Improving the governance of the health system: the example of Veneto Region 8 June 2017, 10:00 – 12:30, room P7C050, European Parliament, Brussels Domenico Mantoan General Director, Health and Social Care Area, Veneto Region

Veneto Region Veneto Italia VENETO Chronic 65% of > 65 years Population 4.9 million 59.8 million Gdp 30,500 euro 26,700 euro Life expectancy at birth M: 80.7 F: 85.4 M 80.1 F: 84.7 Unemployment 7.1% 12.1% % < 14 years 13.8% 13.7% % > 65 years 22% Net migration -0.3 +0.4 Average age at childbirth 31.9 31.6  Old age ratio 159.4 157.7 Healthcare costs pro capita 1 794 euro 1 849 euro VENETO Chronic 65% of > 65 years disability 25% of >75 years Childbirth 37.000 Heart failure 1.5% Diabetes 5.4% Cancer mortality 30,9% (-0.4% in 3 years) Tasso di diasoccupazioen il secodno p http://demo.istat.it/altridati/indicatori/index.htmliù basso d’italia

STRATEGIES, TOOLS, PRINCIPAL RESULTS

Long-term planning policies REGIONAL HEALTHCARE PLAN (2012) HOSPITAL (2013) AND TERRITORIAL FORMS (first time) OBJECTIVES OF GENERAL DIRECTORS 4

COST LIMITS & ACTIVITIES In the Veneto: the use of specific instruments STANDARD COST LIMITS & ACTIVITIES HTA THROUGH ACTIONS ON ….. “CORE” HEALTHCARE PROCESSES Prevention Hospital care Specialist Intermediate care Primary care Pharmaceutical Social …. SUPPORT PROCESSES Human resource management Economic resource management Balance Management Management control Acquisitions 5

In the Veneto: STARTING PARAMETERS Hospitalization: Hospital Beds: Ambulatory Performance: Personnel: Pharmaceutical: Hospitalization rate and compliance with national " hospital standards" Outpatient service use rate (excluding laboratory) Economic limit for single organization in comparison with the national limit Minimum Care Time Agreed pharmaceutical cost Economic limit for single organization on pharmaceuticals and devices 135 /1000 3,5 /1000 4 /1000 limit MCT 114 pro capita limit

Synthesis Activity Data   2013 2014 2015 2016 2013-2016 Hospital beds /1000 inhab. 3,74 3,78 3,66 3,59 -4% HOSPITALIZATION RATE /1000 inhab. 134,03 132,42 130,8 130,19 -3% OUTPATIENT SERVICES (LAB EXCLUDED )/1000 inhab. 3,89 3,88 3,73 3,5 -10% AGREED PHARMACEUTICAL COST PRO CAPITA 120,1 116,5 113,7 -5% NUMBER OF EMPLOYEES 57.844 57.835 57.679 58.152 1%

Governance of the personnel Regional analysis and monitoring MONITORing of Region DEFINItion DGR n. 610 of the 29th of april 2014

Hospital costs in the Veneto Pharmaceutical Costs Hospital costs in the Veneto Agreed Pharmaceutical Costs in the Veneto Fonte: Tabelle monitoraggio spesa farmaceutica AIFA

THE NEW EXECUTIVE POLICIES FOR GOVERNANCE OF THE SYSTEM

Local healthcare units 1979 (Regional Law 25 October 1979, n. 78) 31 LHU IN IMPLEMENTION OF NATIONAL PROVISION LN 833/1978 1994 (Regional Law 14 September 1994, n. 56 ) 21 LHU IMPLEMENTION OF NATIONAL PROVISION D.LGS 502/1992 2017: 9 LHU 1 DOLOMITES 2 MARCA TREVIGIANA 3 SERENISSIMA 4 EASTERN VENETO 5 POLESANA 6 EUGANEA 7 PEDEMONTANA 8 BERICA 9 SCALIGERA 206.856 inhab. 885.447 inhab. 626.847 inhab. 228.849 inhab. 240.540 inhab. 936.887 inhab. 367.982 inhab. 499.332 inhab. 922.383 inhab.

