Background
Introduction
The measurement of PCC activity and expenditure
Research goals and contributions
Methods
The collaborative research procedure
Foundations
| |
Tiers
| The INHS has three tiers: Central Government, responsible for guaranteeing essential levels of assistance for every citizen; 21 Regional Governments; and 154 Local Health Authorities (LHAs and 95 Independent SSN Hospitals (or IHs; similar to British NHS Trusts). The LHAs are regional public agencies that manage healthcare services for subsets of the regional population in a defined geographical area. Each LHA serves an average population of about 390,000 inhabitants and manages an average budget of 662 million euros, partly for in-house provision, partly to purchase services from public IHs (on average, 132 million euros per LHA, [23]) and from private contracted providers (on average, 128 million euros per LHA, [23, 24]). |
Reforms
| Over the last 15 years the INHS has undergone a series of reforms that have introduced quasi-markets, regionalization, and managerialism. A quasi-market system implies that money follows the patient: LHAs pay a provider for their resident’s consumption of healthcare if this is not provided directly by themselves. Patients are free to choose other public or private providers from elsewhere in the country and services are paid for by their LHA [25]. The LHAs are usually funded on a capitation basis and each LHA is expected to reimburse other LHAs, IHs, and accredited private providers for services supplied to its residents [25]. However, regionalization reforms have led to significant variability in how this model is implemented, mainly in the number of facilities directly managed by LHAs, in the degree of autonomy of LHAs in strategic and operational decisions, and in the modification of the capitation funding scheme to match historic expenses. |
The data collection
Results
LHA expenditure on types of PCC service and trends in the period 2003-2007
Type of service | Average cost per inhabitant 2007 (in euros) | % on total expenditure | Standard deviation in euros(and%on average cost per inhabitant) | Average yearly percentage variation between 2003 and2007 |
---|---|---|---|---|
Hospital admissions | 697 | 41% | 89 (13%) | 2% |
Pharmaceutical | 273 | 16% | 37 (14%) | 2% |
Outpatient visits and examinations | 220 | 13% | 76 (35%) | 7% |
General Practitioners (including night service) | 103 | 6% | 9 (9%) | 3% |
Admissions of elderly people to residential structures | 77 | 5% | 39 (51%) | 4% |
Mental healthcare | 59 | 4% | 22 (37%) | 2% |
Prevention, public health and screening | 56 | 3% | 14 (25%) | 3% |
Emergency services | 49 | 3% | 26 (53%) | 6% |
Rehabilitation | 28 | 2% | 27 (95%) | 9% |
Disabled people | 35 | 2% | 24 (68%) | 9% |
Prosthesis | 27 | 2% | 11 (40%) | 4% |
Home healthcare | 22 | 1% | 11 (50%) | 7% |
Mother and child | 18 | 1%w | 12 (65%) | 3% |
Dependencies | 16 | 1% | 4 (25%) | 17% |
Hospice | 3 | 0% | 3 (118%) | 6% |
Overall cost per inhabitant | 1,682 | 100% | 171 (10%) | 3% |
Type of service | Description of the service |
---|---|
Hospital admissions | Costs for ordinary and day hospital admissions. It includes all the costs for inpatients and is measured through DRG system |
Pharmaceutical | Costs for drugs distributed directly or through local private chemists |
Outpatient visits and examinations | It includes the costs for specialist visits in hospital and ambulatory facilities, diagnostic exams and laboratory exams to outpatients |
General Practitioners (including night service) | It includes the costs for General Practitioners, General Practitioners for children under 14 (“Pediatri di Libera Scelta” in the INHS) and 24 hours, night service |
Admissions of elderly people to residential structures | Costs for institutionalization of old people (>65) in intermediate facilities and for access to daily structures, including healthcare assistance |
Mental healthcare | Costs for institutionalization and ambulatory services for mental care. It does not include neuro-psychiatry (included in mother and child) and dependencies |
Prevention, public health and screening | Costs for screening programs (e.g. Colon-rectum cancer and breast cancer) and more general expenditure for illness prevention managed by LHAs |
Emergency services | It includes emergency departments and ambulance services |
Rehabilitation | Costs for long term care in residential, intermediate structures and in ambulatory facilities. It does not include assistance in hospital departments for inpatients (included in hospital admissions) |
