National Health Care System (‘Servizio Sanitario Nazionale’)
Italy has a national health system, similar but not identical to the one used in the UK, France and Spain. Other European countries, including Germany and Switzerland (and the ACA, for that matter) use a government-regulated insurance approach.
In Italy, all citizens are automatically enrolled in the national health system. Legal Italian residents who are citizens of another EU country are also entitled to use the health care system under EU reciprocal agreements. Certain family members of those in the previous two categories are also eligible. Legal residents from other countries are allowed to buy into the system. Premiums are income-based, and range from €400 to €2700 per person per year.
Coverage is comprehensive, and includes things like rehabilitation services which are often treated as supplemental services in the US. There are no deductibles, and for new registrants, there are no exclusions for pre-existing conditions. Public system doctors do not make house calls, but the system does provide transportation for the elderly or others in frail health who are unable to get themselves to a treatment facility.
Co-Pays and Other Costs
Coverage includes an unlimited number of visits to your primary care physician, without co-pays.
There are co-pays for certain items like annual blood tests. Co-pays are subject to a statutory maximum, currently €46 (about $50), but depending on the test can sometimes be less. Co-pays are waived for those on limited incomes, or for those in certain medical categories like cancer survivors.
Co-pays also apply to consultations with specialists. If you get a referral from your primary physician, and are willing to take the next available specialist, you pay €46. If you make the appointment on your own, or you want to see a specific doctor, you pay €100 (about $110).
There are no co-pays for emergency room or hospital services.
Mammograms are free every two years. If you (or your doctor) want them more frequently, you can schedule them, subject to the standard co-pay.
Drugs prescribed for active conditions (e.g., antibiotics for current infections) are free. Maintenance drugs are either free or low cost (see “Medications” below).
When you are enrolled in the system, you select a primary care doctor who is generally your point of entry. If you don’t like your doctor, you can change without cost or penalty (although you will have to wait in line at the administrative office).
The system is administered locally. Within each region, there are smaller administrative areas which ensure that most of your medical care will be provided for by practitioners close to where you live. In our case, our primary care physician is a 10-minute walk from our house. Our primary hospital and emergency room is a 10-minute drive from our house, or 20 minutes by bus (served by three bus lines). Within walking distance from where we live, there is a satellite center for blood tests and immunizations, so you don’t have to go all the way to the hospital. There is also a small private hospital within walking distance where you can get some services at additional cost.
Although your primary care physician is located in your area, you can actually go to a public system doctor anywhere in the country. If you want to see a knee specialist in Perugia or a heart specialist in Rome, you are covered, subject to co-pays and availability. If you have a rare condition and the only available specialist is in another city, the system will cover your train ticket.
The system is set up for efficiency, which is not necessarily the same as convenience for the patient. If you are very sick, or have a medical emergency, you will be seen quickly, for example only a few days between cancer diagnosis and treatment. On the other hand, if you go to your doctor with an important but not urgent medical problem, you will probably sit for 2 hours in your doctor’s waiting room. Most primary care doctors here practice individually, with at most a nurse assisting.
Waiting times for non-urgent specialist consultations, or non-urgent medical procedures, like “extra” mammograms or colonoscopies, can sometimes be months long. If the appointment is truly non-urgent (e.g., you want a second medical opinion to confirm a prior medical conclusion) you may not mind the wait. And you can sometimes get an appointment quicker if you are willing to go to another doctor in the region, which can be an hour or two away. Or you can go to a private doctor.
Private System as Supplement
One of the most interesting features of the Italian medical system is the way you can go to a private doctor or a private hospital on a one-off basis, even though you are covered by the national health care system. This is not the case in the UK (or the US for that matter), where you are either in the public system or the private system, but you generally can’t utilize both systems at the same time.
So, for example, if you want a colonoscopy, and don’t want to wait months for a hospital appointment, you can make an appointment for the same procedure at a private hospital, generally with a much shorter waiting time. Similarly, if you want a specialist consultation in weeks instead of months, you can pay for a private doctor.
Private facilities also provide services for the public system on a contract basis. A friend of ours had minor surgery at the local private hospital, which was fully covered by the public system. Private facilities also provide diagnostic services for the national health system on a space available basis.
There are also some doctors who have both public and private patients, with shorter wait times (and higher fees) for the private patients.
The reason why this back-and-forth between the public and private systems works is that the costs, even at most private facilities, are very reasonable The cost of a mammogram from a private doctor, for example, is 80 euro. A consultation with a private surgeon is €150. And the cost of a colonoscopy at the private hospital was €130. These costs are not only reasonable for us as Americans, used to paying staggeringly high prices, but they are also within the means of middle-class Italians.
We think that most people in our area use the public health system for most of their medical needs. People in certain situations might use private doctors for primary care. People with chronic medical conditions, women expecting a baby, or working parents with small children, for example, often prefer the convenience of being able to make an appointment.
With respect to major medical services, though – surgery, broken bones, treatment for cancer or other serious illnesses – it seems that most people, rich or poor, use the public system.
Registering for the SSN
As stated above, the SSN is administered locally, so each region (or sub-region) will have it’s own processes. In Ascoli, the administration function for SSN enrollees is performed at the Anagrafe Assistiti in an office at the main hospital, but the acronym ASL (Agenzia Sanitaria Locale) is more generally used to name this office. The office handles SSN signups, choice/change of doctor, and exemption on co-pays (tickets) for people of lesser means.
Italian citizens and family members of citizens are eligible for Iscrizione Obbligatoria (gratis enrollment), and most likely will not have to visit this office again except maybe to change primary doctors (medico di base).
