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Report CEIS - Sanità 2008 Regional Health Care. Assessment and Perspective seven years after the costitutional reform and just on the eve of fiscal federalism CEIS - Faculty of Economics, University of Rome “Tor Vergata”. Health Communication The 6th publication of CEIS , University of Tor Vergata- Rome, is the result of a public-private partnership. This partnership flanks CEIS with organizations which believe in the necessity of supporting stakeholders of the healthecare system and offering policymakers access to knowledge. The publication and circulation of the volume to healthecare operators and experts has been made possible thanks to the financial support and commitment of : • A.N.I.A. • Boehringer Ingelheim Italia • GlaxoSmithKline Italia • J&J Medical Holding • Pfizer Italia S.r.l. • TEVA Pharma Italia S.p.A. The partners in this initiative share with CEIS Sanità the necessity to offer elements that are necessary when taking rational decisions both to the operators in the sector and to politicians; offering business administrations the necessary information to improve their programming and organizational levels; as well as offering citizens and their associations some elements for understanding the system’s performance. The Report (which has been conceived, planned and accomplished in the dual Italian/English version) collects the work carried out by CEIS Sanità researchers, and other experts in the sector. 1 Index Difference and Uniformity: where Efficiency ends and Equity begins (or vice versa). 6 1 - Financing healthcare: an overview 16 1.1 Financing healthcare in OECD countries 18 1.2 SSN funding and gross profit in Italy 23 1.3 Regional Health Services funding and gross profits 28 1.4 The allocation of healthcare resources 33 Bibliography 43 2 - The hospital care system 44 2.1 Hospitals and beds 51 2.2 Medical imaging and diagnostic equipment (MIDE) 62 2.3 Human resources 65 2.3.1 Public hospital staff 70 2.4 Acute cases healthcare 74 2.4.1 Hospitalization rates in acute cases 74 2.4.2 Average hospital stay and case-mix 85 2.4.3 Value of production 87 2.4.4 Appropriateness 93 2.4.5 Tariff policies 95 2.5 Rehabilitation healthcare 100 2.5.1 Hospitalization rates 100 2.5.2 Average hospital stay 103 2.5.3 The value of production 104 2.6 Long-term healthcare 104 2.6.1 The need 104 2.6.2 Average hospital stay 107 2.6.3 The value of production 107 2.7 Hospital in-patient care expenditure in OECD countries 108 2.8 An estimate of total in-patient hospital expenditure 111 2.9 Expenditure trends for private hospitals accredited by the National Health System 114 Focus: Organ transplantation in Italy: A regional analysis of transplant demand and supply 119 2.A.1. Transplant supply 120 2.A.2 Transplant demand 121 2.A.3 Outcome of the estimates and open problems 129 2 Bibliography 133 3 - The Emergency Care System in Italy 135 3.1 The framework legislation 136 3.2 Facilities and care services 137 3.3 Cost-sharing charges on emergency room visits 140 Bibliography 145 4 – Residential assistance system: Healthcare Residential Structures. 146 4.1 Healthcare Residential Structures: characterization 147 4.2 Healthcare residences 149 4.3 Data on Healthcare Residences 153 Regions 154 Bibliography 157 5 - Pharmaceutical assistance system 158 5.1 National policies about drugs 161 5.2 Regional interventions 162 5.2.1. Pharmaceutical ticket 162 5.2.2. Direct and ‘on behalf of’ distribution 163 5.2.3. Prescription limits 165 5.2.3.1 Prescription limits for Inhibitors of Pump 165 5.2.3.2 Minimum quotas of generically equivalent drugs 166 5.3 Expenditure on drugs and medicines: the trends 168 5.4 National and regional expenditure on drugs and medicines 170 Bibliography 177 6 - The specialist medical assistance system in Italy 178 6.1 OECD specialist expenditure 181 6.2 The Requirements 184 6.3 Medical services 186 6.4 Offer 192 6.5 Dimensions of the delivering facilities 194 6.6 Evolution of specialist medical expenditure financed by the medical insurance plan 198 6.7 Total specialist medical expenditure (estimate) 202 6.8 Prescription Charges 205 7 - Health and Social care integration: the Italian regions experience 208 7.1 Health and Social care integration reforms 208 3 7.2 Devolution and social services provision 209 7.3 Managed integration: regional and area plans 210 7.4 Managed integration: models of intervention for social and health care services development 211 7.5 Concluding remarks 215 Bibliography 217 8 - The Home Care system 219 8.1 National orientations on the subject of home healthcare 221 8.2 Home Healthcare in the Regions 227 8.3 Disability figures in Italy 230 8.4 Potential ADI offer on the territory 234 8.5 Resorting to Integrated Home Care 236 8.6 Health expenditure for ADI (estimate) 238 Bibliography 240 9 - Healthcare Spending 241 9.1 Analysis of healthcare