ORIGINAL ARTICLE
Mental Health Care Financing in Italy Current Situation and Perspectives Francesco Amaddeo, MD, PhD, Laura Grigoletti, PhD, and Ilaria Montagni, PhD Abstract: Through a review of the studies conducted on the analysis of the costs of the Italian mental health provision of care, this study aimed at describing the current financing system for mental health care in Italy. From the deinstitutionalization to the present days, Italian mental health care financing has evolved in line with both national plans and the actual European directives. The description of the current situation of mental health care financing in Italy can be useful to inform service planning and resource allocation, and to offer a wider European perspective. Key Words: Costs evaluation, mental health financing, Italian mental health care (J Nerv Ment Dis 2014;202: 464Y468)
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ealth expenditure represents one of the largest components in the total public spending of all countries in the world, and in 2010, in the European Union countries, the total health expenditure on the gross domestic product ranged from 6% in Estonia, Romania, and Cyprus to 12% in France, Germany, and the Netherlands, whereas Italy registered a 10% expenditure (World Health Organization [WHO], 2013). As for mental health in particular, its costs in the European Union countries are substantial, accounting for 9% of total health care costs on average (OECD, 2008), whereas Italy registered in the same year a 5% expenditure (WHO, 2008). The financing of mental health care in Italy is analyzed here with the aim of describing the changes that occurred in the provision of this specific type of care in the last decades and their repercussions on the costs of mental health services. The Italian situation can be seen in the light of the current international economic crisis and the consequent reallocation of the resources. Starting from the example of our country, a possible reform of service planning and delivery should be suggested for a comparable provision of mental health services within the European Union. This is the case of the Research on FINancing systems’ Effect on the quality of MENTal health care (REFINEMENT) project financed for the years 2011 to 2013 by the European Union within the Seventh Framework Programme for investigating the financing of mental health care in Europe and its effects on the quality and outcomes of mental health services. Some of the data reported here on the Italian policies and laws about mental health care are obtained directly from the analysis by the REFINEMENT panel of mental health care experts. Within this framework, the economic evaluation of mental health care in Italy will then be of help for other countries. In detail, economic evaluation is the process through which the costs of the provision of care (in all its different forms) are compared with their effects in terms of health improvement and/or resource savings (Amaddeo et al., 1999). Thanks to this rational
Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy. Send reprint requests to Francesco Amaddeo, MD, PhD, Department of Public Health and Community Medicine, Section of Psychiatry and Clinical Psychology, Ospedale Policlinico ‘‘G.B. Rossi,’’ P.le L.A. Scuro, 10, 37134 Verona, Italy. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20206Y0464 DOI: 10.1097/NMD.0000000000000146
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economic evaluation, policy makers can decide how to allocate funding for both mental health provision of care and research. This article will first analyze the Italian funding system for general health care. Second, a specific insight on mental health care will be provided throughout the history of the Italian policies and reforms for mental health and the financing system. Finally, a review of the main studies conducted in the last decade in Italy on costs for mental health care is proposed before discussing the results of this exhaustive description of the Italian financing system. The present economic scenario with its international crisis makes it imperative to perform careful cost analyses to evaluate the direct costs of different options of mental health care, in Italy and in other countries.
HEALTH CARE FINANCING IN ITALY: LEGISLATION AND FUNDING SYSTEM The Italian legislation about health care was deeply revised in 1992 (Decree No. 502, December 30, 1992) and 1993 (Decree No. 517, December 7, 1993), with specific laws aimed at reorganizing the resources allocation for hospitals and health centers. Before these two laws, the decisions concerning the use of the ‘‘Fondo Sanitario Nazionale’’ (the state economic resources for the provision of health care) were mainly taken afterward, when money had already been spent. The actual legislation is instead characterized by a system based on the products sale and not on the direct financing by producers. Moreover, whereas in the past, the funding was based on the borne costs, without any check on the number and quality of the supplied services, the Law No. 502 introduced in 1992 the payment according to the number of supplied services. As for the hospital wards, the service corresponds to the admission and not to the number of days spent in the ward, and both the case mix and the use of the services are now the bases of the Italian health care funding system. Following this law, in 1994, the Italian Ministry of Health issued two decrees (April 15, 1994, and December 14, 1994) containing the rules regulating the rates of specialized hospital and rehabilitation health care performances. Rates are fixed singularly by each Italian region. As for hospital services, the diagnosis-related groups (DRGs) started to be adopted: it allows the grouping of diagnoses according to patient discharges data to obtain homogenous groups for the resources use, its length, and its cost. The December 14, 1994, decree distinguishes the hospital services into three categories: hospital services for patients with acute illness performed within a regular admission, within a daily admission (day hospital care), and services of hospital rehabilitation performed within a regular admission. To regular admissions, excluding those lasting only 1 day, the flat rate for that specific DRG is applied. To extraordinary admissions for length of stay, the specific flat rate is applied and increased by the product of the number of days in surplus and the specific daily rate for that specific DRG. These categories should then be in line with the actual costs of the health care production. As for the specialized hospital- and community-based services, the April 15, 1994, decree stated that rates had to be fixed on the basis of the standard cost of production and of the general costs, in percentage as regards the standard costs of production. Moreover, according to this degree, the standard cost
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of production for each service or performance is preventively calculated by regions and autonomous provinces on the basis of the costs seen in a sample of both public and private providers, all working within the National Health System (NHS) of an Italian region or province, and preventively selected according to efficacy and efficiency criteria.
POLICY AND LEGISLATIVE FRAMEWORK OF THE ITALIAN MENTAL HEALTH PROVISION OF CARE Italy is the only example in which a specific mental health legislation has adopted community psychiatry as the ‘‘framework’’ of psychiatric care (Fattore et al., 2000). The Mental Health Policy was established at a national level in 1978 (Legge 180, May 13, 1978, Legge Basaglia), especially known for the abolition of mental hospitals and the consequent reallocation of patients with acute illness in different nonhospital residential settings. This policy includes the organization of services (developing community mental health services [CMHSs], downsizing large mental hospitals, and developing a mental health component in primary health care), human resources, advocacy and promotion, human rights protection of users, financing, and quality improvement. As for the mental health plan, it is established at a regional level. For example, the last version of the mental health plan in Veneto region is related to the years 2010 to 2012 (Progetto Obiettivo Tutela della Salute Mentale). Other than the topics mentioned in the Legge 180, this plan includes the organization of the involvement of users and families, equity of access to mental health services across different groups, and monitoring system. As for the disaster/emergency preparedness plan for mental health in emergency, nothing has ever been published so far on this topic. Several laws and decrees have been issued during natural catastrophes and/or emergency situations but with no references to mental health. As for organizational integration of mental health services, each Italian region is provided with a regional mental health authority that provides advice to the government on mental health policies and legislation and is involved in service planning, service management, and monitoring and quality assessment of mental health services. Catchment areas/service areas exist as a way to organize mental health services to communities. Finally, in Italy nowadays, there are only six forensic inpatient hospitals, Ospedali Psichiatrici Giudiziari, here listed according to their size: Barcellona Pozzo di Gotto in Messina, Sicily region (437 beds); F. Saporito in Aversa, Campania region (259 beds); Montelupo Fiorentino in Firenze, Tuscany region (201 beds); Castiglione delle Stiviere in Mantova, Lombardy region (193 beds); Reggio Emilia in Reggio Emilia, Emilia Romagna region (132 beds); and Sant’Eframo in Napoli, Campania region (100 beds). These forensic inpatient hospitals are planned to be replaced by other small facilities, with different levels of seclusion and protection. This will definitively affect the allocation of resources for mental health care.
