Milena Vainieri

Disinvestment for re-allocation: A process to identify priorities in healthcare

Resource scarcity and increasing service demand lead health systems to cope with choices within constrained budgets. The aim of the paper is to describe the study carried out in the Tuscan Health System in Italy on how to set priorities in the disinvestment process for re-allocation. The analysis was based on 2007 data benchmarking of the Tuscan Health System with an impact on the level of resources used. For each indicator, the first step was to estimate the gap between the performance of each Health Authority (HA) and the best performance or the regional average. The second step was to measure this gap in terms of financial value. The results of the analysis demonstrated that, at the regional level, 2-7% of the healthcare budget can be re-allocated if all the institutions achieve the regional average or the best practice. The implications of this study can be useful for policy makers and the HA top management. In the context of resource scarcity, it allows managers to identify the areas where the institutions can achieve a higher level of efficiency without negative effects on quality of care and instead re-allocate resources toward services with more value for patients.

Assessment and Improvement of the Italian Healthcare System: First Evidence from a Pilot National Performance Evaluation System

EXECUTIVE SUMMARY The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.

What drives hospital performance? The impact of comparative outcome evaluation of patients admitted for hip fracture in two Italian regions

Background From 2006 to 2007 Lazio and Tuscany, two Italian regions, released data about hospital performance and implemented strategic programmes aimed at improving the quality of hospital care. Furthermore, different pay-for-performance systems were introduced: the hospitals performance determined the DRG (Diagnosis-Related Group) reimbursement rate for Lazio providers while in Tuscany the chief executive officers compensation was linked to the hospitals performance. The authors evaluated the impact of the Lazio and Tuscany programmes on quality of healthcare for orthopaedic patients compared with other Italian regions. Methods The proportion of older patients admitted with hip fractures who had surgery within 48 h and the median waiting time for surgical treatment of fractures of the tibia or fibula were estimated separately for Lazio, Tuscany and other Italian regions for two periods: 2006–2007 and 2008–2009. Risk-adjusted proportions were obtained using the direct standardisation method and a multivariate logistic regression was performed taking into account age, gender and comorbidity status. Results The proportion of hip operations performed within 48 h was increased by 34% for Lazio (p<0.001) and 46% for Tuscany (p<0.001) and reduced by 3% in other Italian regions (p<0.001). To assess for possible adverse consequences, such as increased waiting times for other orthopaedic procedures, the authors monitored time to surgery for tibia or fibula fractures. There were no significant differences in the median time to surgery for tibia or fibula fractures between the two periods. Conclusions The Lazio and Tuscany programmes appeared to have a positive impact on quality of care for older patients admitted with hip fracture without having a negative impact on other orthopaedic interventions. The results highlight the need for continuous quality improvement by repeating the evaluation process and by combining the performance system with a management strategy.

Relationships between technical efficiency and the quality and costs of health care in Italy

Objectives This paper reports the measurement of technical efficiency of Tuscan Local Health Authorities and its relationship with quality and appropriateness of care. Design First, a bias-corrected measure of technical efficiency was developed using the bootstrap technique applied to data envelopment analysis. Then, correlation analysis was used to investigate the relationships among technical efficiency, quality and appropriateness of care. Setting and Participants These analyses have been applied to the Local Health Authorities of Tuscany Region (Italy), which provide not only hospital inpatient services, but also prevention and primary care. All top managers of Tuscan Local Health Authorities were involved in selection of the inputs and outputs for calculating technical efficiency. Main Outcome Measures The main measures used in this study are volume, quality and appropriateness indicators monitored by the multidimensional performance evaluation system developed in the Tuscany Region. Results On average, Tuscan Local Health Authorities experienced 14(%) of bias-corrected inefficiency in 2007. Correlation analyses showed a significant negative correlation between per capita costs and overall performance. No correlation was found in 2007 between technical efficiency and overall performance or between technical efficiency and per capita costs. Conclusions Technical efficiency cannot be considered as an extensive measure of healthcare performance, but evidence shows that Tuscan Local Health Authorities have room for improvement in productivity levels. Indeed, correlation findings suggest that, to pursue financial sustainability, Local Health Authorities mainly have to improve their performance in terms of quality and appropriateness.

Making governance work in the health care sector: evidence from a 'natural experiment' in Italy

The Italian Health care System provides universal coverage for comprehensive health services and is mainly financed through general taxation. Since the early 1990s, a strong decentralization policy has been adopted in Italy and the state has gradually ceded its jurisdiction to regional governments, of which there are twenty. These regions now have political, administrative, fiscal and organizational responsibility for the provision of health care. This paper examines the different governance models that the regions have adopted and investigates the performance evaluation systems (PESs) associated with them, focusing on the experience of a network of ten regional governments that share the same PES. The article draws on the wide range of governance models and PESs in order to design a natural experiment. Through an analysis of 14 indicators measured in 2007 and in 2012 for all the regions, the study examines how different performance evaluation models are associated with different health care performances and whether the network-shared PES has made any difference to the results achieved by the regions involved. The initial results support the idea that systematic benchmarking and public disclosure of data are powerful tools to guarantee the balanced and sustained improvement of the health care systems, but only if they are integrated with the regional governance mechanisms.