26 2 2 4 2 1 4 4 5 2 New Districts DISTRICTS ART 26, comma 1, 6

Council – Assembly – Area – PLANNING MANAGEMENT- SUPERINTENDENCE PROVISION OF SERVICES

Consiglio – Giunta – Area – PLANNING (ex ante) REGIONAL COUNCIL (Regional Laws…) Consiglio – Giunta – Area – REGIONAL ASSEMBLY (Resolution of the Assembly…) HEALTH AND SOCIAL AREA (Criteria…) STRATEGIC PLANNING: REGIONAL SOCIAL-HEALTHCARE PLAN RESOURCE ALLOCATION AND HEALTHCARE BALANCE STRATEGIES OF IMPLEMENTATION AND ORGANIZATION

Management-SUPERINTENDENCE (EX POST) AZIENDA ZERO (Decrees-resolutions of the azienda zero) MANAGEMENT OF TECHNICAL-ADMINISTRATIVE FUNCTIONS MANAGEMENT OF CENTRALISED HEALTHCARE MANAGEMENT OF INDICATIONS IN THE ECONOMIC-FINANCIAL AREA …

9 LOCAL HEALTHCARE AGENCIES & TREATMENT SITES PROVISION OF SERVICES 2 HOSPITAL ORGANIZATIONS AND 1 ONCOLOGY INSTITUTE 9 LOCAL HEALTHCARE AGENCIES & TREATMENT SITES Hospitals Hub Hospital unit Network node Integration of the network Districts Integrated Territories and Medicine

ORGANIZATIONAL MODELS

Population and costs by level of risk Very High 20% High 75% Low Healthy user Non user

The reorganization does not modify the model of treatment centres ACUTE 17.448 HOSPITAL BEDS Regional centres ACUTE BEDS 3,5‰ Hub Spoke, Network node INTERMEDIATE CARE 3.000 HOSPITAL BEDS Territorial Rehabilitation Units, Hospice, CommunityHospital INTERMEDIATE BEDS 0,6‰ Greater treatment intensity RESIDENTIAL CARE 30.000 HOSPITAL BEDS 75% minimum intensity 25% average intensity Nursing Homes RESIDENTIAL BEDS 6,1‰ HOME 120.000 HOME CARE 10,2 ‰

68 structures NETWORK HOSPITAL HUB 2 REGIONAL HUB 5 PROVINCE HUB 670.000 admissions 2015 65.000.000 outpatient service 1.700.000 access to first aid 57.000 public employees 15.000 private employess 2 REGIONAL HUB 5 PROVINCE HUB 1 REGIONAL CANCER CENTER SPOKE 17 SPOKE PUBLIC HOSPITALS 3 SPOKE PRIVATE HOSPITALS NODE NETWORK 17 NODE NETWORK PUBLIC HOSPITALS 23 NODE NETWORK PRIVATE HOSPITALS Precedenti erano 42 PUBLIC 14.576 beds (84%) + 320 beds for extra region patients 68 structures 26 PRIVATE 2.872 beds (16%) + 467 beds for extra region patients

Intermediate recovery structures CARE SERVICES NEAREST TO HOME Hospice Community Hospital RTU 21

Territorial services COT CA – Doctors on call MGI-Medical homes COT “Centrale operativa territoriale” coordinate and monitor the transitions between MGI and intermediate hospital structures and long-term facilities MGI: «MEDICINE DI GRUPPO INTEGRATE» one for 15.000 people assisted. multiprofessional team of general practitioners, medical specialists, nurses, related to specialist and guaranteed a 12 hour opening time MEDICAL CARE 24/24 h headquarters CA – Doctors on call MGI-Medical homes COT GPs 3.213 territorial pediatricians 564 COT 21 180.000 assisted by district MGI:310 CA “Continuità Assistenziale” Out-of-hours primary care service. On call medical doctors providing medical advice and home visits when needed. A free service operating at night and during the weekend

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