MENTAL HEALTH CARE FUNDING SYSTEM IN ITALY: STRUCTURES, ORGANIZATION OF THE SERVICES, AND COSTS In Italy, the costs of mental health are related both to the diagnosis and treatment of mental illnesses and to the consequences of mental illnesses that involve the whole community. These costs are divided into direct and indirect costs, the latter to be further divided into health, social, and community costs. For the costs of Italian mental health care, the following settings should be taken into account: community psychiatric services (CPSs); outpatient services; group therapies; rehabilitation groups; criminal justice services; informal care; hospital admissions (general hospital acute psychiatric wards); provision of medical and social services by general practitioners, psychiatrists, nurses, psychologists, social workers, and other psychiatric staff; day care (day centers and day hospital); nonresidential services; and * 2014 Lippincott Williams & Wilkins
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residents’ living expenses. Costs also include the financing of staff. These facilities can be directly managed by the NHS; by private or voluntary, nonprofit organizations; local board; or other type of management. The network of such services is then really complicated, and their organization and management are not well established. A clear comprehension of this intricate provision of mental health care can help the Italian health system to better allocate resources for psychiatric services. The complexity of the psychiatric services and facilities in Italy explains why the analysis of costs cannot be focused exclusively on the length of stay. In fact, the mental health care provided by the Department of Mental Health comprises, together with the length of stay, outpatient services, residential facilities (RFs), activity of mental health centers, rehabilitation, and supporting housing. At present, Italian mental health costs come from the following sources: tax-based, out-of-pocket, and private insurance. Actually, for the psychiatric sector, notwithstanding the fact that the fee for service is considered as one of the possible solutions for the rationalization of the hospital expenditures, the results of the studies published on this subject seem to demonstrate the weakness of the diagnosis in predicting, in general, the use of the services and, in particular, the length of stay in the acute psychiatric wards. Previous researches (Amaddeo et al., 1997b; Donisi et al., 2013; English et al., 1986; Essock and Norquist, 1988; Pertile et al., 2011) have in fact reported the outstanding variability in the length of stay within diagnostic groups for psychiatry, thus demonstrating that this sole variable can predict less than 10% of such variability. For example, Keefler et al. (2001) reported in their study on a sample of 160 patients that the severity of the patient’s psychosocial problem was a more significant predictor of length of stay than the DRG variable. The American Psychiatric Association studied the potential impact of DRGs on psychiatric patients and inpatient psychiatric units in general hospitals, reporting a substantial inaccuracy in the psychiatric DRGs’ prediction of resource use (English et al., 1986). Notwithstanding the evidences reported by these and other similar studies (Essock-Vitale, 1987; Goldman et al., 1984), DRG seems to be, at present, the most complete, easily applicable, and robust system of funding for health care in Italy. Finally, it is necessary to underline that the costs of mental health provision of care in Italy have been affected in the 2 latest decades by the deinstitutionalization process, which started in the most industrialized countries in the 1960s. With the national mental health reform and its consequential replacement of mental hospitals with community-based facilities, the costs of care of Italian psychiatric patients have noticeably changed. The development of these new facilities has changed the Italian scenario of mental health financing because they include a variety of settings ranging from board homes to wards in the community (de Girolamo et al., 2004), whose costs were supposed to be lower than the growing costs of hospital care. The downsizing of mental health services reflected the need in the 1980s to save money in an era of international increase in health care costs (Knapp et al., 1990). Moreover, in Italy, the marked socioeconomic differences between the three macroareas of the country (North, Center, South and Islands) are reflected also in the provision of mental health services. Consequently, costs vary from area to area and also within the same area, following the differences in the organization of local models of care and resource availability. In fact, the Italian Psychiatric Reform also established geographically defined catchment areas, and residents of a particular area are supposed to receive care from the services within that same area.
ITALIAN STUDIES ON MENTAL HEALTH ECONOMICS As for other world countries, also for Italy, the different economic approaches have been used: the burden of illness and the cost of illness (COI), which estimate the costs for treating an illness and www.jonmd.com
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for managing its consequences on the population according to prevalence and incidence of mental diseases, and cost prediction, which aims to predict the costs of specific groups of patients. A scarcity of studies on cost-effectiveness of community and rehabilitative intervention can be observed. In 1996, an Italian version for the Client Service Receipt Interview (Intervista Costi Assistenza Psichiatrica [ICAP]) was developed and published from the University of Verona research team (Amaddeo et al., 1996). The ICAP was conceived with the aim of evaluating in Italy the costs of either a single community-based service or a whole Department of Mental Health, that is, complex systems structured in a network of integrated and interconnected services and agencies. This instrument allows the monitoring of the costs of mental health provision of care, and it was used to calculate the cost for psychiatric care in Verona in 1996. In general, studies at the macrolevel on the costs of mental health care are scarce. Recent literature has in fact focused on evaluations and information at the microlevel, with studies conducted in local or regional services. The fragmentation of these data is probably due to the fact that the 1978 national legislation devolved to Italian regions the responsibility of managing the resources devoted to the provision of mental health care. We review here some of the major studies conducted in singular services and/or departments. For a national general overview of the Italian mental health care financing, these studies have to be integrated with the results from the REFINEMENT project. In other words, these descriptions of local and regional structures for mental health care provide some insights for a broader evaluation of the Italian NHS for mental health. In the 1990s, some evaluative researches on costs were carried out in South Verona (Amaddeo et al., 1997a) on the totality of the patients of the Territorial Psychiatric Service of Verona, whose main agency providing psychiatric care for the adult population is the South Verona CMHS, run by the Section of Psychiatry, Department of Medicine and Public Health, of the University of Verona and supplying a wide range of well-integrated hospital and community services. In this study, the direct costs for their psychiatric treatment were calculated for 1 year after their first contact in 1992. Some variables seemed to be significantly associated with higher middle costs (for each patient and for 1-year treatment): for example, unemployed patients or patients seeking their first employment used a major quantity of resources, whereas patients living alone and those living with their family had similar costs. The analysis of the costs for diagnostic groups showed that annual cost per patient was 8,884 euros for schizophrenia and related disorders, 2,376 euros for affective disorders, and 1,395 euros for neurotic disorders. The variability among disorders was very high, thus confirming that the sole diagnosis cannot predict the use of the services by the patients. As for their composition, costs are mainly linked to admissions and residential services (from 50% to 66% according to the diagnosis) and to the day hospital, particularly for schizophrenic patients. A similar research (Amaddeo et al., 1998) was conducted on all the patients of South Verona who contacted either public or private psychiatric services, from hospital to RFs, in the province of Verona in the years 1992 and 1993 and who were at their early episodes of illness (299 patients), that is, first-ever users of psychiatric services. In this case, the composition of the costs was different because the expenditure for outpatient services was higher than for the other services in each diagnostic group, thus revealing a different pattern of use for patients at their first episode of illness. The multivariate analysis showed that only 6% of the variability of the costs for patients could be explained by the diagnosis. If, in the multiple regression, we add to the diagnosis some sociodemographic characteristics (such as age, sex, education, housing, and working) together with some other anamnestic characteristics (period of contact with the services, conditions of the place, etc.) of the patient, we get 40% to 50% of the explained variability. 466