Managing waiting times in diagnostic medical imaging

Objective This paper aims to analyse the variation in the delivery of diagnostic imaging services in order to suggest possible solutions for the reduction of waiting times, increase the quality of services and reduce financial costs. Design This study provides a logic model to manage waiting times in a regional context. Waiting times measured per day were compared on the basis of the variability in the use rates of CT and MRI examinations in Tuscany for the population, as well as on the basis of the capacity offered with respect to the number of radiologists available. The analysis was performed at the local health authority level to support the decision-making process of local managers. Setting Diagnostic imaging services, in particular the CT and MRI examinations. The study involved all the 12 local health authorities that provide services for 3.7 million inhabitants of the Italian Tuscany Region. Primary and secondary outcome measures Participants: the study uses regional administrative data on outpatients and survey data on inpatient diagnostic examinations in order to measure productivity. Primary and secondary outcome measures The study uses the volumes per 1000 inhabitants, the days of waiting times and the number of examinations per radiologist. Variability was measured using the traditional SD measures. Results A significant variation in areas considered homogeneous in terms of age, gender or mortality may indicate that the use of radiological services is not optimal and underuse or overuse occurs and that there is room for improvement in the service organisation. Conclusions Considering that there is a high level of variability among district use rates and waiting times, this study provides managers with a specific tool to find the cause of the problem, identify a possible solution, assess the financial impact and initiate the eventual reduction of waste.

Healthcare Resources and Expenditure in Financial Crisis: Scenarios and Managerial Strategies

Objective: What are the implications of financial crisis on healthcare expenditure? This paper explores different approaches applied across European countries focusing on the role that managerial tools may have in coping with this challenge. Method: The paper reports the results of recent studies on responses to financial crisis from European countries and which are the techniques they had applied to reallocate resources. Results: Although resources scarcity, some governments did not reduce the healthcare expenditure because they believe in its focal role on the economic development and on maintaining social cohesion and protection of vulnerable people. Other countries decided a strong reduction of costs which often has affected services delivered. In both cases authors suggest to avoid across-the-board cuts in favor of approach involving priority setting. Conclusion: The public sector has assumed new responsibilities following the global crisis and the rising demand for social services. Some countries shifted the healthcare costs from the public purse to private households undermining the survival of the health system and the universal coverage. A way to avoid this risk is based on the ability to share discussion about where to cut and where to reallocate resources.

Performance Measurement Features of the Italian Regional Healthcare Systems: Differences and Similarities

A growing number of factors among which rising costs, technological advancements, aging population, health market failure and medical errors, led many industrialized countries to manage their health services and goals through performance measurement (Arah et al, 2003; Kelley & Hurst., 2006; Smith, 2002). In this context it became a commonplace for countries to formally assess the performance of their healthcare system (Mc Loughlin et al., 2001). Since the 1980s the introduction of “New Public Management” (NPM) principles has promoted a number of reforms in order to drive a more efficient, effective and accountable public sector (Hood, 1995a; Lapsley, 1999; Saltman et al. 2007). OECD countries have applied these principles in different ways with different emphasis (Hood 1995b). Among the NPM principles, the one asking the public sector to adopt more explicit and measurable standards of performance measurement, has motivated countries to create different performance measurement systems (PMS). In the Italian health sector, the development of PMS can be traced back to the 90s reforms that introduced managerial tools and devolved the organization and assessment of healthcare services to Regions. This devolution, enforced by the recent federalist reform of 2009, has led Regions to shape their own organizational structures and relationships among health system actors (Censis, 2008; Formez, 2007). As a consequence of these reforms, Italy has now 21 Regional Health Systems with significant differences from each other. On the basis of these considerations the Italian health sector provides with an interesting scenario in order to detect and analyze the differences and similarities in PMS adopted by the Regional governments. This chapter attempts to provide a cross sectional analysis of the Italian Regional PMS characteristics using evidences of an empirical study carried out in 2008-2009.

Priorities and targets: supporting target-setting in healthcare

Management by objectives requires selecting the appropriate number of indicators to measure objectives and then defining high-priority indicators. Failing to address these two issues often results in the so-called ‘performance paradox’. This paper describes an algorithm applied in the healthcare sector in the Italian regions. The resulting performance evaluation system is able to detect priority indicators in the target-setting phase, improving management and saving costs.

Esternalizzazione e centralizzazione dei processi di approvvigionamento: risultati e criticità dell'esperienza degli Estav nella sanità toscana

Le opportunita ed i vantaggi derivanti dall’esternalizzazione e dalla centralizzazione dei processi aziendali, evidenziati in letteratura nel contesto privato, sono riscontrabili anche nel contesto sanitario pubblico? L’articolo si propone di compiere una prima valutazione dei risultati raggiunti in Toscana con l’introduzione degli ESTAV, la cui istituzione e avvenuta per razionalizzare, a livello sovra-aziendale, le funzioni tecnicoamministrative ed in particolare gli approvvigionamenti. Valutando i risultati raggiunti in termini di efficienza e di efficacia, viene evidenziato come tale esperienza presenti, pur con ampi spazi di miglioramento, risultati indubbiamente positivi e assimilabili a quelli presenti nel contesto privato.