In the Pirelli skyscraper, known as the Pirellone, seat of the Lombardy Regional Council, one of the longest sessions of the last thirty years is underway: the directors are discussing yet another attempt to reform the regional health care after the obvious gaps that emerged during the first wave of the coronavirus pandemic. The comparisons and discussions on the reorganization of the healthcare system in Lombardy began over a year ago, but only in recent months – with the appointment of the councilor for Welfare Letizia Moratti, who replaced Giulio Gallera – the debate has focused on a series of precise proposals.
More than reform, Moratti and the majority speak of “lines of development” or of simple changes to the so-called Maroni law of 2015 which in turn had reformed the health care reform of 1997 approved during Roberto Formigoni’s first term.
The main points of the new text are four: the so-called “One Health” approach, which recognizes a link between the health of individuals and that of animals and the environment; the freedom of the citizen both in the choice of hospitals and personnel; the relationship between public and private health; the link between Lombard healthcare, companies and universities.
In the cards that indicate the objectives of the reform, we read that among other things there will be a “general strengthening of territorial medicine and the area of prevention” with the establishment of “Community Houses, community hospitals, Territorial Operational Centers and strengthening Integrated Home Assistance (ADI) “(we go back). The role of general practitioners is described as “central” in the care of patients, especially those with chronic diseases. “The spirit of this reform proposal is certainly the strengthening of local health care, in a very concrete way,” said Moratti.
The two most important points of the guidelines, and on which there were many expectations from regional policy, are the so-called freedom of choice of the citizen and the relationship between public and private health. Healthcare in Lombardy, in fact, is still today based on the vision of former president Roberto Formigoni who during his mandates, from 1995 to 2013, created a system based precisely on the freedom to be treated by the public or private health service.
Formigoni’s vision was made possible by the 1997 reform which made Italian hospitals more and more similar to companies, with autonomous budgets and professional managers, and which handed over autonomy to the regional governments – competent on health according to the provisions of the Constitution – to organize them as they liked.
Today just under half of Lombardy’s healthcare is private: most of it operates under an agreement with the public, that is, it is paid by the Region to offer the same rates and the same quality of public service performance. In some areas of the region, private individuals have become the dominant managers of local health. And in many ways, as we have seen in recent years, this is a problem.
Letizia Moratti (Ansa / Matteo Corner)
Private companies, which operate to make a profit, focus their activity above all on low-risk operations and specialist visits, while public hospitals mainly take care of first aid, trauma caused by road accidents, care for the elderly and the chronic, of rare diseases.
This approach was confirmed by the latest data from AGENAS, the National Agency for Regional Health Services, released by Corriere della Sera: in 2019, before the epidemic, there were 29,308 beds in Lombardy in total, 70 percent public and 30 percent private.
But if we look at the different types of interventions in detail, the percentages change. Interventions that are profitable and with wide discretion in deciding whether or not it is useful to do them, for example those for obesity or for heart valves, are mostly performed by private individuals. The same is true for other operations such as implantation of defibrillators, coronary bypasses, hip and knee replacements. Public hospitals perform the most expensive and riskiest interventions: they treat 80 percent of brain haemorrhages, 87 percent of leukemias, 82 percent of respiratory tract neoplasms. 87.2 percent of severely immature babies are cared for by public facilities.
In short: despite being financed in a similar way and put in fact on the same level, public structures take on much more risky operations than private ones, which can instead focus on maximizing their profits with ultra-specialized and well-paid operations. “Private providers can choose what they do and the services they offer, they do not have the constraints of the public service and therefore can identify the most profitable services, without considering which ones have a higher cost-benefit ratio and which may not be profitable , such as prevention, ”explained a The Submarine Angelo Barbato, researcher at the Mario Negri Institute for Pharmacological Research. According to AGENAS, this approach allows individuals to grab the most profitable services, leaving the public with the services that are perhaps most necessary but a source of debt rather than income.
Over the years, among other things, this facility – a strong private component concentrated in a series of large modern hospitals, often identified as an image of the efficiency of Lombard healthcare – has neglected territorial assistance, that is, the network formed by medical doctors. general, medical guards, local clinics and RSA, which according to many experts today would need greater development and greater investments.