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In 2000, a new study was conducted by the same research group (Bonizzato et al., 2000) to detect and compare any differences in service costs between patients with different diagnoses and to examine the associations between patient characteristics, including sociodemographic, clinical and service history variables, and service costs, by calculating all direct costs (psychiatric and nonpsychiatric) and incorporating additional clinical, social, and previous service use variables into the explanatory model, in an attempt to explain a higher proportion of variance. Patients in South Verona were interviewed 3 months after the clinical evaluation, using the ICAP. The data referring to these 3 months were used for estimating costs for 1 year. Data from the Psychiatric Case Register of Verona (Tansella et al., 1999) were also collected and compared with those from ICAP interviews. For each patient, costs were grouped by service type into five components: inpatient costs, which included all days spent in a public or private sector hospital for psychiatric care; sheltered accommodation costs, which included all days spent in public sector specialized accommodation; day-patient costs, which covered all contacts at day hospitals or at rehabilitation groups; outpatient costs, derived from all contacts at the outpatient department and community psychiatric clinics, general hospital liaison, and accident and emergency department; and community costs, which included visits made to patients’ or relatives’ homes, visits to patients temporarily registered with other agencies, or visits to the premises of voluntary organizations, as well as the provision of social services by psychiatrists, nurses, psychologists, social workers, and other psychiatric staff. The high explanatory power of the model resulted from this study suggests that costs of care in Italy can now be predicted with an unusually large degree of confidence for this population, using a limited set of readily available sociodemographic and clinical measures. The results of this study also confirm that more resources are targeted on patients with severe mental illness. In 2002, a study analyzed service use in routine clinical activity and the costs of providing mental health care during 24 months for the whole population of patients who had first contact with the Magenta Community Mental Health Centre (CMHC) in 1994 (Percudani et al., 2002). All 330 patients who had first contact with the Magenta CMHC between January 1 and December 31, 1994, were included in this study and were diagnosed on the basis of ICD-10 classification. Service use data for the Magenta CMHC patients were extracted from the Psychiatric Information Computerised System promoted by the Lombardy Regional Health Authority and run by the Magenta CPS since 1992. The analysis of these data showed that, during the 24 months after the first contact, the 330 patients incurred costs of 461,511 euros (1394 euros per patient). Inpatient activity accounted for 49.7% of total costs; and community services, for 50.3%. According to the different diagnoses, total costs of care of patients with a diagnosis of schizophrenia and related disorders were higher than those for the other diagnostic groups. Care of patients with a previous psychiatric contact and a longer duration of illness was more costly than that of the other patients. The trend of the results of two previous analyses conducted in the same setting in 1995 (Fattore et al., 1997) and in 2000 (Fattore et al., 2000) was thus confirmed. In 2000, for the Magenta CPS, whereas patients with schizophrenia and related disorders had a mean cost of 3771 euros, those with neurotic and related disorders had a mean cost of 439 euros. Both the Magenta studies showed that hospital treatment is a major cost component and that schizophrenia patients present special cost patterns, influenced by nonclinical characteristics. In fact, it is mainly for these patients that the concept of community psychiatric care was developed, and this is the approach used to manage severely ill psychiatric patients in a CPS in Italy, 20 years after the Italian mental health reform. After some cost-analysis studies conducted only in limited areas of the country (see for a review Mirandola et al., 2004), three * 2014 Lippincott Williams & Wilkins
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multicentered studies compared the costs of CPSs in Italy: the GISIES (Interdisciplinary Study Group on the Economic Impact of Schizophrenia) in 1995, the PROGRES project (PROGetto RESidenze, i.e., Residential Care Project) in 2000, and the I-psycost study in 2009. The GISIES study (Tarricone et al., 2000) is a COI study aimed at assessing total direct and indirect costs of schizophrenic patients in 10 CPSs in Italy (Milan, Magenta, Brescia) and identifying the variables that influence costs. Results on 100 recruited patients showed that more than half of total direct costs were attributed to CMHC interventions. The yearly mean costs of schizophrenia per patient amounted to nearly 26,000 euros: 30% for direct costs and 70% for indirect costs, as assessed by two questionnaires compiled by mental health professionals. Direct cost components concerned CMHC interventions, living in RFs, inpatient care (e.g., use of psychiatric acute beds, day hospitals), pharmacological treatment, laboratory tests, and out-of pocket expenditures (e.g., transportation to and from health providers, legal and court expenditures, other medical expenditures). Indirect costs measure production lost because of the illness. In this work, indirect cost components concerned patients’ time off (paid and unpaid) work, informal care (care provided by nonprofessionals) that consisted of caregivers’ time off (paid and unpaid) work, and leisure time forgone. The GIES study tried to make a step forward compared with other COI analysis by including into the study design a statistical analysis that aimed at identifying main regressors of either total direct or indirect costs. The PROGRES project, launched in 2000 by the Italian National Institute of Health (Amaddeo et al., 2007), is the first attempt to estimate the costs of Italian nonhospital RFs in all 20 Italian regions and to evaluate the factors affecting both the costs of a sample of 265 Italian RFs, providing psychiatric, medical, and informal care, and their 2962 patients. This sample actually included 20% of the facilities operating throughout Italy whose financial information was derived from an interview with the managers of facilities. With this interview, information was collected about the management, the structure, the care, and the direct costs linked to the structure and patient administration. From this sample, it was evaluated that, in Italy, there are 2.98 places in RF per 10,000 inhabitants and that approximately 4,000 patients use an RF place in a year. Results of the PROGRES study showed that care of patients in RFs costs between 5,848 and 25,812 euros per year, to which it should be added from 1,513 to 3,500 euros per year for the CPSs. Differences between facility types and size and geographical location were tested by analyses of variance, and costs were analyzed at individual/patient level to take into account individual patients’ clinical and sociodemographic characteristics. From a regional point of view, comparing facilities in the three Italian geographical macroareas (North, Center, South and Islands), Northern RFs were more expensive (24,900 euros per patient per year) than Central RFs (18,840 euros) or Southern RFs (17,890 euros), and this holds true for every kind of facility. On the other hand, CPS costs were higher in the North, medium in the South and Islands, and lower in the Center. After the Italian Mental Health Plan (1998Y2000) and the Progetto Obiettivo for the Mental Health, Italy has adopted an organizational model for community psychiatric care focused on large multidisciplinary teams (Grigoletti et al., 2010). The I-psycost study analyzed in 2009 five Italian CMHCs CMHSs located in five different regions, three in the northern (Verona, Bologna, and Legnago), one in the central (Rome), and one in southern Italy (Avellino), the possibility to estimate the costs of each package of care for patients in charge. In fact, costs were calculated for each type of contact with the following results: the most expensive contacts were the admissions in psychiatric ward (230 euros) and in private clinic (138 euros), and these, with the employment/rehabilitation workshop and the day in residential care, were the only services to cost more than 100 euros. * 2014 Lippincott Williams & Wilkins
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The less expensive services were the individual rehabilitation contact, the rehabilitation group, the pharmacotherapy contact, the advocacy service, and the nurse’s support contact, with costs in a range from 13 and 23 euros. Contacts as the outpatient psychiatric and psychological contact, the individual or group psychotherapy, and the home visits have costs going from 35 to 59 euros. Costs varied also according to the frequency in the use of the services. For low service users, the funding system may be based on the principle of fee-for-service (for example, 1 day in an acute psychiatric ward costs 229.25 euros, an outpatient visit costs 59.53 euros, and an initial outpatient psychiatric assessment costs 60.77 euros). For frequent service users, the costs are higher because of their use of more complex packages of care, ranging from 4,133 euros to 11,984 euros per 6 months. The fact that this study was carried out in the three representative geographical areas of Italy makes the results exhaustive for the whole country.
