Since Italy is now at the European epicenter of the COVID-19 epidemic and second only to China in number of
cases and deaths, American scientists and public health officials are now closely scrutinizing Italy’s response and outcomes.
I emailed Nicola to see what his situation was and he provided this information and advice for my readers:
Hello everyone from Milan, as you already know Italy is in lockdown over the new coronavirus (Covid-19). The northern regions of Lombardy, Veneto and Emilia-Romagna have been most affected by the outbreak and what’s happening here it’s just surreal. I just wanted to reach out to you because we all have the responsibilities to prevent this. The majority of infections are mild but the pandemic is growing at an exponential speed. The infection is much more aggressive for certain groups: elderly, cancer patients and patient with cardiovascular disease are at higher risk of dying. Hospitals are severely overloaded and the real problem is that medical staff gets sick.
My only take on is: stay home for as long as possible, lots of contagions happen before there are symptoms. Virus doesn’t spread if people don’tinteract. If we can postpone cases the healthcare system will be able to handle contagions much better. I hope the US authorities will stop public gatherings and everything really not necessary. Last but not least, we need to test everybody as limited testing only postpones the problem.
Dott. Nicola Triglione
Specialista in Cardiologia
For those who want to learn more about the situation in Italy, watch this video interview with Dr. Cecconi of Humanitas University in Milan discussing the region’s approach to the surge, including clinical and supply management, health care worker training and protection, and ventilation strategies, with JAMA Editor Howard Bauchner.
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.
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.
Dr. and Mrs. Skeptical Cardiologist have returned from two weeks in Italy and I have to say, this is one of the most beautiful places I’ve ever seen.
Here are my top 3 experiences:
The Cinque Terre. Five villages tucked into the cliffs above the Mediterranean and connected by trains and trails, featuring gorgeous vistas available to those willing to climb and hike.
2. The heart of Tuscany, in the Val d’Orcia,
3. Florence, chock full of Renaissance architecture, art, tourists and incredible panoramic views from Giotto’s Campanille and the top of the Duomo:
To any patients who were inconvenienced by my delayed return, my sincere apologies. The good news is that your cardiologist is now fully recharged and ready to resume practice with renewed vigor and enthusiasm.
Antonio Maria Valsalva (1666-1723) was an Italian anatomist, physician and surgeon whose name is familiar to cardiologists for two reasons. First, he described what are now termed the sinuses of Valsalva, the three areas of dilatation in the proximal portion of the aorta just outside the opening of the aortic valve.
Second, in his textbook on the ear, De aure humana tractatus, published in 1704 in Bologna, he showed an original method of inflating the middle ear (now called Valsalva’s manoeuvre) in order to expel pus. A variation of this classic Valsalva maneuver is used frequently in cardiology for diagnostic and therapeutic purposes.
The skeptical cardiologist and his newly-minted bride, will be jetting off to Italy in a few weeks but, alas, we are not visiting Bologna. Hopefully we won’t need to utilize the original Valsalva manouevre to equalize the pressure between our middle ears and the cabin atmosphere in order to prevent otic barotrauma as we descend.
I’ve been fascinated by the Roman Empire since I took Latin in high school. I was so obsessed with all things Roman that when my family traveled back to England to visit relatives and such, I insisted on us visiting Hadrian’s Wall. Don’t tell the authorities, but I still possess a rock I took from said wall.
The only time I’ve been to Italy was 30 years ago after presenting at the European Society of Cardiology meeting in Nice, France. I foolishly rented a car and drove north to Lago Maggiore. It was one of the most harrowing experiences of my life.
The Italian Itinerary
This time we are flying into Rome and then taking a train to Florence.
From Florence I’m planning to rent a car (having failed to learn my lesson) to drive to La Foce, an historic estate, which lies on the hills overlooking the Val d’Orcia.
We’ll spend two nights in the B&B portion of this place, which sounds amazing:
Midway between Florence and Rome, it is also within easy reach of Siena, Arezzo, Perugia, Assisi, Orvieto. Renaissance and medieval gems such as Pienza, Montepulciano, Monticchiello and Montalcino are only a few miles away. The countryside abounds in lovely walks among woods and the characteristic crete senesi (clay hills); the food is among the best in Tuscany and famous wines such as the Vino Nobile and Brunello can be tasted in the local cellars. The Val d’Orcia has recently been included among the World Heritage sites of UNESCO.
From the heart of Tuscany, we then drive to the coast of northern Tuscany to meet up with the in-laws in Viareggio.
Lastly, we will travel to Milan, and then fly home.
I’ve got a good idea of what the top tourist destinations are in these cities from reading Rick Steves’ book on Italy and from discussions with friends who have been there.
However, we typically prefer wandering semi-aimlessly in great cities, rather than dealing with large tourist herds at the must-see attractions.
I’m actually more interested in La Specola in Florence than I am in seeing Michaelangelo’s David. La Specola:
spans 34 rooms and contains not only zoological subjects, such as a stuffed hippopotamus(a 17th-century Medici pet, which once lived in the Boboli Gardens), but also a collection of anatomical waxes (including those by Gaetano Giulio Zumbo and Clemente Susini), an art developed in Florence in the 17th century for the purpose of teaching medicine. This collection is very famous worldwide for the incredible accuracy and realism of the details, copied from real corpses. Also in La Specola on display are scientific and medical instruments. Parts of the museum are decorated with frescoes and pietra dura representing some of the principal Italian scientific achievements from the Renaissance to the late 18th century.
I tend to rely on Rick Steves’ books for European travel, but if any readers have experience in these Italian areas please feel free to add them to the comments section or send me an email at email@example.com. I would be especially interested in “off-the-beaten path” things of interest (especially if they have a literary, medical or scientific connection) and restaurant recommendations.
To all my patients, please accept my apologies for any rescheduling this may have caused.
In my absence you will be in good hands as my partners, primarily Brian Kaebnick, will be covering for me.