Policy responses for Italy - HSRM


Policy responses for Italy

4. Paying for services

Adequate funding for health is important to manage the excess demands on the health system. This section considers how countries are PAYING FOR COVID-19 SERVICES. Health financing describes how much is spent on health and the distribution of health spending across different service areas. The section also describes who is covered for COVID-19 testing and treatment, whether there are any notable gaps (in population coverage and service coverage), and how much people pay (if at all) for those services out-of-pocket.

4.1 Health financing

On May 15 2020, the government adopted a further €55 billion (3.5 percent of GDP) “Relaunch” package of fiscal measures. It provides funds for the healthcare system (€3.3 billion). According to a report conducted by ALTEMS, by 26th May 2020, the 144,658 Covid-19 hospitalizations for COVID-19 with positive outcomes, each valued at an average DRG of EUR 8,476 has an estimated total cost of EUR 1,226,137,474, of which 33% sustained by Lombardy. The estimated 23,069 hospitalizations for COVID-19 with death as an outcome, each valued at an average DRG of EUR 9,796, have led to an estimated overall cost of EUR 225 958 333 of which 48% sustained by Lombardy. Considering a total of 176,145 days of hospitalization (at 26th May) in ICUs, with an average daily cost of EUR 1,425, the burden on the entire country is  EUR 250 million, 36% of which is attributable to Lombardy.

Under Italy’s National Recovery and Resilience Plan for accessing the EU Recovery Fund to be finalized by April 2021 (See Section 6 Measures in other sectors: the economy), measures addressing the healthcare sector in particular, specify the intention to invest in digitization, urging the spread of electronic health records and of telemedicine systems. Investments will be put towards improving care for patients with chronic conditions and home care (including enhancing prevention services) and care in nursing homes. An important contribution will be destined to support medical, immunological and pharmaceutical research.

As a consequence of the EU Cohesion Fund mobilization authorised by the European Commission on 22 September 2020 (see also Section 6. Measures in other sectors), both the regions of Lombardy and Sicily have received additional funds to be put towards strengthening their health services (EUR 193 million and 4.3 million respectively).

The National Health Budget
The 2019 National Health Budget was EUR 113,810 million for the three-year period 2019-2021. At the time, the forecast amount for 2020, was EUR 116 439 million and EUR 117 939 million for 2021. Due to the COVID-19 pandemic, the actual expenditure was EUR 119 556 million for 2020. In fact, Stability Law 2021 (Law 178/2020) has set the National Health Budget for 2021 to EUR 121 370 million.

Among the initiatives, specific funds have been allocated to incentivize health workers engaged during the emergency. EUR 105 million have been allocated to raise the number of  medical internships, EUR 5 million to increase the production and procurement of oxygen – in response to the severe lack of supply experienced during the acute phase of the pandemic and EUR 400 million for the purchase of COVID-19 vaccines and drugs . Furthermore, the reinforcement of rapid antigen swab testing was supported by another EUR 70 million, to enable GPs and paediatricians to perform them. Lastly, EUR 100 million will be dedicated to the improvement of healthcare facilities and buildings.

In March 2021 Law Decree 41 allocated EUR 345 million to fund the work of health professionals (eg. GPs, specialists, pediatricians, dentists, medical interns) responsible for the administration of COVID-19 vaccines.

- ALTEMS Covid-19 working group - Instant REPORT#9: 28 Maggio 2020  - Analisi dei modelli organizzativi di risposta al Covid-19, available at http://www.cerismas.com/web/images/COVID-19/InstantReport/INSTANT_REPORT_NUMERO_9.pdf
- https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=85796
- https://sep.luiss.it/sites/sep.luiss.it/files/Aspen%20Institute%20Italia%20Recovery%20Fund.pdf
- https://www.adnkronos.com/fatti/politica/2020/09/16/linee-guida-del-governo-recovery_qAfPoFtKbn0KgRIVIQDCGL.html
- http://www.regioni.it/news/2020/09/21/ue-riassegna-660-mln-a-italia-su-fondi-coesione-contro-crisi-covid-618800/
- Senato della Repubblica e Camera dei Deputati. Principali iniziative dell'Unione europea per fronteggiare l'impatto economico-sociale della pandemia COVID-19. 21 Settembre 2020 [Available at: http://documenti.camera.it/leg18/dossier/pdf/AT039.pdf?_1601306858343]
- https://www.quotidianosanita.it/governo-e-parlamento/articolo.php?articolo_id=91256
- https://www.mef.gov.it/focus/Legge-di-Bilancio-2021/
- http://www.quotidianosanita.it/governo-e-parlamento/articolo.php?articolo_id=90913
- https://temi.camera.it/leg18/temi/tl18_il_fabbisogno_sanitario.html
- http://www.quotidianosanita.it/governo-e-parlamento/articolo.php?articolo_id=93907 
- Department of Civil Protection ‘Linee di indirizzo organizzativo e strutturale dei punti vaccinali territoriali straordinari relativi alla campagna di vaccinazione anti SARS-COV-2/COVID-19”, March 2021. [Available at: http://www.quotidianosanita.it/allegati/allegato9668681.pdf]

The Coronavirus emergency in Italy has been addressed with additional funds for the National Health Service (NHS).  There are two main channels of additional funding:

1) State funding in accordance with the “Cure Italy” Legislative Decree approved on 17th March 2020, which provides for an allocation of EUR 3.2 billion to the National Health Service and the Department of Civil Protection, out of the total 25 Billion emergency fund approved by the government (as of April 2nd).
2) Philanthropic activities of individual citizens and large companies in support of regions, municipalities and health care providers (a total of EUR 425.6 million donated as at 29th March 2020).