Folks who are not family members of EU citizens must sign up for Iscrizione Voluntaria. There is a form that you will need from the ASL. This form does not appear online as far as we can tell, so you will have to go there or find someone else with a copy. Payment is made according to the formula below. Income in most regions is self-certified and is intended to include worldwide sources. (Some regions require official income certification, which causes those folks serious pain.)
7,5% of total income up to €20,658.28 plus 4% of the amount exceeding €20,658.28 up to €51,645.69, and in no case less than €387.34 .
Payment is for a calendar year. It is not possible to pay in advance, and there is no pro rata reduction for a partial year. Payment is made by F24 form, the same form using which income tax is paid. But you need to include the specific coordinates for your regions SSN. Our ASL is known to be picky in that an “original receipt” must be shown for the electronic F24 payment. We suggest that you go to your bank to make the electronic transfer and ask the clerk to produce an official receipt. Actually, ask for two official receipt (see below).
You must provide your Carta d’Identità or other proof of local residence, and your Permesso or Carta di Soggiorno. Your SSN enrollment will be valid only until the expiry of your Permesso/Carta, so you may need to return to this office after any renewal. Renewal receipts are supposed to be sufficient, but this is Italy, so you can’t be sure. The ASL may also ask you for another “original receipt” of payment like the one you submitted at the beginning of the year. So, it’s best to ask for two when you make your payment at the bank.
Once you have your payment receipt, you can go back to the ASL to complete the signup.
Choosing a Doctor
Choosing a medico di base is not easy given that the rolls are fairly full and that there is not much to go on. The best method may well be to get a recommendation from someone you trust. Keep in mind that there is a mandatory retirement age, so if you sign up with an older doctor, you may be choosing again in a few years.
Doctors have a lot of flexibility when it comes to organizing their practices. Some practice in small groups. Some schedule appointments. Some have assistants, some don’t. But it is most common, at least in Ascoli, for doctors to offer office hours, usually for a few hours a day. You go to the office, ask “Chi è l’ultimo?” and wait. You may want to choose a doctor best suited to your tolerance for waiting. Bear in mind that the amount of attention that a doctor may choose to spend helping you may be proportional to your wait time.
Using the SSN
After visiting the ASL, your first experience with the SSN will probably be with your chosen medico di base. After waiting for your turn, your doctor will probably talk to you, maybe take your blood pressure, and then order a battery of tests. For blood tests, you can go to a local centro prelievi. In Ascoli, the ASL operates one at ex-Gil and one at the hospital. You will supply the co-pay first, of course. Private facilities are possible as well, although those might cost more. Your results will be available at the same location, or online.
For specialized tests, for example an ECG, you need to go to the CUP (Centro Ufficio Prenotazione). In Ascoli, that is at the hospital. (They are currently experimenting with allowing appointments to be made online or at pharmacies.) When you return to the hospital for your test, be prepared to pay in advance at the CUP or just afterwards. Policies differ. And of course, you can always go to a private facility instead. Or, the CUP might send you to a private facility for your test at the public rate.
Quality of Medical Care
The quality of the medical care is difficult to judge for those of us who are not doctors. But the SSN doctors seem attentive and well-informed. In cases where we have had the same procedure done both in the US and here, our experience here was better.
Many procedures done by physician assistants or nurses in the US are done by doctors here. In the US, when a test is done by a medical tech, the technician is often prohibited by law from discussing the results of the test with the patient. In Italy, when tests are done by doctors, they write up and discuss their results with you in real time.
In our experience, doctors, or at least medici di base, are a lot less “hands on” than doctors in the US. They rely a lot more on looking at test results rather than examining you physically.
In the Italian medical system, test results, whether in a public or private facility, are typically immediately available and are your property. This puts the responsibility on you for maintaining your personal medical records – you often see people in doctor’s offices carrying around thick folders with their medical history. But it also means that if you change doctors or move to another region, you don’t have to struggle to get copies of your medical records.
Private insurance is available, and is generally not costly, but in my region, at least, it seems that few people use it.
Certain specialties are not well-covered in the national health service, but you can find excellent service in private practice. Here are some details specific to Ascoli Piceno.
- Dental service, at least in Ascoli, is excellent in our experience. At least as good at the US if not better, and an approximately half the cost. We recommend Dr. Gino Chiodi on Via Cola d’Amatrice.
- Again, we have found opthamalogical service here to be on a par with that in the US. Eyeglasses, however, seem to be more expensive. We recommend dott.ssa. Stefania Aliberti on Via Marcello Federici.
- Dermatology specialists are hard to find in the SSN. We have had good luck with dott. Massimo Cioccolini who is in private practice on Via Erasmo Mari.
Doctors can issue two types of prescription. One is directly in the SSN computerized system allowing you to pay the “ticket” price for the medicine, which is close to nothing. Such prescriptions are typically for limited duration: 2 months at most. Or your doctor can hand-write a prescription outside the system for up to 6 months. In this case, you pay full freight which is not usually very much. This can save time waiting in the doctors office. For example, a common statin costs €6 per month.
Vaccines (especially flu vaccines) are sometimes available at doctors offices, but çan often be available directly at pharmacies (at reasonable cost). A pharmacy may or may not be equipped to administer the vaccine. It is not so uncommon for people to give shots at home.
Painkillers are less widely used here, whether by prescription or OTC. Doctors here use painkillers for pain reduction, not pain obliteration — increased pain is a symptom they don’t want to mask. There are drug abuse problems in Italy, but there doesn’t seem to be an epidemic of opiate abuse.
- European equivalents to Common US over the counter drugs
- Importing special drugs