Healthcare Systems: Focus on Italy
A NextGen Article
By Christina Grassi
Since 2000, the United States wears “37” as its scarlet letter- a number branded on America by the World Health Organization in its public ranking on the quality of close to 200 national healthcare systems [1]. Longing for inspiration, policy makers have been carefully scrutinizing those countries spotlighted at the top of the charts. Italy, ranked second, becomes a natural pick for the United States to emulate.
But is it this simple? Doctors at Cisanello Hospital in Pisa, Italy share their concerns and describe the challenges associated with being a doctor or a patient in Italy, raising the question of whether the United States should be careful before it institutes legislation that could mimic elements of the Italian healthcare system [2].
The World Healthcare Organization’s monumental 2000 study evaluated nearly 200 countries on five parameters: Health Level (25 percent), measured by life expectancy; Responsiveness (12.5 percent), which includes quality of amenities, privacy protection, and choice of doctor; Health and Responsiveness Distribution (each 25 percent), measuring the level of health inequality within the country, and financial fairness (25 percent), determining if the privileged pay more for health care, with poorer citizens contributing less.
According to these WHO standards, Italy excelled. The country operates close to a socialized system, with the objective to provide all care to every citizen at high quality. The central government decides on funding allocation for hospitals, research, new technology, and labor contracts for doctors and staff. However, providing all care to every citizen at high quality is a goal commendable in its philosophy yet impractical in its execution. While all citizens receive access to any form of care, organization and quality become difficult to maintain at high standards, leading to problems for those delivering and receiving care. What are these ultimate effects on doctor and patient?
A DAY IN THE LIFE OF AN ITALIAN DOCTORHuddled over a computer monitor, an attending Radiologist at Cisanello Hospital in Pisa, Italy, wearily examines a long list of computed tomography scans. “We’re taxed each day with high volumes of exams to be read, analyzed, and diagnosed- all within business hours. Many of these exams just aren’t even necessary”. Because these radiographs are largely government funded, with negligible copayments, many exams are ordered whimsically. High volumes translate into filled waiting rooms and long lines. 
Meanwhile, just behind the hospital lobby, another attending Radiologist carefully oversees technologists administering the CT exam. “Since the government is spending all its money on providing free health care for all Italians, there seems to be so little left to buy new technology. We’ve been waiting for this new CT scanner for months. Finally they [government officials] agreed to the purchase”.
Should a physician wish to conduct research on top of her increasingly more demanding daily workload, chances are low that any small amount of research funding would be provided by the government. A system with little money left to support clinical studies ultimately discourages physicians from actively starting new projects. “If you want to do research, it’s on your own time and resources. It makes it so hard to start a study,” remarks another frustrated physician.
While the majority of government spending is focused on providing healthcare to all Italians, policy makers tighten compensation rates for doctors. Physicians at Cisanello Hospital, an academic institution affiliated with the University of Pisa Medical School, see bright students turning to other careers. “They’re going in different directions: business, or law, but not medicine,” adds a senior attending.
What are doctors doing in response to these challenges? Many are turning to independent clinics and hospitals. Adds a resident, “There’s definitely been increased privatization. There are many doctors who will work both at the hospital and at a private clinic during the course of a week to make a living.”
A PATIENT’S PERSPECTIVEFor patients, Italy’s system may appear superficially attractive. For a patient entering the Radiology Department for a CT exam, only a small copayment is required, for which over 40% of Italians receive exemptions (exemptions include those over 65, or in a low income bracket, or suffering from a serious disease). However, it can take four weeks or more to receive a CT exam. And yet, once it is finally time to receive the study, the patient encounters mass confusion and disorganization in hospitals under tremendous pressure to accommodate a plethora of patients.
This can force some patients to visit further clinics to receive a higher quality of care. One elderly man arrived at Cisanello Hospital after traveling for twelve hours by train from Sicily. “Cisanello is just more organized and more efficient than my local hospital,” he explained.
To escape the unappealing environment of government-run care, Italians in the middle class and above frequent independent clinics and pay for efficient, quality service, similar to the appeal of a five star hotel. Another senior attending adds, “For Italians who can afford it, why wait three weeks for your CT scan when you can pay 100 euros and be seen the next day in a quiet, comfortable atmosphere? It’s an easy decision for them.”
Physicians at Cisanello are informally discussing a new solution—one in which essential services would be provided for all citizens, including emergency visits and major surgical interventions. However, “minor” diseases, and smaller accidents (such as a broken bone or athletic injury), would not be covered. “If you break your wrist going skiing, then that’s your fault. But if you need a tumor removed surgically, then that service should be provided by the government,” interjects one physician in a discussion. They argue that providing some care to all citizens at high quality is both a commendable goal and feasible in execution, compared with the current impractical mission to provide all care for everyone at high quality. However, until government agrees to alter current policy, physicians at Cisanello and other hospitals across Italy will continue to face these challenges.
What can Americans learn from Italy’s healthcare predicaments? Economist Paul Krugman claims that “the obvious way to make the United States health care system more efficient is to make it more like the systems of other advanced countries.” [4] Yet examining Italy’s situation shows that this approach may not be the answer. Perhaps the most important factor that future physicians should remember is that attempts to mimic elements of the Italian medical system could present us with these similar challenges as doctors and as patients.
[1] Health Systems: Improving Performance. Publication. 2000. World Health Organization. Geneva, Switzerland.
[2] 1 September 2008. Interview and tour with physicians at Cisanello Hospital, Pisa, Italy.
[3] Tanner, Michael. "The Grass is Not Always Greener: A Look at National Health Care Systems Around the World." Policy Analysis 613 (2008).
[4] Krugman, Paul and Wells, Robin. "The Health Care Crisis and What to Do About It." New York Review of Books 53(5) (2006). http://www.nybooks.com/articles/18802
Christina Grassi is a writer for the Next Generation and a member of the Harvard University Class of 2010.