CONCLUSIONS The current Italian mental health care system is complex and composed of different services and facilities. This situation must be taken into account when reflecting upon the choice of an appropriate funding system. For example, a fee-for-service system is not sufficient for certain activities especially in community mental health centers where care is provided to the whole community and not exclusively to single patients. The Italian approach to community psychiatry suggests that the funding system should be focused on patients and their needs rather than on the services themselves (Fattore et al., 1997). The financing system for mental health care should be produced in the pathway of care of the psychiatric patient within the service, thus identifying what are the indicators and variables that can predict this pathway. Among the several propositions, that of the need-related groups (McCrone and Strathdee, 1994) seems to be the most valid one because it bases the planning and financing of the services on the characteristics and needs of the patient (age, socioeconomic status, education, family, etc.), of the community (caregivers, informal care, etc.), of the provided service (setting, accessibility, etc.), and of the territory (urban versus rural, unemployment rate, etc.). In general, the main objective of a financing system is to transfer the economic resources by allocating them in an efficient and efficacious way, with a specific focus on patient needs and well-being. Throughout a review of the literature about the costs of mental health provision of care in Italy, a clear representation of the Italian situation as it is now, after the psychiatric hospital closure, was drawn. This description could help policy makers, key managers, and mental health care organizations in the decision making of money allocation. The Italian financing system for mental health care should then be analyzed within the European economic scenario to understand the cost variations among different countries that, however, cooperate for a strong European integration in mental health care provision. As in other industrialized countries, in Italy the concerns about the single market and health expenditure have been recently translated into cost cuttings in the health sector. From the 1990s, a series of laws and decrees have been issued to economically reorganize the Italian health care system. Especially today, with the economic crisis, economic resources for mental health care in particular are limited and constantly rationalized. It is necessary to reread the history of mental health care financing to understand what the best solutions are for providing a good service with scarce economic resources. Scientific-technical aspects should then be strictly linked to ethical ones: on the one hand, resources should be equally allocated according to a specific services plan; on the other hand, the needs of the users should be seriously taken into account together with the effects of their treatments. In other words, to be useful and efficacious, any economic evaluation should be based on the needs of the users, the quality of the www.jonmd.com
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services, the satisfaction of the users, and the obtained results. Specific indicators are used to provide this information. Another peculiarity of the Italian mental health care system is that psychiatric patients often use a wide range of both private and public services that can be also provided by voluntary or self-help associations. Costs must then be measured in a larger context by considering all the elements that determine together the social cost of the illness. For example, general practitioner consultations and private mobile care should be included in the analysis of the costs for psychiatric care. To the best of our knowledge, a review of mental health financing in Italy has never been produced, and the evaluation of the efficacy of psychiatric interventions associated to their costs is an almost neglected sector of epidemiology. It is instead useful to evaluate the current status of psychiatric services to allocate resources in a more effective way and to develop a funding system that can support the pathways of care of frequent users of these services. The information provided within this article may then be useful for managers and clinicians for choosing the best criteria for allocating resources. DISCLOSURE The authors declare no conflict of interest. REFERENCES Amaddeo F, Beecham J, Bonizzato P, Fenyo A, Knapp M, Tansella M (1997a) The use of a case register to evaluate the costs of psychiatric care. Acta Psychiatr Scand. 95:189Y198. Amaddeo F, Beecham J, Bonizzato P, Fenyo A, Tansella M, Knapp M (1998) The costs of community-based psychiatric care for first-ever patients. A case register study. Psychol Med. 28:173Y183. Amaddeo F, Bonizzato P, Beecham JK, Knapp M, Tansella M (1996) ICAP. Un’intervista per la raccolta dei dati necessari per la valutazione dei costi dell’assistenza psichiatrica. Epidemiol Psichiatr Soc. 5:201Y213. Amaddeo F, Bonizzato P, Tansella M (1997b) Valutare i costi in psichiatria. L’analisi economica per migliorare l’assistenza. Rome: Il Pensiero Scientifico. Amaddeo F, Bonizzato P, Tansella M (1999) I costi delle malattie mentali e la valutazione economica dell’assistenza psichiatrica. In Cassano GB, Pancheri P, Pavan L, Pazzagli A, Ravizza L, Rossi R, Smeraldi E, Volterra V (Eds), Trattato Italiano di Psichiatria (2nd ed, Vol 3, pp 3743Y3762). Milan: Masson. Amaddeo F, Grigoletti L, de Girolamo G, Picardi A, Santone G (2007) Which factors affect the costs of psychiatric residential care? Findings from the Italian PROGRES study PROGRES study group, Acta Psychiatr Scand. 115: 132Y141. Bonizzato P, Bisoffi G, Amaddeo F, Chisholm D, Tansella M (2000) Communitybased mental health care: To what extent are service costs associated with clinical, social and service history variables? Psychol Med. 30:1205Y1215. de Girolamo G, Picardi A, Santone G, Semisa D, Morosini P, Gruppo Nazionale PROGRES (2004) Le Strutture Residenziali e i loro ospiti: I risultati della Fase 2 del Progetto Nazionale PROGRES [Residential structures and their guests: Results of the phase 2 of the National Project PROGRES]. Epidemiol Psichiatr Soc. 13:1Y100. Donisi V, Tedeschi F, Percudani M, Fiorillo A, Confalonieri L, De Rosa C, Salazzari D, Tansella M, Thornicroft G, Amaddeo F (2013) Prediction of
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community mental health service utilization by individual and ecological level socio-economic factors. Psychiatry Res. 209:691Y698. English JT, Sharfstein SS, Scherl DJ, Astrachan B, Muszynski IL (1986) Diagnosis-related groups and general hospital psychiatry: The APA Study. Am J Psychiatry. 143:131Y139. Essock SM, Norquist GS (1988) Toward a fairer prospective payment system. Arch Gen Psychiatry. 45:1041Y1044. Essock-Vitale S (1987) Patient characteristics predictive of treatment costs on inpatient psychiatric wards. Hosp Community Psychiatry. 38:263Y269. Fattore G, Percudani M, Pugnoli C, Contini A (1997) Costs of psychiatric services: A study performed at a public mental center in the Lombardy Region, Italy. Epidemiol Psichiatr Soc. 6:139Y147. Fattore G, Percudani M, Pugnoli C, Contini A, Beecham J (2000) Mental health care in Italy: Organisational structure, routine clinical activity and costs of a community psychiatric service in Lombardy region. Int J Soc Psychiatry. 46:250Y265. Goldman HH, Pincus HA, Taube CA, Regier DA (1984) Prospective payment for psychiatric hospitalization: Questions and issues. Hosp Community Psychiatry. 35:460Y464. Grigoletti L, Amaddeo F, Grassi A, Boldrini M, Chiappelli M, Percudani M, Catapano F, Fiorillo A, Perris F, Bacigalupi M, Albanese P, Simonetti S, De Agostini P, Tansella M, , I-PSYCOST Group (2010) A predictive model to allocate frequent service users of community-based mental health services to different packages of care. Epidemiol Psichiatr Soc. 19:168Y177. Keefler J, Duder S, Lechman C (2001) Predicting length of stay in an acute care hospital: The role of psychosocial problems. Soc Work Health Care. 33:1Y16. Knapp M, Beecham J, Anderson J, et al. (1990) The TAPS project. 3: Predicting the community costs of closing psychiatric hospitals. Br J Psychiatry. 157: 661Y670. McCrone P, Strathdee G (1994) Needs not diagnosis: Towards a more rational approach to community mental health resourcing in Britain. Int J Soc Psychiatry. 40:79Y86. Mirandola M, Amaddeo F, Dunn G, et al. (2004) The effect of previous psychiatric history on the cost of care: A comparison of various regression models. Acta Psychiatr Scand. 109:132Y139. OECD (2008) Policy brief. Retrieved from http://www.oecd.org/els/healthpoliciesanddata/ 41686440.pdf. Accessed December 2, 2013. Percudani M, Giovanni Fattore G, Belloni GC, Gerzeli S, Contini A (2002) Service utilisation and costs of first-contact patients in a community psychiatric service in Italy. Eur Psychiatry. 17:432Y442. Pertile R, Donisi V, Grigoletti L, Angelozzi A, Zamengo G, Zulian G, Amaddeo F (2011) DRGs and other patient-, service- and area-level factors influencing length of stay in acute psychiatric wards: The Veneto Region experience. Soc Psychiatry Psychiatr Epidemiol. 46:651Y660. Tansella M, Amaddeo F, Meneghelli G (1999) South-Verona psychiatric case register data. Internal report, Department of Medicine and Public Health. Verona, Italy: University of Verona. Tarricone R, Gerzeli S, Montanelli R, Frattura L, Percudani M, Racagni G (2000) Direct and indirect costs of schizophrenia in community psychiatric services in Italy. The GISIES study. Health Policy. 51:1Y18. World Health Organization (2008) Policies and practices for mental health in Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0006/ 96450/E91732.pdf. Accessed December 2, 2013. World Health Organization (2013) Global health expenditure database. Retrieved from http://apps.who.int/nha/database/DataExplorerRegime.aspx. Accessed December 2, 2013.
