Public and Private Health Services: Wait Times for Health Services and the Risk of Inequality from the Italian Perspective.

Abstract

Population Health ManagementVol. 24, No. 3 Points of ViewFree AccessPublic and Private Health Services: Wait Times for Health Services and the Risk of Inequality from the Italian PerspectiveAndrea CioffiAndrea CioffiAddress correspondence to: Andrea Cioffi, MD, Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena, 336, Rome 00161, Italy E-mail Address: an.cioffi19@gmail.comDepartment of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.Search for more papers by this authorPublished Online:8 Jun 2021https://doi.org/10.1089/pop.2020.0091AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Recently, it emerged that Medicaid patients have greater difficulty scheduling health care appointments compared with privately insured patients.1 This is very significant, and it is considered that a comparison with the performance provided by the National Health System (NHS) in Italy may be useful.In Italy, the NHS was established in 1978 by Law 833.2 This law has totally revolutionized Italian health care with the aim of providing full population coverage, local control, public funding, and comprehensive services. In Italy today, health care is totally free and accessible to all and is managed by regional health systems: every Italian region is responsible for the health services provided in its territory. However, there are a number of problems that the NHS has not yet solved. The first problem is a significant difference in the quality of health care provided in the north and south. In fact, in the Annual Report of the National Institute of Statistics of 2018, a very worrying picture emerged regarding the differences between north and south in terms of health quality.3 The result of this disparity is that many citizens of southern Italy migrate to the north, hoping to benefit from better quality health services.Another problem, aggravated in recent years, is related to the very long wait times that patients must undergo before receiving an examination, an instrumental investigation, or surgery in Italian public facilities. The Consorzio per la Ricerca Economica Applicata in Sanità (CREA) analyzed average wait times to receive a health service in 4 Italian regions (ie, Lombardy, Veneto, Lazio, Campania) with a sample of 26 million subjects (44% of the Italian population).4 The analysis was conducted over the 3-year period (2014-2017) and revealed that the average wait time to receive a (nonurgent) health service in public facilities is 65 days. On the contrary, the average wait time for a private health benefit is about 7 days. In addition, visits and specialist tests require longer wait times on average. These results are in line with the findings of the Hsiang et al1 study that analyzed health data from the United States and found that Medicaid patients have reduced access to appointments compared with their privately insured counterparts. Specifically, Medicaid patients have a more difficult time securing an appointment for specialty care compared with primary care.Moreover, what also has emerged from the CREA data is that, unlike public services, intramoenia services, like totally private ones, have much shorter wait times. (In the Italian NHS, intramoenia services are paid health services provided by an individual doctor employed by a public hospital but outside of regular working hours and using the facilities of the hospital itself. Part of the doctor's income is paid to the hospital.) This shows that the discriminating element in the differences in wait times is payment for health care: If you pay, you get an appointment for a medical examination or for a diagnostic investigation more quickly; if you don't pay, you can wait ≥2 months. The risk, of course, is that health care will become easily accessible only to well-off citizens.Although the context of public institutions is characterized by a “lower quality” (the long wait before a visit or survey is an important quality indicator), it is believed that publicly funded health systems can provide quality of care that is potentially as high as, if not higher than, that of private health systems.5Of course, this gap in the waiting period for the provision of health care between public and private health care undermines citizens' right to health. Like all fundamental rights, states have a duty to safeguard this right by promoting and ensuring all the conditions necessary to protect it. Moreover, the aforementioned gap in the quality of health care between north and south (within the NHS) shows that, as is evident in the regions of northern Italy, public health can be at least comparable with private health care in terms of quality of care, although the opposite may be thought.5 The protection of public health care should be a fundamental objective of the Italian State but also an objective to be achieved in regions where health care is not fully accessible to all without socioeconomic distinctions. Certainly, private health care is an important tool available to citizens who must, however, have choices and, above all, must have the opportunity to have access to necessary (even expensive) health care that they could not afford in the private sector. Definitely, the optimization of health care based on public funding would not exclude the usefulness of health based on private funding, in order to achieve a “pluralist health care” with a “combined logic” that would benefit the patient and her or his freedom of choice. For example, according to the report of the Italian Institute for Socioeconomic Research, Italians prefer to access both public and private health facilities.6According to a report by the World Health Organization (WHO), health and diseases are not evenly distributed in society. This means that, to date, an individual's health depends on the region of the world in which he or she is born and on the social position he or she holds.7Nevertheless, in the 21st century – with the attainment of a new social, bioethical, legal patient awareness8 – the failure of health systems because of public funding cannot be acceptable. It is instead necessary to strengthen them.Therefore, the optimization of public health care, which must be made competitive with private standards, is a fundamental objective because the approach of public health facilities must be based on the rights of citizens. This makes national governments guarantors of these rights, facilitating access for all, including the most deprived, to essential health services.With the COVID-19 emergency further increasing wait times for health care in public health, the Italian Ministry of Health has, in fact, issued a measure that obliges the postponement of all health services that are not urgent or to be carried out within 10 days.9 It is not yet clear when the provision of health care in public health will resume. Surely the accumulation of visits and medical tests that are occurring in this period will become a serious problem for the NHS. From now on it is essential to plan for a recovery of the normal functioning of the health system. It is unthinkable that we can postpone the predisposition of specific health policies, until when the emergency will end. Even in emergency situations, it is essential to be able to protect the right to health of all citizens. To do this it will be necessary to adequately finance public health and closely monitor the functioning of the NHS in the post-emergency phase.Author Disclosure StatementThe author declares that there are no conflicts of interest.Funding InformationNo funding was received for this article.