Prof. Francesco Carelli, Milan

The aim of NHS (National Health System) should be to produce health, but the attention of LHA (Local Health Authorities) in organization and remuneration of activities of people working in NHS in Italy is  up to now focused mainly on multiplication of diagnostic and therapeutic interventions, sometimes of not proved efficacy, so maybe unuseful or even harmful. 

Often sponsored by pharmacological and technological industries helped by press and media,  this multiplication leads to always  increasing expenses, as happened after the introduction of DRG system, and as happens with increasing use of sophisticated technologies not always appropriated, and with confusion between real primary prevention (attention on life habits, environment, and so on) and early diagnosis ( mass screenings ) .
In addition to other measures of audit and control, in large part already proved ineffective to assure the appropriateness of actions and interventions, it is urgent to experiment and introduce systems of remuneration, which do not encourage the number of performances per se, but are consistent in pursuing higher and sustainable levels of health for the population (in essence: try to make population live longer and in good health, optimizing the use of available resources and reward / encourage the actors with their actions to promote this outcome ).
Regulators, to earn more money or keep their earnings,  should not be pressured to do more performance, but to improve the level of health of the clients (alignment of their interests with those of the population).

From Milan, we propose a system essentially based on capitation pay with a strong and continuous progression in age of patients, applied (with a few exceptions, consistent or additions) to all possible levels.
In the years following the introduction of the model, the Local Health Authorities that manage to increase, in comparison with the others, the longevity of  their people, will have a greater funding, with the same regional health fund. To achieve this result will encourage preventive interventions, treatment and care services that allow people to maintain good health.
To apply this model of pay, there should be a period of transition from the current remuneration arrangements in the proposal. This modulation will allow you to explore in the first instance the applicability of the proposed model, check the first results, the different aspects of application and correct any errors appearing during the trial, finally achieving a progressive consensus of the various stakeholders.
Although the first application will have inevitable limitations in the number of parties involved and the duration, necessarily limited to a few years, you can introduce elements of monitoring and verification that would constitute a partial experimentation. In fact, these are the goals to be verified:
– If in this time frame will highlight problems of implementation (the assumption is that there are no problems that can not be resolved and overcome)
– The performance (with any changes positive or negative) of parameters related to the fields:
° health of the population (the hypothesis is an increase in life expectancy / longevity, more than the other LHA)
– Economic ° (the hypothesis is an overall decrease in spending on health care not generated by opportunistic behavior).
We need to collect a set of data which, when properly analyzed, will be the basis of the evaluation of the trial, to be implemented during the course and at the end of the period. Particular attention must be paid to the emergence of alarm symptoms, highlighting the need for corrective action. It will be necessary a flow of information relating to the economic aspects and activities of the LHA, the health of citizens.
Health data:
– Longevity of the population (life expectancy and population subdivision by age)
° Life expectancy in good health (as long as defined in an objective manner, and allowing scrubbed distortionary effects of disease mongering on the definition of health)
° avoidable mortality according to a pragmatic extension of the OECD definition
° mortality of the population, in its various aspects (age, sex, cause)
economic data
– LHA budget according to the model
– Business Expenses
– Compensation to company performance extra
– Annual values of expenditure
° hospitalizations and access to emergency rooms
° medications (even for targeted categories of drugs)
° specialist referrals (even for individual specialties)
° diagnostics (also for individual exams)
° total public health expenditure
It will be useful to define LHA control, for which collect a set of corresponding data. It should be stressed that the assessment is based on the trend indicators detectable from the data described above; to this end, it is still important for the long-term evaluation, within the time limits of this experiment.
An important part of the remuneration of the result of all operators must be connected to the improvement of indicators of life expectancy and satisfaction of citizens – assisted. Should the first  grow faster than the regional average, then the revenues of the LHA experimenter will grow more than the average: this could become an incentive based on results, and may be expressly agreed .

As already suggested, it is quite likely that the payment for performance tends to increase the performance that (locally and even individually) promotes/enhances profitable and also improper use of technology. However, In the payment,  according to the proposed model, there would be no incentive for the proliferation of interventions whose usefulness to the patient the family doctor was not convinced.
Compared to the DRG, the proposed model for incentives, educational interventions, preventive, diagnostic and therapeutic choices that are effective and appropriate to the length and quality of life, prevents misuse of technology, encourages a behavior more respectful of  patients’  dignity, will not abandon them in post acute care, research the quality of life through the integration with  other services and care of welfare benefits, as far as possible.

Nova A, Donzelli A. – First regional application of the remuneration model of health care companies according to economic progression heavily weighted by age