Economy and Healthcare, Healthcare and Economy: these are now terms that are regularly associated, and it seems it has become almost impossible to discuss medical care without dragging in the cost of services and the cost-benefit effectiveness comparison. Ever since the concept of healthcare was identified with the broader concept of health protection, and its responsibility transferred to the State first and to the Regional Authorities later, we have lost sight of disease and patient treatment, and are solely concentrating on the healthcare cost aspect. Besides, having identified healthcare with health protection rather than disease treatment, it is quite obvious that the subjects entitled to benefit from the associated services are the healthy citizens rather than the sick, and hence the service cost becomes an expense factor to be kept under control. The entire political approach to healthcare for the last few decades has therefore been focussing on saving costs rather than on improving the quality of services. Whilst, from a family medical care point of view, the system has been trying to introduce the expense budget concept in connection with medical services, from a Hospital medical care viewpoint, the great concept of Hospital financing based on pathology grouping is asserting itself. In addition to all this, we need to take into account the project relating to the Managerialisation of Hospitals and healthcare facilities as a whole, which are forced to adopt management and saving principles typical of entrepreneurial company organisations; in operating terms, the underlying principle for this approach is not disease or patient treatment. The well known DRG (diagnosis related groups) system, practically introduced in the United States in 1983, is designed to abolish payment of hospital fees based on the length of the stay and of the medical treatment provided to the individual patients requiring admission to hospital, and at the same time is aimed at controlling healthcare expenses through the representation of all hospitalised patients in terms of diagnosis, implemented procedures, hospitalisation period and costs borne. Individual DRGs are identified through this analysis and we could describe them as “hospitalisation categories that are homogeneous in terms of amount of resources absorbed during the assistance process”. With the Ministerial Decree dated 14 Dec. 1994, Italy decided to emulate the USA system by introducing the same procedure into our country. As a matter of fact, it should be stated that the American DRG system does not have managerial significance for the Hospital, which is run regardless of reimbursements; it only has an impact with respect to the agreements existing with Insurance Companies, in order to classify compensations paid out, so as to parametrize insurance premiums and risk coverage by the Companies. In order to appreciate the amount of complications that the American system has caused to Italian hospital care, through the grouping of the 492 patient classes into 25 Chief Diagnostic Categories, it is sufficient to know that: “ the value of each DRG is equal to the product of the DRG relative weight multiplied by the base fee value (PNSA = Adjusted Standardised National Payment) set as unit of payment. Therefore the relative weight is the cost index expressing the DRG’s relative expensiveness degree compared to the average cost per patient discharge expressed by the PNSA factor” Of course, we cannot ignore the fact that, since this type of system was introduced in Italy, there has been a substantial change in the type of care provided to the patient, who, from that time on, has become for the Hospital Enterprise, the financial factor on which the entire Hospital economy system pivots. The complex computer calculations on diagnostic groupings and on the identification of the ICD-9-CMs, that is on the composite classification of diagnoses and discharge procedures, have led to the establishment of a classification of our own of the most remunerative DRGs, whereby certain surgical operation placed in a class which allows the granting by the Regional Authorises of reimbursements that are higher than the actual operation cost may be privileged compared to others that prove less remunerative. Of course, to prevent certain abuses which have an impact on the care provided to patients, highly sophisticated controls would be required, which Regional Authorities are in no way in a position to conduct, also in view of the fact that these would involve a preventive approach and, what’s more, a change in our way of thinking. The risks which are most frequently associated to this incentive system are basically the following: . Reduction in the duration of the hospitalisation period per individual patient, with the risk of an untimely discharge of the patient; . Increase in the number of admissions to hospital for the patient categories whose fees exceed the marginal production costs, with the risk of an increase in unrequited admissions; . Selection, within each DRG, of the patients involving costs that are lower than the related fees, with the risk of accessibility problems and of a drop in system equity; . Unbundling of the patients’ treatment profile into a number of separate hospitalisation periods, with each admission charged at full price; . Manipulation of the SDO (Hospital Admission Form) so as to impute the admission to a higher weight, and fee, DRG than the applicable one. It is quite obvious that the system cannot continue to be exclusively based on the DRG criterion, but has to be integrated by other parameters, designed to qualify the healthcare service, so as to be able to judge the performance of the health workers practicing their profession within the Hospital according to the results achieved through their treatments and not on the fact that the accounts balance in compliance with a theoretically set budget. In Germany there is a desire to introduce the same DRG criteria currently in use in Italy, but German Hospital medical staff are objecting to a system pivoting on merely financial criteria, since, as they claim, this would lower the quality of treatments, and in the end this would be at the patients’ health expense. In Italy, many members of Hospital medical staff are becoming increasingly demotivated as the days go on, being subject to performance assessments exclusively based on regional reimbursements, and are hoping for the system to switch to one which acknowledges results, scientific and human qualification and research work, rather than the fact that their performance involves a good or bad DRG.

Translated by interpres sas