In Italy, for an indefinite time, only those who can afford to pay have the certainty of having an exam or a medical visit quickly. Before the pandemic, according to Censis, 19.6 million Italians were denied at least one service of the essential levels of assistance in a year and, having seen the length of the waiting list, they proceeded to do it out of their own pocket: every 100 booking attempts, 28 ended up in the private sector (here the document). After the two peak years of Covid (2020-2021) what is happening? The image that we have used several times is valid: imagine a long queue at the platform waiting to get on the train to which today’s passengers add up. If no other carriages are added to the train, there will be more and more passengers who will have to postpone that journey, which in many cases can save their lives, or alternatively pay for private transport. This is why quickly recovering the health services lost during Covid, due to the paralysis of the planned activity, is a top priority for the National Health Service. And for two reasons: 1) the majority of the population cannot afford paid healthcare; 2) the delay of a treatment or a diagnosis aggravates both the patient and the public coffers. A data processing done for Computer room by the National Agency for Regional Health Services (Agenas) which belongs to the Ministry of Health allows us to understand how long that queue is and why it cannot be shortened.
Missed exams and visits
Compared to 2019, more than 12.8 million fewer first visits and 17.1 million follow-up visits were made in 2020 and 2021. As for exams, 1.3 million abdominal ultrasounds were missed, 3.1 million electrocardiograms and more than half a million mammograms were missed. The list goes on, but the story doesn’t change: at least one out of five outpatient services has been postponed. So now the diktat for all the Regions – also on the advice of the governments that took turns – is to return at least to the levels of 2019. A goal about which at least two objections could be raised. The first: unfortunately there have been over 186,000 deaths from Covid, especially among them chronically ill people who are the main consumers of Healthcare. The second: a part of the skipped services could not be strictly necessary and therefore, after that particular moment, it could no longer be requested. In summary: exams and visits could be skipped which today do not have to be recovered because those who needed them have died or because the problem has resolved itself spontaneously.
Request for benefits
The reality of facts and numbers, however, is merciless: in 2022 the request for visits and exams not only returned to the levels of 2019, but is even growing exponentially. This is demonstrated by the data from Tuscany, the only Region to also keep prescriptions monitored: in 2022 the number of prescriptions for visits increased by 25% compared to 2019, by 28% for check-ups, for diagnostic imaging of the 31%, and for the instrumental one 17%. It is likely that the trend is more or less everywhere.
The question then is: compared to 2019, how many healthcare services were provided in 2022? The data analysis by Agenas for Dataroom makes a projection for the whole of 2022 for the first time. The results: first visits are still down by 3.1 million (-14%), follow-up visits are down 5.3 million (- 16%), mammograms minus 127 thousand (- 7%), abdominal ultrasounds minus 334 thousand (- 9%), electrocardiograms minus 1 million (- 20%). Knowing the exact size of the problem is the first step to solving it. The difficulty of recovering citizens’ health demand concerns all Regions, albeit with differences between one and another.
The results of the Regions
If we look at the data compared to the volumes of activity in 2019, the picture is this: Piedmont is still minus 17%, the Autonomous Province of Bolzano minus 46%, Friuli Venezia-Giulia minus 25%, Veneto minus 13%, Lombardy minus 11.12%, Emilia-Romagna minus 12% , Liguria minus 16%, Lazio minus 10.9%, Marche and Sicily minus 19%, Calabria minus 22%. Only Tuscany has recovered a plus 1%.
Going into the details of the individual requests: for an electrocardiogram, Piedmont is 39% below, Veneto is 27%, Liguria minus 40%, Tuscany minus 18%, Sardinia minus 31%. And hoping throughout the country not to need an eye examination, for example Lombardy must recover 21%, Veneto 25%, Emilia-Romagna 15%, Calabria 45% and Sicily 25%. %.
The money is there
Nevertheless, with the 2021 Budget Law, 500 million were made available to pay for more services and doctors (a salary increase for those who work extra shifts: from 60 euros per hour to 80). Why, then, does the problem remain? The main reasons are two. The first concerns public structures: already strangled before the pandemic due to a chronic shortage of doctors, they have to deal with organizational difficulties. Being able to extend the hours of visits and examinations presupposes planning skills on the part of directors general, which they often do not have because their appointment by politics does not consider it an essential requirement. The second reason concerns the accredited private structures: rather than offering services with the National Health Service, it is more convenient for them to offer paid services. Just to give an example: in 2019 in Milan 27% of the overall activity and 41% of the first visits were carried out in a solvency regime, in 2022 they rose to 36% and 58% respectively. On a large scale, the phenomenon is the same: they shorten the contracted activity and expand the one where the patient pays out of his own pocket because the profit margin is greater.
(…) they shorten the contracted activity and widen the one where the patient pays out of pocket because the profit margin is greater.
The waiting times
To summarize: if, as we have seen, the demand for healthcare services is increasing but the volume of activity is not growing at the same pace in accredited public and private structures, the resulting consequence is a disastrous worsening of waiting lists. The paradox is that this effect could not be seen from the data with which the Regions monitor the times to obtain a visit or an exam. In addition to the detection system problems already reported in a Computer room of May 2022 which make it in itself unreliable (here), reality can be altered by two other factors: 1) the increase in the use of paid services by assisted persons 2) the impossibility of booking due to the closure of diaries by the providers. A masking that shows an apparently perfect picture. And for the patients, in addition to the damage, even the insult.
Who pays and who waits
From the Censis report: «Recourse to paid healthcare is the result, not of a rush to inappropriate healthcare consumerism, but of services prescribed by doctors that citizens are unable to obtain in the Healthcare Service in adequate times». Indeed, the expenditure that Italians support out of their own pockets for treatment is constantly growing: according to the latest data available from the State General Accounting Office it went from 34.85 billion euros in 2019 to 37 billion in 2021 (here the document, page 113). An additional 6%, equivalent to 2.15 billion. Half of this expense is for specialist visits and interventions. In essence: those who can pay, the others wait.