Since traveling to Italy, the skeptical cardiologist has been in contact with Nicola Triglione, a native of Southern Italy who completed his cardiology fellowship in Milan.
As he has spent some time training in Seattle, WA and recently set up his practice in Milan, I asked him to compare and contrast the Italian health care system to our American system.
The Italian Perspective
by Nicola Triglione,
Medico Specialista in Cardiologia
Italy ranks among the World Health Organization’s top 10 countries for quality health services. The Italian healthcare system is far from perfect though, as this rating is mainly based on equality of access and health outcomes such as life expectancy and healthy life years.
Let’s take a closer look at the national healthcare system (NHS).
Universal Access To Care
Italy’s NHS is tax-funded, regionally-based and it provides universal coverage, largely free of charge at the point of service. Italian territory is made up of 20 administrative Regions, which are extremely varied in size, population, and levels of socioeconomic development. The well-known divide between Northern and Southern areas is still relevant nowadays.
Regions are responsible for ensuring the delivery of services through a network of population-based local health authorities and both public and private accredited hospitals.
The Origins Of Healthcare In Italy
During the Italian Renaissance, hospitals were the embodiment of physical and spiritual healing. The poor received free treatments, senior doctors were employed and food and wine were served to patients. Monks and nuns did the nursing with almost one nurse per patient. There are similarities with the contemporary era, in fact, the medical models developed by Tuscan hospitals formed the foundations for today’s healthcare practices.
The NHS was established by the government in 1978 in order to fight public dissatisfaction with the existing system. Those who want to have a ruthless and ironic portrait of the Italian healthcare before this date should watch one of the greatest Alberto Sordi’s movies “Be sick..it’s free” (1968).
Contained Healthcare Expenditure
In 2015 total health expenditure in Italy was about 9% of GDP, 75% of which was financed by the public sector. Out-of-pocket expenditure accounted for 23% of healthcare expenditure and the remaining 2% related to voluntary schemes like private insurances and mutual funds. There are two main types of out-of-pocket expenses: 1) co-payments for diagnostic procedures, pharmaceuticals and specialist consultations; 2) direct payments by users for the purchase of private health care services and over-the-counter drugs.
One of the most reassuring aspects of Italy’s NHS is that emergency care is considered a right, and it’s available to anyone in Italy whether or not they are registered in the national system. Residents have free or limited cost emergency care, and even visitors can access emergency care at a very low co-payment.
Yes, if you plan to break your leg while on vacation then Italy is the destination of choice.
What About Non-Urgent Visits?
If you are sick, you go to your General Practitioner and thanks to your national health card you do not pay anything at the time of the visit. If you need a specialist, things might become complicated because waits can be long. The average wait time for a cardiological visit is 67 days. At best, it’s 51 days in the north-east and 79 days in central Italy. So what do wealthy Italians do? They go to a private pay doctor who charges more than the government rate and the patient pays the difference. The fees are usually very reasonable, compared to other countries with similar costs of living.
On the other hand, the US is the only country spending 17 percent of its GDP on healthcare and according to many, it doesn’t get the expected value. It wasn’t uncommon during my stay in the US hearing colleagues defining the American healthcare system as “broken”.
Drug companies and emergency rooms charge whatever they want. As a result, they get lower patient compliance and therapy adherence.
What else? Hospital services and diagnostic tests cost more. Doctors get paid more, however education does have a cost, in fact, medical-school graduates carry a median $200,000 in student debt. A lot more money goes to planning and managing medical services at the administrative level.
Choice And Access
To me, one particular misconception about the US system is the notion of choice. People are led to believe that buying into a private insurance plan means they will have more choices. In reality, I think that sometimes the choice of care is neither on patients nor on doctors. More often it is insurance companies that decide when, where and for how long people can receive treatments.
I have no doubt that the best healthcare is available in the US, but how many Americans have access to it?
In my opinion, the US could work on providing universal access to treatments and medications, with minimal point-of-service payments as well as prices softened by government negotiation.
In the last 10 years, American citizens have witnessed nearly a doubling in prescriptions and health-related costs have become the leading cause of personal bankruptcy. We have the same issue in Italy, though hubris instead of money drives the phenomenon. In fact, it’s a common belief that a longer prescription means a smarter and considerate prescriber. That’s why in the last few years some virtuous Italian Regions have established a medication reconciliation clinic where general practitioners, internists, and pharmacists work together in order the refine the art of deprescribing.