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Mental Health Care Financing in Italy Current Situation and Perspectives Francesco Amaddeo, MD, PhD, Laura Grigoletti, PhD, and Ilaria Montagni, PhD Abstract: Through a review of the studies conducted on the analysis of the costs of the Italian mental health provision of care, this study aimed at describing the current financing system for mental health care in Italy. From the deinstitutionalization to the present days, Italian mental health care financing has evolved in line with both national plans and the actual European directives. The description of the current situation of mental health care financing in Italy can be useful to inform service planning and resource allocation, and to offer a wider European perspective. Key Words: Costs evaluation, mental health financing, Italian mental health care (J Nerv Ment Dis 2014;202: 464Y468)
H
ealth expenditure represents one of the largest components in the total public spending of all countries in the world, and in 2010, in the European Union countries, the total health expenditure on the gross domestic product ranged from 6% in Estonia, Romania, and Cyprus to 12% in France, Germany, and the Netherlands, whereas Italy registered a 10% expenditure (World Health Organization [WHO], 2013). As for mental health in particular, its costs in the European Union countries are substantial, accounting for 9% of total health care costs on average (OECD, 2008), whereas Italy registered in the same year a 5% expenditure (WHO, 2008). The financing of mental health care in Italy is analyzed here with the aim of describing the changes that occurred in the provision of this specific type of care in the last decades and their repercussions on the costs of mental health services. The Italian situation can be seen in the light of the current international economic crisis and the consequent reallocation of the resources. Starting from the example of our country, a possible reform of service planning and delivery should be suggested for a comparable provision of mental health services within the European Union. This is the case of the Research on FINancing systems’ Effect on the quality of MENTal health care (REFINEMENT) project financed for the years 2011 to 2013 by the European Union within the Seventh Framework Programme for investigating the financing of mental health care in Europe and its effects on the quality and outcomes of mental health services. Some of the data reported here on the Italian policies and laws about mental health care are obtained directly from the analysis by the REFINEMENT panel of mental health care experts. Within this framework, the economic evaluation of mental health care in Italy will then be of help for other countries. In detail, economic evaluation is the process through which the costs of the provision of care (in all its different forms) are compared with their effects in terms of health improvement and/or resource savings (Amaddeo et al., 1999). Thanks to this rational
Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy. Send reprint requests to Francesco Amaddeo, MD, PhD, Department of Public Health and Community Medicine, Section of Psychiatry and Clinical Psychology, Ospedale Policlinico ‘‘G.B. Rossi,’’ P.le L.A. Scuro, 10, 37134 Verona, Italy. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20206Y0464 DOI: 10.1097/NMD.0000000000000146
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economic evaluation, policy makers can decide how to allocate funding for both mental health provision of care and research. This article will first analyze the Italian funding system for general health care. Second, a specific insight on mental health care will be provided throughout the history of the Italian policies and reforms for mental health and the financing system. Finally, a review of the main studies conducted in the last decade in Italy on costs for mental health care is proposed before discussing the results of this exhaustive description of the Italian financing system. The present economic scenario with its international crisis makes it imperative to perform careful cost analyses to evaluate the direct costs of different options of mental health care, in Italy and in other countries.
HEALTH CARE FINANCING IN ITALY: LEGISLATION AND FUNDING SYSTEM The Italian legislation about health care was deeply revised in 1992 (Decree No. 502, December 30, 1992) and 1993 (Decree No. 517, December 7, 1993), with specific laws aimed at reorganizing the resources allocation for hospitals and health centers. Before these two laws, the decisions concerning the use of the ‘‘Fondo Sanitario Nazionale’’ (the state economic resources for the provision of health care) were mainly taken afterward, when money had already been spent. The actual legislation is instead characterized by a system based on the products sale and not on the direct financing by producers. Moreover, whereas in the past, the funding was based on the borne costs, without any check on the number and quality of the supplied services, the Law No. 502 introduced in 1992 the payment according to the number of supplied services. As for the hospital wards, the service corresponds to the admission and not to the number of days spent in the ward, and both the case mix and the use of the services are now the bases of the Italian health care funding system. Following this law, in 1994, the Italian Ministry of Health issued two decrees (April 15, 1994, and December 14, 1994) containing the rules regulating the rates of specialized hospital and rehabilitation health care performances. Rates are fixed singularly by each Italian region. As for hospital services, the diagnosis-related groups (DRGs) started to be adopted: it allows the grouping of diagnoses according to patient discharges data to obtain homogenous groups for the resources use, its length, and its cost. The December 14, 1994, decree distinguishes the hospital services into three categories: hospital services for patients with acute illness performed within a regular admission, within a daily admission (day hospital care), and services of hospital rehabilitation performed within a regular admission. To regular admissions, excluding those lasting only 1 day, the flat rate for that specific DRG is applied. To extraordinary admissions for length of stay, the specific flat rate is applied and increased by the product of the number of days in surplus and the specific daily rate for that specific DRG. These categories should then be in line with the actual costs of the health care production. As for the specialized hospital- and community-based services, the April 15, 1994, decree stated that rates had to be fixed on the basis of the standard cost of production and of the general costs, in percentage as regards the standard costs of production. Moreover, according to this degree, the standard cost
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of production for each service or performance is preventively calculated by regions and autonomous provinces on the basis of the costs seen in a sample of both public and private providers, all working within the National Health System (NHS) of an Italian region or province, and preventively selected according to efficacy and efficiency criteria.