The evident gaps in this network were one of the causes of the inadequate response to the first wave of infections: without an intermediate reference between general practitioners and hospitals, many sick people turned to 118 and hospitals had enormous difficulties in ‘ assistance of thousands of patients.
– Read also: The two months that shook Lombardy
The shortcomings and problems of setting up Lombard healthcare were also identified by AGENAS, which in a document published at the end of 2020 tried to explain the limits of healthcare in Lombardy including the absence of a strong central control and the dispersion of responsibilities in headed by 8 health protection companies (ATS), the lack of a link between hospitals and territorial medicine, the difficulties in managing economic resources and controlling performance due to competition between public and private hospitals.
AGENAS proposed to establish a single ATS, to return the supervisory functions of all private individuals to the Region through control structures, to establish prevention departments and districts. In short, more medicine in the area and more checks.
The new attempt at reform has only partially accepted the suggestions.
Lombard territorial health care will effectively be based on the network made up of districts: there will be one for every 100,000 inhabitants and one for every 20,000 in the mountain areas. The districts will have the task of “assessing the local need, planning and integrating health professionals (general practitioners, pediatricians, outpatient specialists, nurses and social workers)”. They will have an “easily recognizable and accessible by citizens” headquarters and will manage the territorial structures: Community Houses, Territorial Operational Centers and Community Hospitals.
There will be 203 Community Houses: clinics open 24 hours a day, seven days a week, where general practitioners work and where people can go for immediate medical assistance without going to the emergency room. The chronically ill will be followed in the Community Houses and social workers will work to create a direct dialogue with the social services of the municipalities. The stated goal is to have greater collaboration between social and health care.
The reform also provides for the construction of 60 community hospitals dedicated to short-term hospitalizations and where simple interventions will be performed. They will have an average of 20 beds, up to a maximum of 40. The Territorial Operations Centers (COT) will make it easier for people to access health care, for example through coordination between home and health services. between hospitals and the emergency-urgency network. In essence, they will decide how the assistance of a patient is to be managed, also taking care of keeping contacts between the various health structures to which they will have to turn.
A large part of the funds guaranteed by the National Recovery and Resilience Plan (PNRR) will be used to finance the reform: 300 million will be invested for Community Homes, over 150 million for Community Hospitals and 17.8 million for COTs . Another 85 million in regional funds will be allocated to the Center for the Prevention of Infectious Diseases.
Overall, including regional resources for strengthening the supply network, 1 billion and 350 million are earmarked for healthcare construction. As the new structures are built, fully operational personnel costs are estimated at 17.8 million in 2022, 28.7 in 2023, 29.7 euros in 2024.
According to the opposition councilors, who presented over 1,900 amendments and more than 4,000 agendas, this is a “non-health reform” because no changes to the territorial organization are envisaged (the 8 ATS have been confirmed) and above all because the imbalance between public and private is maintained, if not aggravated. Even with the new reform, private structures will continue to be completely disconnected from regional planning, ie from the request for assistance services based on an analysis of the demand. The discussion of so many amendments and agendas forced the president of the regional council, Alessandro Fermi, to convene the councilors for sessions that last many hours, from 8 to midnight. The goal of the majority is to arrive at the final approval of the reform by the end of the week.
The center-left mayors of the Lombard capitals – Milan (Beppe Sala), Bergamo (Giorgio Gori), Brescia (Emilio Del Bono), Varese (Davide Galimberti), Cremona (Gianluca Galimberti) and Lecco (Mauro Gattinoni) – complain about the lack of involvement of territories. “It is not certain that the structures identified correspond to real needs, based on the needs and density of the population,” Sala said. While according to Gori “the pandemic crisis has highlighted the limitations of the Lombard health system: from waiting lists, to the overload of emergency rooms, to the shortage of general practitioners. With respect to the limits, the response of the region seems to us to only partially grasp the opportunity for change ”.
ANAAO-ASSOMED Lombardia (National Association of Aid and Hospital Assistants), one of the unions of Italian doctors, is also very critical. The union reports “lack of courage in radically changing a system that has many critical issues, present since before the pandemic, the absence of a systemic reasoning on the hospital network, the fear of openness to the private sector also on the side envisaged by the PNRR – that is of territorial care – which obviously implies the lack of investment in public medicine, the timid correction of the excessive freedom of the accredited and contracted private individual, despite some improvements in detail in the text, however insufficient for an immediate practical translation ».