The Exodus Of Doctors
As I have already pointed out, the Italian NHS is far from perfect. In fact, although medical facilities are considered to be adequate for any emergencies, some public hospitals are overcrowded and under-funded. Public finances are constrained by high levels of government debt. Consequently, resources available for welfare expenditure are considerably lower than in other countries. More than ten thousand Italian doctors left Italy to go working abroad between 2005 and 2015 in search of meritocracy, better career prospects, and higher salaries.
Of course, they miss the five weeks’ vacation, the maternity leave, and the sick leave but once they experience healthcare elsewhere they wouldn’t return to Italy unless the circumstances changed. Italy is not an attractive place to work for doctors because of poor working conditions, little career progression, low salaries and so on.
However, people who live here are some of the healthiest in the world. Long story short, Italy boasts excellent life expectancy and healthy life expectancy rates, 82.7 and 72.5 years, respectively. Life expectancy is the third highest in Europe, after Switzerland and Spain.
What’s the secret ingredient?
Italian Ministry of Health, Open Database
Italian National Institute of Statistics, Health statistics
N.B. As Nicola pointed out, the cost of healthcare in the US (including both government and private expenses) equals 17.1% of the national GDP, compared to 9.1% in Italy. whereas life expectancy in Italy is 4 years higher than in the US.
8 thoughts on “What Can Be Learned From The Italian Healthcare Experience?”
Wonder how much the Med diet in Italy helps with their life expectancy.
Hi Holly, I have to say Med diet sure helps, but only when coupled with few other things I will discuss in the next article.
The quality of food in Europe is sooooo much better than here in the USA. The Med diet will be of benefit in Italy & NOT at all here in the USA based on the above.
I thank TSC for sharing this comparison of our two healthcare systems. Our ad hoc system is unsustainable. If we make explicit the assumptions underlying what we will accept, progress might be made. If you have money in both countries you can access a higher level and more expeditious care. Both countries are already deficit spending with the US also shouldering the burden of keeping the world safe for democracies (and some cooperative dictatorships). Let’s agree it is currently unsustainable, that no one works for free and that we want to provide some care for everyone as a start. Add on the need for some kind of profit motive if you want to have even a trickle of innovation and we will begin to head in a better direction.
10,000 doctors leaving Italy for elsewhere tells u a lot. Until very recently, Italy was a quite uniform population, educated, and free of marijuana-cocaine-heroin, hi calorie highly processed junk foods.The USA takes care of their defense, freeing up Italian $$$$ for social concerns Comparing Italy to the USA is absurd in the current full circumstances.
The skeptical cardiologist is not free of patriotism. The middle man, the insurance companies and the managers and administrators are the big ticket items in the US. A neurologist gets paid $300,000 but at an average generates over two million dollars for the corporation, cardiologists even more. It is a scam ( 2019 report) for non productive MBAs. The standards are being lowered. Put in MAs for nurses and nurse practitioners for physicians, and lets call them all ‘providers.’ Bare foot doctors of Mao. One size fits all, per the lowest denominator of so-called ‘evidence based medicine’. The McDonaldization of American medicine.
I am not free of patriotism. But what does that mean in this context?
My only comment was that we in the US spend twice as much as Italy does and live on average 4 years less.
Thanks for a great post on one of my favorite topics.
My family and I had the pleasure of working in Italy for 2+ years in the Milan area (Bergamo) from 2000-2002. From a patient’s point of view I would 100% validate your perspective. Our “assigned” GP was essentially the equivalent of a NP or a PA. (My wife loved that her appointments with him always started at the coffee shop across from the clinic.). Following an accident She had that involved a large head laceration I will vouch that emergency care is outstanding and seamless — ambulance, ER, hospital admission, post-care, and meds all expertly delivered and w/o any cost after showing our Italian ID cards.
All my employees were European and all were equally baffled by our various conversations describing our U.S.’s bewildering assortment and layers of expensive insurance (e.g. private and employer sponsored major medical, prescription drug, pre-paid medical reimbursement plans, dental, vision, etc.)
Having personally experienced both systems (and even some “medical tourism”) I can definitely see opportunities for the U.S. to improve overall care and provide reasonable access as long as we begin authentic dialogue and stop the political fear-mongering and pandering that we see on both sides of the debate. For our 17+% of GDP we need to do better.