POLICY AND LEGISLATIVE FRAMEWORK OF THE ITALIAN MENTAL HEALTH PROVISION OF CARE Italy is the only example in which a specific mental health legislation has adopted community psychiatry as the ‘‘framework’’ of psychiatric care (Fattore et al., 2000). The Mental Health Policy was established at a national level in 1978 (Legge 180, May 13, 1978, Legge Basaglia), especially known for the abolition of mental hospitals and the consequent reallocation of patients with acute illness in different nonhospital residential settings. This policy includes the organization of services (developing community mental health services [CMHSs], downsizing large mental hospitals, and developing a mental health component in primary health care), human resources, advocacy and promotion, human rights protection of users, financing, and quality improvement. As for the mental health plan, it is established at a regional level. For example, the last version of the mental health plan in Veneto region is related to the years 2010 to 2012 (Progetto Obiettivo Tutela della Salute Mentale). Other than the topics mentioned in the Legge 180, this plan includes the organization of the involvement of users and families, equity of access to mental health services across different groups, and monitoring system. As for the disaster/emergency preparedness plan for mental health in emergency, nothing has ever been published so far on this topic. Several laws and decrees have been issued during natural catastrophes and/or emergency situations but with no references to mental health. As for organizational integration of mental health services, each Italian region is provided with a regional mental health authority that provides advice to the government on mental health policies and legislation and is involved in service planning, service management, and monitoring and quality assessment of mental health services. Catchment areas/service areas exist as a way to organize mental health services to communities. Finally, in Italy nowadays, there are only six forensic inpatient hospitals, Ospedali Psichiatrici Giudiziari, here listed according to their size: Barcellona Pozzo di Gotto in Messina, Sicily region (437 beds); F. Saporito in Aversa, Campania region (259 beds); Montelupo Fiorentino in Firenze, Tuscany region (201 beds); Castiglione delle Stiviere in Mantova, Lombardy region (193 beds); Reggio Emilia in Reggio Emilia, Emilia Romagna region (132 beds); and Sant’Eframo in Napoli, Campania region (100 beds). These forensic inpatient hospitals are planned to be replaced by other small facilities, with different levels of seclusion and protection. This will definitively affect the allocation of resources for mental health care.
MENTAL HEALTH CARE FUNDING SYSTEM IN ITALY: STRUCTURES, ORGANIZATION OF THE SERVICES, AND COSTS In Italy, the costs of mental health are related both to the diagnosis and treatment of mental illnesses and to the consequences of mental illnesses that involve the whole community. These costs are divided into direct and indirect costs, the latter to be further divided into health, social, and community costs. For the costs of Italian mental health care, the following settings should be taken into account: community psychiatric services (CPSs); outpatient services; group therapies; rehabilitation groups; criminal justice services; informal care; hospital admissions (general hospital acute psychiatric wards); provision of medical and social services by general practitioners, psychiatrists, nurses, psychologists, social workers, and other psychiatric staff; day care (day centers and day hospital); nonresidential services; and * 2014 Lippincott Williams & Wilkins
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residents’ living expenses. Costs also include the financing of staff. These facilities can be directly managed by the NHS; by private or voluntary, nonprofit organizations; local board; or other type of management. The network of such services is then really complicated, and their organization and management are not well established. A clear comprehension of this intricate provision of mental health care can help the Italian health system to better allocate resources for psychiatric services. The complexity of the psychiatric services and facilities in Italy explains why the analysis of costs cannot be focused exclusively on the length of stay. In fact, the mental health care provided by the Department of Mental Health comprises, together with the length of stay, outpatient services, residential facilities (RFs), activity of mental health centers, rehabilitation, and supporting housing. At present, Italian mental health costs come from the following sources: tax-based, out-of-pocket, and private insurance. Actually, for the psychiatric sector, notwithstanding the fact that the fee for service is considered as one of the possible solutions for the rationalization of the hospital expenditures, the results of the studies published on this subject seem to demonstrate the weakness of the diagnosis in predicting, in general, the use of the services and, in particular, the length of stay in the acute psychiatric wards. Previous researches (Amaddeo et al., 1997b; Donisi et al., 2013; English et al., 1986; Essock and Norquist, 1988; Pertile et al., 2011) have in fact reported the outstanding variability in the length of stay within diagnostic groups for psychiatry, thus demonstrating that this sole variable can predict less than 10% of such variability. For example, Keefler et al. (2001) reported in their study on a sample of 160 patients that the severity of the patient’s psychosocial problem was a more significant predictor of length of stay than the DRG variable. The American Psychiatric Association studied the potential impact of DRGs on psychiatric patients and inpatient psychiatric units in general hospitals, reporting a substantial inaccuracy in the psychiatric DRGs’ prediction of resource use (English et al., 1986). Notwithstanding the evidences reported by these and other similar studies (Essock-Vitale, 1987; Goldman et al., 1984), DRG seems to be, at present, the most complete, easily applicable, and robust system of funding for health care in Italy. Finally, it is necessary to underline that the costs of mental health provision of care in Italy have been affected in the 2 latest decades by the deinstitutionalization process, which started in the most industrialized countries in the 1960s. With the national mental health reform and its consequential replacement of mental hospitals with community-based facilities, the costs of care of Italian psychiatric patients have noticeably changed. The development of these new facilities has changed the Italian scenario of mental health financing because they include a variety of settings ranging from board homes to wards in the community (de Girolamo et al., 2004), whose costs were supposed to be lower than the growing costs of hospital care. The downsizing of mental health services reflected the need in the 1980s to save money in an era of international increase in health care costs (Knapp et al., 1990). Moreover, in Italy, the marked socioeconomic differences between the three macroareas of the country (North, Center, South and Islands) are reflected also in the provision of mental health services. Consequently, costs vary from area to area and also within the same area, following the differences in the organization of local models of care and resource availability. In fact, the Italian Psychiatric Reform also established geographically defined catchment areas, and residents of a particular area are supposed to receive care from the services within that same area.