spending in the OECD countries 246 9.2 The dynamics of healthcare spending in the OECD countries 249 9.3 The break-down of healthcare spending in the OECD countries 253 9.4 Public healthcare spending in Italy 254 9.5 Private spending on healthcare in Italy 262 9.6 Direct public spending on healthcare functions in Italy 266 9.7 Public healthcare spending on subsidies for functions in Italy 274 9.8 An analysis of Healthcare Costs 284 9.9 Databanks and estimated model 287 9.10 Forecast of total healthcare spending 290 9.11 The future development of public and private healthcare spending 290 10 - L’equità nel SSN 293 10.1 Data and methodology 296 10.2 Impoverishment and catastrophic payments 296 10.3 The impact of different kind of out of pocket expenditures 302 Bibliography 304 11 - The impact of the Health National System on economy 306 11.1 The pharmaceutical industry 306 11.1.1 The world pharmaceutical industry 308 11.1.2 The pharmaceutical industry in Italy 313 11.1.3 The industrial market for generic drugs 317 11.1.4 Industry of pharmaceutical drugs in Italy 319 11.2 The medical device manufacturing sector 321 4 11.2.1 The medical device market worlwide 322 11.2.2 The European medical device market 325 11.2.3 Medical device public expenditure in Italy 330 11.3 The insurance market 332 11.3.1 The international market 333 11.3.2 The domestic market 335 11.3.3 Supplementary insurance cover 336 Bibliography 339 5 Report CEIS - Sanità 2008 presentation Presentation We are very glad to introduce the 6th Publication of the CEIS Report, University of Tor Vergata-Rome, entitled “Regional Health Care. Assessment and Perspective seven years after the costitutional reform and just on the eve of fiscal federalism”. The Report has been born from the work or research that CEIS has been working out for years in the field of healthcare economy, in the economical evaluation of healthcare projects and in the private/public business administrations; this research also increases an intensive post-Lau ream activity and a scientific support to private/public institutions This year too the report wishes to offer that scientific support which is necessary when taking rational decisions both to the operators in the sector and to politicians stressing the most relevant thematics for the realization of the fiscal federalism, maintaining an adequate level of solidarity within the public healthcare system. This year too the Report has been conceived, planned and accomplished in the dual Italian/English version to spread the knowledge of the Italian healthcare system to the international scientific community Luigi Paganetto Giovanni Tria Presidente CEIS Direttore CEIS Univ. di Roma Tor Vergata Univ. di Roma Tor Vergata 6 Report CEIS - Sanità 2008 Regional Health Care. Assessment and Perspective seven years after the costitutional reform and just on the eve of fiscal federalism Regional Health Care. Assessment and Perspective seven years after the costitutional reform and just on the eve of fiscal federalism.1 The CEIS Health Report is now in its sixth edition. As the Report’s editor, since the first edition, I am of course very pleased about the growing attention it is receiving; I wish to add that the nature of the Report has not changed, its purpose still being to disseminate the results of the research and survey activities carried out by CEIS in the field of health care, in a form that can be easily understood and used by both expert and layperson alike. Some changes, however, have been introduced to the structure of the index, by taking a more organic approach, which will presumably be maintained in the forthcoming editions. Accordingly, the Report addresses first of all the funding of the Italian national health service (NHS); this is followed by an overview of the key health care sectors (Hospital, A&E, Residential, Pharmaceutical, Specialist, Social & Health, Home care), which combines economic and statistical data and regulatory issues; the next section presents an analysis of the financial (and, possibly, economic) effects of the care services, and the related expenditure, but also the equity impact of the system. Finally, the last chapter is dedicated to the principal health- related “industries” (Pharmaceutics, Medical Equipment, Insurance), as a reminder that the health sector, although unquestionably “costly”, also contributes significantly to the overall economy of the country. This new approach is a result of the awareness that federalism in health care is now a fact, although this raises two issues that are best addressed in this new framework. First of all, we believe that without a mutually accepted system of fiscal federalism, the current institutional arrangements are inadequate, as they provide no ties between regional autonomy and the related financial responsibilities.
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