Synergus

The Italian National HTA body (Agenas) recently published a report to evaluate the current national and regional regulation of patients’ co-payments for put-patient care.

The analysis considers the overall normative context as of April the 31st 2015 (link).

The Italian publicly funded Servizio Sanitario Nazionale (SSN) envisages forms of patient’s co-payments (called ticket in Italy) for out-patient services and pharmaceuticals. The impact of these co-pays has been growing during the last years as an effect of the increasing financial constraints existing for regional healthcare systems.

Tickets for out-patient care were firstly regulated by the Law No. 553/1993, which introduced national co-pays for specialist services up to a limit of €36.15 for each referral. Regions, however, were acknowledged a level of autonomy in setting different maximum caps (Only 5 Regions introdued different caps) and in introducing possible additional forms of cost sharing.

The Table below summarizes the regulative setting in Italian regions as of April the 31st 2015.

The Decree Law No. 98/2001 introduced an optional and additional co-pay of €10 per referral. Regions were again left free to substitute this co-pay on referral with different measures able to grant the same increase in revenues on local budgets.

Province of Trento the alternative measure (consisting of €3 co-pay per referral) will be implemented on September the 1sr of 2015.

Regions adopting alternative measures to the €10 co-pay implement very different tools. Two main groups of policies can be identified: As of today, 3 regions (Aosta Valley, A.P. Bolzano, Basilicata) have not introduced the €10 additional co-pay set by the Legislative Decree of 2011, 9 regions applied it and 10 regions rely on alternative measures.

1. The ticket per referral is calculated by considering household income. Veneto, Emilia Romagna, Marche, Tuscany and Umbria implement this model. However, both income ranges considered and the criteria used to calcite house hold income.
2. The ticket per referral is calculated by considering the value of the service prescribed in the referral.  Piedmont, Lombardy and Friuli-Venezia Giulia refer to this scheme.

Also criteria for exemption largely vary in the country. The national Law makes exempt from paying the ticket some particular categories of citizens identified according to:

• their health status (patients with some chronic diseases, with rare diseases, pregnant women and disables) 
• their age (children below 6 years and the elderly above 65 do not pay any co-payment) 
• their social and income status (e.g. unemployed whose household income is lower than €8,263.31

Moreover screening tests for HIV and some forms of cancer are set as free of charge for patients.
Most of the regions enlarged the spectrum of these exemptions by including additional health conditions, additional social factors or by modifying income thresholds.
The extremely diverging regulation implemented in regional healthcare systems reveals how different criteria are used and different economic incentives may arise for patients when they access out-patient care.
On the other hand, Agenas itself underlines how the consumption of out-patient services has extremely diminished in all SSN during the last years. Main reasons are both the increase of co-payments, which led many patients to shift to seek services to private providers, and the reduced supply of public providers, due to the increasing budget constraints existing on regional systems.