Disabled people | Costs for institutionalization of disabled people in residential structures and ambulatory services, including eventual vouchers to be spent by disabled people |
Prosthesis | Costs for providing and managing prosthesis |
Home healthcare | Mono-professional or multi-professional (eg. GPs, nurses, specialists) home care |
Mother and child | Costs for ambulatory services including family planning clinics, neuro-psychiatry for children and community support to lone parents |
Dependencies | It includes ambulatory services for dependencies. |
Hospice | Costs for admissions in hospice structures |
Overall cost per inhabitant | Full costing for citizens’ healthcare. It includes administrative and general costs (eg. Costs for LHAs’ top managers), which are shared in percentage to all the other services. It also includes eventual health expenditure deficits (which have an average value within our sample of 2.5% of the overall expenditure) [28]. |
Activity indicator | Average value 2007 | Standard deviation and%on the average value | Average yearly percentage variation between 2003 and2007 |
---|---|---|---|
Hospitalization rate per 1,000 inhabitants | 194 | 42 (22%) | −3% |
Inappropriate access to Emergency Services per 1,000 inhabitants | 98 | 68 (70%) | −2% |
Inappropriate hospital admissions (51 DRGs) per 1,000 inhabitants | 20 | 13 (67%) | −4% |
Access to mother and child structures per 1,000 inhabitants | 174 | 128 (74%) | + 6% |
Access to mental health structures per 1,000 inhabitants | 195 | 171 (77%) | + 8% |
Home care visits per 1,000 inhabitants | 425 | 161(38%) | + 9% |
Variance in expenditure and activity among LHAs
Indicator | LHA 1 | LHA 2 | LHA 3 | LHA 4 | LHA 5 | LHA 6 | LHA 7 | LHA 8 | LHA 9 | LHA 10 | LHA 11 | LHA 12 | LHA 13 | Average value |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Hospitalization rate per 1,000 inhabitants | 188 | 173 | 142 | 150 | 222 | 284 | 186 | 191 | 225 | 191 | 185 | 194 | ||
Inappropriate access to Emergency Services per 1,000 inhabitants | 136 | 31 | 137 | 57 | 60 | 165 | 41 | 35 | 100 | 228 | 99 | |||
Inappropriate hospital admissions (51 DRGs) per 1,000 inhabitants | 11 | 22 | 14 | 15 | 17 | 40 | 22 | 5 | 38 | 10 | 20 | 33 | 21 | |
Access to mother and child structures per 1,000 inhabitants | 432 | 53 | 30 | 222 | 175 | 111 | 253 | 37 | 78 | 104 | 341 | 250 | 174 | |
Access to mental health structures per 1,000 inhabitants | 466 | 275 | 237 | 84 | 101 | 42 | 244 | 43 | 311 | 192 | 380 | 28 | 200 | |
Home care visits per 1,000 inhabitants | 514 | 594 | 87 | 444 | 477 | 221 | 530 | 393 | 579 | 494 | 231 | 531 | 425 |
Indicator | Description |
---|---|
Hospitalization rate per 1,000 inhabitants | Number of admissions to public and private hospitals per 1,000 LHA inhabitants in 2007. Data have been weighted for inhabitants’ age and sex. They have been also validated by the Regions. |
Inappropriate access to Emergency Services per 1,000 inhabitants | White code access to Emergency Services per 1,000 LHA inhabitants in 2007. Data have been weighted for inhabitants’ age and sex. |
Inappropriate hospital admissions (51 DRGs) per 1,000 inhabitants | Overall number of admissions to public and private hospitals for a list of 51 Diagnosis Related Groups listed by the Italian Ministry of Health as at high risk of inappropriateness, for 1,000 LHA inhabitants in 2007. Data have been weighted for inhabitants’ age and sex. |
Access to mother and child structures per 1,000 inhabitants | Overall number of registered accesses to clinics or other structures devoted to mother and child health managed by LHAs for 1,000 non-weighted LHA inhabitants in 2007. |
Access to mental health structures per 1,000 inhabitants | Overall number of registered accesses to mental health structures managed by LHAs for 1,000 non-weighted LHA inhabitants in 2007. |
Home care visits per 1,000 inhabitants | Overall number of home visits provided by LHA PCC services or by private providers financed by LHA for 1,000 non-weighted LHA inhabitants in 2007. |
Aggregation of services | Yearly percentage variation in expenditure 2003-2007 |
---|---|
Primary and ambulatory services | + 4% |
of which: primary care | + 3% |
of which: home care | + 7% |
Intermediate structures with patients’ admission | + 5% |
of which: structures for old people | + 4% |
of which: rehabilitation structures | + 9% |
Prevention and Public Health and Mental Health Departments | + 2% |
of which: mental healthcare | + 2% |
of which: prevention and public health | + 3% |