European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Italy

3.4 Out of pocket payments

OOP payments play a significant role in Italy: between 17% and 19% of total health expenditure between 2005 and 2012 (Table3.3), which is in line with the OECD average. In 2012, a total of more than US$ 32 million PPP was paid by patients for health-care services in the form of cost-sharing for services covered by the SSN or direct payments outside the SSN (Fig3.6).

3.4.1 Cost-sharing (user charges)

Cost-sharing mainly refers to co-payments for diagnostic procedures (laboratory tests and imaging), pharmaceuticals, specialist visits and for unjustified (non-urgent) interventions provided in hospital emergency departments. Primary and inpatient care are totally free at the point of use for everyone. Co-payments for pharmaceuticals were first introduced in 1978 and are regulated at both national and regional level; co-payments for specialist visits and other outpatient services were established in 1982 and are regulated by national legislation with some regional variations. Since their introduction both have undergone several extensive changes (Lo Scalzo et al., 2009). Co-payments on medicines are applied in 15 of the regions as a flat rate or percentage of the price (pursuant to Legislative Decree n. 98/2011) (Osservatorio Farmaci, 2013).

Turning to prescriptions for diagnostic procedures and specialist visits, the co-payments structure varies among regions and has a rather long history. Since 1993, patients have paid for the total cost per visit up to a ceiling determined by law. The ceiling currently stands at €36.15 per prescription. Therefore, a patient who receives two separate prescriptions (e.g. a magnetic resonance imaging (MRI) scan and a laboratory test) after a visit has to pay the first €36.15 on each prescription. To address the public finance crisis, in July 2011 (Legislative Decree n. 98/2011) the government introduced an additional €10 co-payment for each ‘prescription’. Co-payments have also been introduced for the ‘unwarranted’ use of hospital emergency services – that is, instances deemed to be noncritical and non-urgent (although some regions have not enforced this co-payment). Public providers, and private providers under a contractual agreement with the SSN, are not allowed to charge above the scheduled fees. Notwithstanding the centralized nature of these interventions, the national government allowed regions to decide whether to apply the co-payment in full or to enact regional rules that allow for varying co-payments according to gross family income or service tariffs. As a result, co-payments differ among the regions.

Total exemptions from cost-sharing are applied to people aged 65 and over; children aged 6 and under; the unemployed; patients who live in households with a gross income below a certain threshold (approximately €8263 for single and €11 362 for larger households); people with severe disabilities; and prisoners. People with chronic or rare diseases, people who are HIV-positive, and pregnant women are exempt from cost-sharing for treatments related to their condition. Most screening services are provided free of charge.

The introduction and increase in co-payments/user charges are emerging health policy responses to the economic and financial crisis in Europe (Mladovsky et al., 2012). However, there is a general concern about their efficiency (e.g. shifting and increasing spending in other areas of care), effectiveness (e.g. reducing the use of needed care services and thus worsening health outcomes) and increased inequity in access.

3.4.2 Direct payments

Direct payments refer to payments by users to purchase health-care services and OTC medicines that are not covered by the SSN. These services may be offered either by public or private facilities. Most private accredited hospitals also offer services to patients who directly pay for them or are covered by VHI. A few private hospitals in Italy are not accredited by the SSN and thus work only with private patients. Services outside SSN coverage can be offered by SSN facilities within the intra-moenia framework, i.e. where SSN professionals, mainly specialists, can also offer their services to privately paying patients within SSN facilities as part of their (part-time) private practice (see also section 3.7.2 and footnote 17). Private health-care services refer mostly to dental services, OTC medicines, diagnostic services (if not during a hospital admission) and specialist visits. The most recent estimate using the national ISTAT survey reports that 56.8% of total specialist visits in 2005 were paid fully by patients, 27.8% applied a co-payment and the remaining 15% were free of charge (Cislaghi & Giuliani, 2008). Dentist12 and gynaecology outpatient visits are the most common privately paid visits outside the SSN. In Italy there is a common perception that in order to ensure faster access and/or enhance consumer choice of providers, people are encouraged to opt for privately paid services. This is especially true for diagnostic and laboratory examinations (PiT Salute, 2012). Moreover, as an incentive to increase private-sector utilization, and to help families bear the burden of co-payments, private health expenditure is eligible for a tax credit: 19% of medical expenses (no caps on OOP spending) can be deducted from individual taxable income (there is a deductible of €129) (see section 3.5.3).

12 Dental care is generally not covered by the SSN and is paid for out of pocket.