Lombardy is the only Italian Region that has established by law equal rights and duties between public and private entities with agreements operating within the health service. The intentions of regulation no. 31 wanted in 1997 by Roberto Formigoni are to promote competitiveness between structures to better meet the needs of patients, who can choose where to be treated, and shorten waiting lists. And the Region indifferently reimburses both (within contracted spending ceilings). But does Lombard health care often also taken as an example to be exported to other regions, does it really have a public-private system capable of guaranteeing more timely care? The data, provided by the National Agency for Regional Health Services (Agenas) and which can be made public for the first time, allow us to understand how the model works in reality.
The analysis concerns the types of hospitalizations and surgeries performed in the public and private sectors and the corresponding amount of reimbursements obtained from the health system
What emerges is not a consequence of the clogging of hospitals caused by Covid, because the situation was photographed considering the numbers of 2019. Afterwards it only got worse.
Beds in comparison
The total beds are 29,308, 70% public and 30% private. It means that of all types of shelters, over 1.2 million, 70% public and 30% private.
Meanwhile, out of 100 beds in a public hospital, 45 are occupied by those who enter for an emergency passing through the emergency room. Out of 100 places in the private sector, only 20 patients come from the PS. For the other 80, the accredited structures can schedule admissions by type. To access the hospital, those who need surgery must book a specialist visit: for public facilities there is a transparent booking system where the regional contact center tells you where to go and in what times. For private ones, on the other hand, it is necessary to contact the individual accredited structures that in the vast majority of cases have never wanted to make their agendas publicly available, despite having been urged to do so as early as 2016.
What services does the private individual offer?
For a long list of hospitalizations and surgeries, the public-private ratio 70 to 30 is reversed, with high volumes in a range of performances. Let’s see which ones. First: well-paid interventions, often at risk of inappropriateness because the doctor has wide discretion in deciding whether or not to perform them. They are those for obesity, which the accredited structures carry out for 74.5%, with a reimbursement of 5,681 euros; on heart valves, which are worth 21,882 euros and are carried out by private individuals for 51% (in Milan for 66.2%); vertebral arthrodesis, where the vertebrae of the back are nailed, more than 80% done by private individuals. In August 2019 the reimbursement of 19,723 euros was cut by almost 40% by the then general manager of Sanit Luigi Cajazzo, precisely to make them less profitable and to try to limit unnecessary interventions.
More profitable interventions
Second: the most profitable services in the specialties of cardiology / heart surgery and orthopedics. These are interventions that involve the implantation of prostheses, where private structures already have high profit margins because they have fewer constraints and standards in purchasing than the public. In Milan, where the giants of accredited healthcare are concentrated, private individuals implant 60% of defibrillators (reimbursement 19,057 euros), 68% of heart valves (17,843 euros), 88% of coronary bypasses (19,018 euros). In addition: 90% of the operations on the lower joints (12,101 euros), and 68% of the hip and knee replacements (8,534 euros). In the whole region, however, for the same types of intervention, the percentage of services carried out by the private sector exceeds 40%, with peaks reaching 77%. Third: out of over 500 types of intervention, the private sector makes half of its turnover with 25 services, the public 43. This is a clear sign that the activity is concentrated in more convenient areas of specialty. The most common concern degenerative diseases of the nervous system, which account for 8.8% of turnover, replacement of major joints or reimplantation of the lower limbs (8.5%), diagnoses of the musculoskeletal system (3, 7%), and interventions on the cardiovascular system (4.4%).
Milan: private domain
On Milan, if patients from outside the region are also taken into consideration, private health care, compared to large public hospitals, reaches percentages between 85 and 97% of interventions and hospitalizations of cardiology, heart surgery, orthopedics, and those with high turnover, but at risk of inappropriateness. the Lombardy Region itself to admit: Private Health has concentrated on some specific lines of activity which, however, impose incisive controls in terms of appropriateness, preventing providers from concentrating on activities characterized by good profitability and unverified epidemiological need (here the document).
What does the audience do?
The very expensive and risky interventions, starting with transplants, which only the public hospital can do. And then 80% of cerebral hemorrhages, 87% of leukemias, 82% of neoplasms of the respiratory system, 75% of extracorporeal oxygenation. 87.2% of severely immature infants are cared for in public facilities. In addition to all those not very profitable, but very common interventions: deliveries (81.8%), abortions (90%), stones (80%), pneumonia (78%), appendicitis (83.9%), tonsils (79.3%). Breast cancer operations, on the other hand, are shared equally.
On balance, public hospitals are at a loss, with the Region having to write off the budgets every year: 44 million for the Policlinico of Milan, 58 for the San Paolo and San Carlo, 87 for the Civilians of Brescia, 75 for Pope John XXIII from Bergamo. While private groups make important profits: 27 million the San Donato group of the Rotelli family, 66.9 the Humanitas of Gianfelice Rocca, 6.7 the Multimedica of Daniele Schwarz. Of course, the public suffers from inefficiencies, while the private sector is more managerial, but it is not enough to explain a gap of this magnitude.
The waiting lists remain
National guidelines give the times: if there is a risk of rapid worsening of the disease, surgery must be performed within 30 days.
In Lombardy for an oncological surgery you have to wait 66 days in 36% of cases; for a non-cancer patient 83 days in 23% of cases
In Regions comparable by health offer, we see other numbers: in Veneto only 6% of urgent operations on tumors are not performed within 30 days, for other operations the overruns are 9%. In Emilia Romagna they are respectively 22% and 15%. And this was the trend until just before the arrival of the pandemic. It must be said that in those very hard months, with public structures collapsing, the private sector made 40% of the beds available for Covid patients.
Model to be reformed
Pulling the strings, the model does not in fact guarantee that equal rights and duties provided for by regional law, does not solve waiting lists, but gradually leads to the deterioration of the public and the hoarding of the best doctors. At that point it will be difficult to go back. In fact, a reform plan is under discussion which in the autumn will lead to a law, considered by the councilor for Welfare Letizia Moratti one of the priorities of his mandate. In the guidelines under study, the commissioner writes that a better governance of the offer is needed. It should mean: I credit you to do more what you need and not just what is convenient for you. We’ll see if you give it parole we will move on to the facts.
(Alessandro Riggio collaborated)
June 27, 2021 | 22:30
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