcomes the transferred patient earns the reimbursement money which will no longer go to the relevant hospital but to the new hospital where the patient was operated on.

In a nutshell, the money "travels" with the transferred patient who constitutes an extra source of income for the most efficient and clinically effective hospitals. Furthermore, since 2012, the hospitals from which patients are transferred have an extra incentive to improve and "retain" their patients as they themselves pay a penalty for each patient transferred equal to 10% of the reimbursement. Brilliant!  

Once the system has been explained, here are the results of SIGIC: in five years the average waiting time for an elective surgical operation has been reduced by 63%, from an average of eight months to just three months. This improvement was only made possible by the new way of managing patients using a single digital platform. The number of interventions carried out in public and private structures increased by 40% without consequences for the quality of the performance. Despite an initial skepticism towards public structures, it has been observed that there has never been, not even at the beginning of the programme, a mass exodus from the public to the private sector for patients who had exceeded waiting times. All public and private facilities have responded to the SIGIC by increasing productivity for pertinent patients during regular working hours and have also increased production capacity by increasing extra working hours for transferred patients (intra moenia). The private sector has absorbed the remainder of the excess demand.  

I would conclude with "And they all lived happily and operated on time" but I'm not Portuguese and I wonder: "What would happen if SIGIC were introduced in Italy?".