ITALIAN STUDIES ON MENTAL HEALTH ECONOMICS As for other world countries, also for Italy, the different economic approaches have been used: the burden of illness and the cost of illness (COI), which estimate the costs for treating an illness and www.jonmd.com
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for managing its consequences on the population according to prevalence and incidence of mental diseases, and cost prediction, which aims to predict the costs of specific groups of patients. A scarcity of studies on cost-effectiveness of community and rehabilitative intervention can be observed. In 1996, an Italian version for the Client Service Receipt Interview (Intervista Costi Assistenza Psichiatrica [ICAP]) was developed and published from the University of Verona research team (Amaddeo et al., 1996). The ICAP was conceived with the aim of evaluating in Italy the costs of either a single community-based service or a whole Department of Mental Health, that is, complex systems structured in a network of integrated and interconnected services and agencies. This instrument allows the monitoring of the costs of mental health provision of care, and it was used to calculate the cost for psychiatric care in Verona in 1996. In general, studies at the macrolevel on the costs of mental health care are scarce. Recent literature has in fact focused on evaluations and information at the microlevel, with studies conducted in local or regional services. The fragmentation of these data is probably due to the fact that the 1978 national legislation devolved to Italian regions the responsibility of managing the resources devoted to the provision of mental health care. We review here some of the major studies conducted in singular services and/or departments. For a national general overview of the Italian mental health care financing, these studies have to be integrated with the results from the REFINEMENT project. In other words, these descriptions of local and regional structures for mental health care provide some insights for a broader evaluation of the Italian NHS for mental health. In the 1990s, some evaluative researches on costs were carried out in South Verona (Amaddeo et al., 1997a) on the totality of the patients of the Territorial Psychiatric Service of Verona, whose main agency providing psychiatric care for the adult population is the South Verona CMHS, run by the Section of Psychiatry, Department of Medicine and Public Health, of the University of Verona and supplying a wide range of well-integrated hospital and community services. In this study, the direct costs for their psychiatric treatment were calculated for 1 year after their first contact in 1992. Some variables seemed to be significantly associated with higher middle costs (for each patient and for 1-year treatment): for example, unemployed patients or patients seeking their first employment used a major quantity of resources, whereas patients living alone and those living with their family had similar costs. The analysis of the costs for diagnostic groups showed that annual cost per patient was 8,884 euros for schizophrenia and related disorders, 2,376 euros for affective disorders, and 1,395 euros for neurotic disorders. The variability among disorders was very high, thus confirming that the sole diagnosis cannot predict the use of the services by the patients. As for their composition, costs are mainly linked to admissions and residential services (from 50% to 66% according to the diagnosis) and to the day hospital, particularly for schizophrenic patients. A similar research (Amaddeo et al., 1998) was conducted on all the patients of South Verona who contacted either public or private psychiatric services, from hospital to RFs, in the province of Verona in the years 1992 and 1993 and who were at their early episodes of illness (299 patients), that is, first-ever users of psychiatric services. In this case, the composition of the costs was different because the expenditure for outpatient services was higher than for the other services in each diagnostic group, thus revealing a different pattern of use for patients at their first episode of illness. The multivariate analysis showed that only 6% of the variability of the costs for patients could be explained by the diagnosis. If, in the multiple regression, we add to the diagnosis some sociodemographic characteristics (such as age, sex, education, housing, and working) together with some other anamnestic characteristics (period of contact with the services, conditions of the place, etc.) of the patient, we get 40% to 50% of the explained variability. 466
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In 2000, a new study was conducted by the same research group (Bonizzato et al., 2000) to detect and compare any differences in service costs between patients with different diagnoses and to examine the associations between patient characteristics, including sociodemographic, clinical and service history variables, and service costs, by calculating all direct costs (psychiatric and nonpsychiatric) and incorporating additional clinical, social, and previous service use variables into the explanatory model, in an attempt to explain a higher proportion of variance. Patients in South Verona were interviewed 3 months after the clinical evaluation, using the ICAP. The data referring to these 3 months were used for estimating costs for 1 year. Data from the Psychiatric Case Register of Verona (Tansella et al., 1999) were also collected and compared with those from ICAP interviews. For each patient, costs were grouped by service type into five components: inpatient costs, which included all days spent in a public or private sector hospital for psychiatric care; sheltered accommodation costs, which included all days spent in public sector specialized accommodation; day-patient costs, which covered all contacts at day hospitals or at rehabilitation groups; outpatient costs, derived from all contacts at the outpatient department and community psychiatric clinics, general hospital liaison, and accident and emergency department; and community costs, which included visits made to patients’ or relatives’ homes, visits to patients temporarily registered with other agencies, or visits to the premises of voluntary organizations, as well as the provision of social services by psychiatrists, nurses, psychologists, social workers, and other psychiatric staff. The high explanatory power of the model resulted from this study suggests that costs of care in Italy can now be predicted with an unusually large degree of confidence for this population, using a limited set of readily available sociodemographic and clinical measures. The results of this study also confirm that more resources are targeted on patients with severe mental illness. In 2002, a study analyzed service use in routine clinical activity and the costs of providing mental health care during 24 months for the whole population of patients who had first contact with the Magenta Community Mental Health Centre (CMHC) in 1994 (Percudani et al., 2002). All 330 patients who had first contact with the Magenta CMHC between January 1 and December 31, 1994, were included in this study and were diagnosed on the basis of ICD-10 classification. Service use data for the Magenta CMHC patients were extracted from the Psychiatric Information Computerised System promoted by the Lombardy Regional Health Authority and run by the Magenta CPS since 1992. The analysis of these data showed that, during the 24 months after the first contact, the 330 patients incurred costs of 461,511 euros (1394 euros per patient). Inpatient activity accounted for 49.7% of total costs; and community services, for 50.3%. According to the different diagnoses, total costs of care of patients with a diagnosis of schizophrenia and related disorders were higher than those for the other diagnostic groups. Care of patients with a previous psychiatric contact and a longer duration of illness was more costly than that of the other patients. The trend of the results of two previous analyses conducted in the same setting in 1995 (Fattore et al., 1997) and in 2000 (Fattore et al., 2000) was thus confirmed. In 2000, for the Magenta CPS, whereas patients with schizophrenia and related disorders had a mean cost of 3771 euros, those with neurotic and related disorders had a mean cost of 439 euros. Both the Magenta studies showed that hospital treatment is a major cost component and that schizophrenia patients present special cost patterns, influenced by nonclinical characteristics. In fact, it is mainly for these patients that the concept of community psychiatric care was developed, and this is the approach used to manage severely ill psychiatric patients in a CPS in Italy, 20 years after the Italian mental health reform. After some cost-analysis studies conducted only in limited areas of the country (see for a review Mirandola et al., 2004), three * 2014 Lippincott Williams & Wilkins
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multicentered studies compared the costs of CPSs in Italy: the GISIES (Interdisciplinary Study Group on the Economic Impact of Schizophrenia) in 1995, the PROGRES project (PROGetto RESidenze, i.e., Residential Care Project) in 2000, and the I-psycost study in 2009. The GISIES study (Tarricone et al., 2000) is a COI study aimed at assessing total direct and indirect costs of schizophrenic patients in 10 CPSs in Italy (Milan, Magenta, Brescia) and identifying the variables that influence costs. Results on 100 recruited patients showed that more than half of total direct costs were attributed to CMHC interventions. The yearly mean costs of schizophrenia per patient amounted to nearly 26,000 euros: 30% for direct costs and 70% for indirect costs, as assessed by two questionnaires compiled by mental health professionals. Direct cost components concerned CMHC interventions, living in RFs, inpatient care (e.g., use of psychiatric acute beds, day hospitals), pharmacological treatment, laboratory tests, and out-of pocket expenditures (e.g., transportation to and from health providers, legal and court expenditures, other medical expenditures). Indirect costs measure production lost because of the illness. In this work, indirect cost components concerned patients’ time off (paid and unpaid) work, informal care (care provided by nonprofessionals) that consisted of caregivers’ time off (paid and unpaid) work, and leisure time forgone. The GIES study tried to make a step forward compared with other COI analysis by including into the study design a statistical analysis that aimed at identifying main regressors of either total direct or indirect costs. The PROGRES project, launched in 2000 by the Italian National Institute of Health (Amaddeo et al., 2007), is the first attempt to estimate the costs of Italian nonhospital RFs in all 20 Italian regions and to evaluate the factors affecting both the costs of a sample of 265 Italian RFs, providing psychiatric, medical, and informal care, and their 2962 patients. This sample actually included 20% of the facilities operating throughout Italy whose financial information was derived from an interview with the managers of facilities. With this interview, information was collected about the management, the structure, the care, and the direct costs linked to the structure and patient administration. From this sample, it was evaluated that, in Italy, there are 2.98 places in RF per 10,000 inhabitants and that approximately 4,000 patients use an RF place in a year. Results of the PROGRES study showed that care of patients in RFs costs between 5,848 and 25,812 euros per year, to which it should be added from 1,513 to 3,500 euros per year for the CPSs. Differences between facility types and size and geographical location were tested by analyses of variance, and costs were analyzed at individual/patient level to take into account individual patients’ clinical and sociodemographic characteristics. From a regional point of view, comparing facilities in the three Italian geographical macroareas (North, Center, South and Islands), Northern RFs were more expensive (24,900 euros per patient per year) than Central RFs (18,840 euros) or Southern RFs (17,890 euros), and this holds true for every kind of facility. On the other hand, CPS costs were higher in the North, medium in the South and Islands, and lower in the Center. After the Italian Mental Health Plan (1998Y2000) and the Progetto Obiettivo for the Mental Health, Italy has adopted an organizational model for community psychiatric care focused on large multidisciplinary teams (Grigoletti et al., 2010). The I-psycost study analyzed in 2009 five Italian CMHCs CMHSs located in five different regions, three in the northern (Verona, Bologna, and Legnago), one in the central (Rome), and one in southern Italy (Avellino), the possibility to estimate the costs of each package of care for patients in charge. In fact, costs were calculated for each type of contact with the following results: the most expensive contacts were the admissions in psychiatric ward (230 euros) and in private clinic (138 euros), and these, with the employment/rehabilitation workshop and the day in residential care, were the only services to cost more than 100 euros. * 2014 Lippincott Williams & Wilkins
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The less expensive services were the individual rehabilitation contact, the rehabilitation group, the pharmacotherapy contact, the advocacy service, and the nurse’s support contact, with costs in a range from 13 and 23 euros. Contacts as the outpatient psychiatric and psychological contact, the individual or group psychotherapy, and the home visits have costs going from 35 to 59 euros. Costs varied also according to the frequency in the use of the services. For low service users, the funding system may be based on the principle of fee-for-service (for example, 1 day in an acute psychiatric ward costs 229.25 euros, an outpatient visit costs 59.53 euros, and an initial outpatient psychiatric assessment costs 60.77 euros). For frequent service users, the costs are higher because of their use of more complex packages of care, ranging from 4,133 euros to 11,984 euros per 6 months. The fact that this study was carried out in the three representative geographical areas of Italy makes the results exhaustive for the whole country.
