1. Improved quality, safety and containing healthcare costs: too good to be true? Bruxelles – 21 February 2013 Claudio Dario, Director General, Padua Teaching Hospital, Veneto Region, Italy

2. The effects of the crisis on Italy, as in the other European Countries, are noticeable from multiple factors. In particular: growth of public debt decrease of production and of GDP increase of unemployment The current scenario

3. Growth of public debt Source: Italian Ministry of Treasure, 2012

4. Public debt / GDP ratio in UE Contries, 2011 Growth of public debt [source: Eurostat, 2012]

5. decrease of production and of GDP The Italian GDP 2007-2011 and forecasts 2012-2013 [Source: The perspectives for italian economy 2012-2013, Italian Bureau of Statistics (ISTAT), 5-nov-2012]

6. Increase of unemployment The amount of Unemployed by class of age 1993-2011 (thousands) Source: Italian Bureau of Statistics (ISTAT), 2012

7. The amount of Unemployed by class of age 1993-2011 (thousands) Source: OECD, 2013

8. But in Italy a good social safety net is in place: extensive use of layoffs (“cassa integrazione”) unemployment compensations (“sussidi di disoccupazione”) family protection network household wealth house of property (the 77,1% of italians live in a house of property*) savings and financial activities The current scenario [*Source: Survey on savings and financial choices of Italians 2012, Intesa San Paolo, 2012]

9. Extensive use of Layoffs (“cassa integrazione") [Source: Italian Bureau of Statistics, ISTAT, 2012]

10. Household wealth Household wealth of italians: 8.619 Billions € on 2011 (almost 4 times the public debt) 62,8% of real activities, 37,2% financial activites, 9,5% financial liabilities. 10% of italians owns the 45% of wealth the net wealth is almost 8 times the income [source: Bank of italy, 2011] Household wealth to income ratio

11. The Italian National Health Service Health Insurance coverage Source: “Health at a Glance Europe 2012”, OECD, 2012 Italy has a tax-funded National Health Service that guarantees universal provision of comprehensive care The central government provides a politicy and planning frameworks, defines the Essential Levels of Care and guarantees the financial sustainability The regions, through public and private providers, deliver the Essential Levels of Care (sometimes additional to the minimal set defined by the Ministry of Health) and are liable for any deficit

12. The Italian National Health Service In the 2006-2010 period the medium increase rate of expenditure was 2,2%, but in 2001-2006 it was higher: 7% The total healthcare expenditure is continuosly increasing: the reduction of the increase of the public funding over the years is compensated by a raising private expenditure Source: Italian Ministry of Health, 2012

13. The deficit of the National Health Service The trend of the deficit of Italian NHS Billion € Year National trend Trend for regions with recovery plan Trend for regions without recovery plan Source: Italian Ministry of Health, 2012

14. The deficit of the National Health Service 85% of the total deficit The polarization of the deficit of Italian NHS among some Regions Year 2011 (Million €) Source: The European House-Ambrosetti, 2012 -815,1

15. The deficit of the National Health Service In the 2001-2011 period Regions generated over 40 Billion € of cumulative deficit 20012002200320042005200620072008200920102011 Public expenditure (Billions €) 77,779,582,391,296,899,6103,8107,1110,2111,2112,9 % on GDP 6,26,16,26,66,86,7 6,87,37,27,1 Deficit (Billions €) -3,8-2,9-2,3-6,4-5,7-4,5-3,7-3,5-3,3-2,3-1,8 Since 2001, Italian government establishes limits to the increase of public expenditure Since 2007, regional recovery plans (Piani di Rientro) are adopted for overspending regions On 2010, further policies has been provided by the Ministry to increase traceability, accountability and appropriateness of the Health Service (Patto per la Salute 2010-12) 2012: Spending Review Source: Italian Ministry of Health, 2012

16. The health expenditure of italian NHS Source: OECD Data Health, 2012

17. The areas of action Reduction of Hospital Beds Organization of hospital beds over the territory (Hospital, Elderly Homes, Nursing Homes, etc…) by intensity of care (acute/cronical disease). 3.5 Hospital Beds/1.000 inhabitants on 2010 [Source: OECD], where the European Average is 5.5 Reorganization of the network of Hospital Assistance depending on High Specialty Hub & spoke networks, pathology networks, etc… Organization of the continuity of care: Primary care, Home Care, specialistic assistance, palliative care, residential care, etc... Appropriateness of hospital admissions: reduction of the number and of the duration of hospitalizations Conversion of day-hospital activities to out-patient regimen, and of hospitalizations to day-hospital activities, with the introduction of co-payment Activation of week-surgery and development of day-surgery

18. The areas of action The National government cut the transfers to regions for disability, childhood, migrants and other welfare policies Introduction of cost-saving measures aimed to reduce pharmaceutical expenditure Increase of indirect business tax (IRAP) to finance healthcare system Elimination of obsolete Essential Levels of care

19. Improved quality, safety and containing healthcare costs: too good to be true?

20. Thank you! Claudio Dario Director General, Padua Teaching Hospital, Veneto Region, Italy

21. if the reduction of public funding is not accompained by the adoption of organizational models that allow to obtain more with the existing resources, healthcare providers will cut services In this scenario, to mantain the level of cares, the patient has to contribute with co-payment. Appropriateness, quality and efficiency of care are strategic levers to ensure that patient accept better the co-payment (because every patient will only pay for good cures…) Improved quality, safety and containing healthcare costs: too good to be true?

22. Policies for social protection and for labour flexibility should be applied (with the increase of the age of retirement, we must think to new functional locations for elderly workers) Privilege “focused” cuts on areas of inefficiency: reduction of redundances process analysis to locate bottlenecks and risky elements Promote prevention and good lifestyles Sustain innovation and research (clinical, technological, organisational, etc…) Improved quality, safety and containing healthcare costs: too good to be true?

23. The health expenditure of italian NHS Source: OECD Data Health, 2012