A turnaround strategy: improving equity in order to achieve quality of care and financial sustainability in Italy

Abstract

BackgroundEquity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.MethodsThe analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.ResultsAll indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.ConclusionsReducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.

A Performance Management System in Healthcare for All Seasons?

“…Focusing on health systems, we may identify three key resources [27,51]: the quality of care level, the equity level, and financial support. A sustainable health system operates by maintaining the desired level of quality, guaranteeing the same level of care response to every person (and over generations) and consuming only the financial resources allocated and not more.…”

The Impact of New Surgical Techniques on Geographical Unwarranted Variation: The Case of Benign Hysterectomy

“…When unwarranted, variation conflicts with the three pillars of public healthcare systems: quality, equity and financial sustainability [ 12 ]. The main categories of geographical variation identified by Wennberg [ 13 ] and then integrated by Nuti et al [ 14 ] are: Effective care: it includes all the services whose effectiveness has been demonstrated and for which benefits clearly outweigh risks. Preference-sensitive care: it includes all those conditions where two or more clinically acceptable options exist, and choice should depend on patient preferences.…”

“…Additionally, the unwarranted geographical variation in the provision of elective care has been widely documented across and within countries [ 17 , 18 ]. Since elective surgical services are related to both preference-sensitive and supply-sensitive factors [ 14 , 19 ], some studies have suggested that policy-makers and healthcare managers should analyse unwarranted geographical variation in order to detect inappropriate care delivery, to improve quality of care and achieve equity of access to healthcare services [ 14 , 20 , 21 , 22 ].…”

“…Beside variation, in Beveridge-model public systems, policy-makers should also guarantee citizens equitable access to care, regardless of individual ability to pay or other characteristics such as income, region of residence, or other [ 14 , 23 , 24 ]. In a context of increased population age (and therefore needs), rapid technological advancements and slower economic growth, the Italian healthcare system faces the challenge of providing equitable, appropriate, and high-quality care while keeping an eye on the financial sustainability.…”

Women’s choices for breast cancer surgery in Italy: quality and equity implications

“…Equity and quality in healthcare are key goals embraced by universal healthcare systems (1); however, inequalities in access and unwarranted variations in quality of care are well documented in the Italian healthcare system (2)(3)(4)(5)(6)(7)(8).…”