This funding does not follow the “usual” channels because the Decree allows companies, agencies and National Health Service bodies to use (until 31st July) the proceeds of donations and government financing more quickly. It is possible to purchase supplies and useful services with direct credit lines, without tenders and without consulting two or more economic operators, as is generally required for public administrative bodies (Article 99). Moreover, these funds are intended to be “extraordinary” because the huge support of the philanthropic initiatives augments the budgets established by regional decrees. All expenses, financing and donations are recorded by opening special accounts, named COVID19, and must be published for reasons of transparency and reporting.

The provision of EUR 3.2 billion to the NHS and Department of Civil Protection are designated to:
• Hire 20 000 new NHS employees
• Increase the National Emergency Fund by EUR 1.65 billion
• Allocate EUR 250 million to pay overtime to healthcare workers
• Allocate EUR 340 million to increase the number of Intensive Care Unit beds
• Allocate EUR 50 million to subsidize companies that produce masks and related products (managed by Invitalia).
• Cover the costs for potential use of movable property or hotels to face the emergency (EUR 150 million)
• Allocate resources for prevention and sanitization measures for industries, schools etc.

In 2020, the resources earmarked to pay overtime for NHS health workers directly employed in COVID-19 related activities have been increased. The expenditure of EUR 250 million is authorized from the current health financing budget established for the year 2020 and will be given to regions through fast-track procedures. Moreover, additional funds (totalling EUR 30 million) have been designated for the purchase of baby-sitting services for the assistance and supervision of children up to 12 years of age.

As far philanthropic activity is concerned, two main channels for collecting donations are possible:
• Current accounts activated by Regions and hospitals (through the Security Decree, it was possible to open special accounts to collect donations, which will be used directly by the beneficiaries)
• Online crowdfunding platforms, hosting numerous campaigns promoted by private citizens, third sector entities and other philanthropists. One example is the innovative non-profit start-up, Italia, which developed a platform to highlight the fundraisers promoted by hospitals. In parallel, the start-up also monitors all other philanthropy initiatives launched by companies, foundations and individuals to support the emergency: 309 have so far been mapped, involving 76 non-profit organizations, for a total of EUR 425.6 million donated.

Beneficiaries are free to choose how they use their donations (upon a quick assessment of needs), unless specific uses are outlined by the donors. All expenses are recorded by opening a special balance sheet account, named COVID-19, and must be published for reasons of transparency and reporting. The funds are mainly directed towards the improvement of intensive and sub-intensive care units, with the creation of new beds and the purchase of necessary equipment. Particular priority is given to the purchase of protection equipment for healthcare and non-healthcare personnel.

As of April 16th, EUR 125 million had been donated by Italian citizens to the Department of Civil Protection to purchase hospital equipment for the crisis. A Private Donor has also opened a fund to support families of healthcare professionals who died during the emergency while caring for Covid-patients.
- https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#I
- http://www.mef.gov.it/en/inevidenza/Protect-health-support-the-economy-preserve-employment-levels-and-incomes-00001/ 
- https://www.marionegri.it/magazine/coronavirus
- http://www.askanews.it/cronaca/2020/03/23/coronavirus-gallera-in-corso-acquisto-di-100-mila-saturimetri-pn_20200323_00067/

Primary Care Funding
The remuneration system for primary care doctors (GPs and paediatricians) is the result of a series of agreements between the central government and trade unions.  Total compensation, which is drawn from the Italian healthcare budget built on a tax-based funding system, is composed of a fixed per-capita payment plus a fee-for-service remuneration for home visits and additional service commissions. Furthermore, extra payments may derive from financial incentives linked to structural indicators such as the use of computerized systems or the recruitment of support staff or other medical personnel (secretarial or nursing staff medical assistants etc). Regions are then allowed to set additional compensation for the remuneration of primary care doctors at their discretion.
These provisions have not been changed during the Covid-19 emergency, however the national government has authorized additional expenditure for overtime work related to the emergency, making available extra public funding.
All doctors, nurses and other healthcare professionals employed by the NHS, or by public or private healthcare facilities insured with INAIL, that contract COVID-19 in the workplace are covered by insurance for occupational accidents. In fact, it is presumed that the contraction of the  infection is a direct consequence of performed duties. NHS doctors working in quarantine receive sickness leave compensation, whereas those working independently (not under the NHS) may be at risk of income losses. Given the need of physicians to face the crisis, new job opportunities for clinicians and nurses have been made available and the Government has allowed GP trainees in their last year of training to practice. Doctors and other health professionals are expected to receive PPEs from their NHS organization, however shortage of supply has been reported in the initial phase of the crisis.

- SISAC, Verbale preintesa Accordo Collettivo Nazionale per la disciplina dei rapporti con i medici di medicina generale, Luglio 2019
- Kringos D, Boema W, Hutchinson A, Saltman R. 2015. Building primary care in a changing Europe-Case studies.
- https://www.inail.it/cs/internet/comunicazione/news-ed-eventi/news/news-nota-17-marzo-contagi-coronavirus-sanita-2020.html 
- https://www.ilsole24ore.com/art/la-catena-danese-tiger-dona-10mila-mascherine-lombardia-lardini-produce-le-marche-ADxFMVI