CONCLUSIONS The current Italian mental health care system is complex and composed of different services and facilities. This situation must be taken into account when reflecting upon the choice of an appropriate funding system. For example, a fee-for-service system is not sufficient for certain activities especially in community mental health centers where care is provided to the whole community and not exclusively to single patients. The Italian approach to community psychiatry suggests that the funding system should be focused on patients and their needs rather than on the services themselves (Fattore et al., 1997). The financing system for mental health care should be produced in the pathway of care of the psychiatric patient within the service, thus identifying what are the indicators and variables that can predict this pathway. Among the several propositions, that of the need-related groups (McCrone and Strathdee, 1994) seems to be the most valid one because it bases the planning and financing of the services on the characteristics and needs of the patient (age, socioeconomic status, education, family, etc.), of the community (caregivers, informal care, etc.), of the provided service (setting, accessibility, etc.), and of the territory (urban versus rural, unemployment rate, etc.). In general, the main objective of a financing system is to transfer the economic resources by allocating them in an efficient and efficacious way, with a specific focus on patient needs and well-being. Throughout a review of the literature about the costs of mental health provision of care in Italy, a clear representation of the Italian situation as it is now, after the psychiatric hospital closure, was drawn. This description could help policy makers, key managers, and mental health care organizations in the decision making of money allocation. The Italian financing system for mental health care should then be analyzed within the European economic scenario to understand the cost variations among different countries that, however, cooperate for a strong European integration in mental health care provision. As in other industrialized countries, in Italy the concerns about the single market and health expenditure have been recently translated into cost cuttings in the health sector. From the 1990s, a series of laws and decrees have been issued to economically reorganize the Italian health care system. Especially today, with the economic crisis, economic resources for mental health care in particular are limited and constantly rationalized. It is necessary to reread the history of mental health care financing to understand what the best solutions are for providing a good service with scarce economic resources. Scientific-technical aspects should then be strictly linked to ethical ones: on the one hand, resources should be equally allocated according to a specific services plan; on the other hand, the needs of the users should be seriously taken into account together with the effects of their treatments. In other words, to be useful and efficacious, any economic evaluation should be based on the needs of the users, the quality of the www.jonmd.com
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services, the satisfaction of the users, and the obtained results. Specific indicators are used to provide this information. Another peculiarity of the Italian mental health care system is that psychiatric patients often use a wide range of both private and public services that can be also provided by voluntary or self-help associations. Costs must then be measured in a larger context by considering all the elements that determine together the social cost of the illness. For example, general practitioner consultations and private mobile care should be included in the analysis of the costs for psychiatric care. To the best of our knowledge, a review of mental health financing in Italy has never been produced, and the evaluation of the efficacy of psychiatric interventions associated to their costs is an almost neglected sector of epidemiology. It is instead useful to evaluate the current status of psychiatric services to allocate resources in a more effective way and to develop a funding system that can support the pathways of care of frequent users of these services. The information provided within this article may then be useful for managers and clinicians for choosing the best criteria for allocating resources. DISCLOSURE The authors declare no conflict of interest. REFERENCES Amaddeo F, Beecham J, Bonizzato P, Fenyo A, Knapp M, Tansella M (1997a) The use of a case register to evaluate the costs of psychiatric care. Acta Psychiatr Scand. 95:189Y198. Amaddeo F, Beecham J, Bonizzato P, Fenyo A, Tansella M, Knapp M (1998) The costs of community-based psychiatric care for first-ever patients. A case register study. Psychol Med. 28:173Y183. Amaddeo F, Bonizzato P, Beecham JK, Knapp M, Tansella M (1996) ICAP. Un’intervista per la raccolta dei dati necessari per la valutazione dei costi dell’assistenza psichiatrica. Epidemiol Psichiatr Soc. 5:201Y213. Amaddeo F, Bonizzato P, Tansella M (1997b) Valutare i costi in psichiatria. L’analisi economica per migliorare l’assistenza. Rome: Il Pensiero Scientifico. Amaddeo F, Bonizzato P, Tansella M (1999) I costi delle malattie mentali e la valutazione economica dell’assistenza psichiatrica. In Cassano GB, Pancheri P, Pavan L, Pazzagli A, Ravizza L, Rossi R, Smeraldi E, Volterra V (Eds), Trattato Italiano di Psichiatria (2nd ed, Vol 3, pp 3743Y3762). Milan: Masson. Amaddeo F, Grigoletti L, de Girolamo G, Picardi A, Santone G (2007) Which factors affect the costs of psychiatric residential care? Findings from the Italian PROGRES study PROGRES study group, Acta Psychiatr Scand. 115: 132Y141. Bonizzato P, Bisoffi G, Amaddeo F, Chisholm D, Tansella M (2000) Communitybased mental health care: To what extent are service costs associated with clinical, social and service history variables? Psychol Med. 30:1205Y1215. de Girolamo G, Picardi A, Santone G, Semisa D, Morosini P, Gruppo Nazionale PROGRES (2004) Le Strutture Residenziali e i loro ospiti: I risultati della Fase 2 del Progetto Nazionale PROGRES [Residential structures and their guests: Results of the phase 2 of the National Project PROGRES]. Epidemiol Psichiatr Soc. 13:1Y100. Donisi V, Tedeschi F, Percudani M, Fiorillo A, Confalonieri L, De Rosa C, Salazzari D, Tansella M, Thornicroft G, Amaddeo F (2013) Prediction of
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