Health Systems Comparative: Italy vs. United States of America

            Italy and the United States (US) are two developed countries with functioning government systems and financial strength yet have two very different approaches to healthcare. As a basic overview, Italy has primarily a public-based health system in which healthcare is supported by tax income (Bezzone, 2018). There is a private system available for purchase in Italy, which is used to occasionally supplement the standard public system (Bezzone, 2018). In America, public healthcare coverage is limited and only available to a small percentage of the population; the private sector supplies the majority of health coverage to American citizens (Bezzone, 2018). As we delve further into the differences between the two health systems, we will discover pros and cons of each. We will look at advanced nursing roles in each country and discuss how we can learn from each other to increase access to healthcare, provide high quality care and increase health outcomes through the delivery of a healthcare system.

Health Policy, Government Regulations and Funding

            In Italy, healthcare is viewed as a fundamental human right of every citizen. When viewed as an intrinsic right, healthcare is then provided by the State through the use of tax income. Italian citizens pay approximately 50% of their income to taxes as part of this service (Bezzone, 2018).  In 1978, the Italian National Health Service established universal coverage for healthcare, naming human dignity and health needs as primary guiding principles to the decision (Donatini, 2017). Guided by the Italian constitution, the central government orders the distribution of the tax revenue and defines healthcare packages that are offered to all residents in every region; the regions then have the responsibility to organize and deliver the healthcare services to the people (Donatini, 2017).  Healthcare coverage is universal and covers all citizens and legal foreign residents automatically. Italy spends approximately 9% of its Gross Domestic Product (GDP) on healthcare, comparatively the US spends 18% of the GDP on healthcare, the highest of all nations (NationMaster, 2018). The Italian National Health Service does not allow the option to opt out of the public healthcare system, however, private health insurance policies are available to be used as a supplement to the public system (Donatini, 2017).

            Opposite of the Italian government, in America, health insurance is ruled mainly through private insurance policies, and the public policy is reserved for only those people who qualify from an income and age standpoint. In 2010, the Affordable Care Act (ACA) was enacted to work towards ensuring more Americans have affordable access to health insurance (The Commonwealth Fund, 2018). Americans continue to see large gaps in coverage for those that do not qualify for the government funded programs nor can afford private insurance. This has left many people at risk without insurance coverage. The private insurance market is regulated at a state level and is funded through employer assistance. In 2015, 67% of Americans received health care coverage through private health insurance, the majority being through employer-provided programs (Commonwealth Fund, 2018). However, in the first quarter of 2016, over 27 million people were still uninsured in America (Commonwealth Fund, 2018).  With the rising cost of healthcare services combined with the high cost of coverage, many Americans feel the financial burden of paying for medical bills. 

Access to Care and Current Issues to Overcome

            Like the American healthcare system, the Italian system also has varying levels of providers. All Italian citizens must choose a primary General Practitioner (GP) to mange their care; these physicians are responsible for prescribing needed medications, diagnosis of health concerns, and referrals to specialists or consultations for increased level of care when needed (Salvadori, 2018).  The GP that we met with in Italy, explained how she would make house visits during the night, keeping nonemergent issues out of the emergency departments. In the cases when a GP is not able to provide after-hours care, exams can be provided by the emergency medical service who can then assess, prescribe or admit to the hospital if needed (Donatini, 2018). When specialist care is needed it is provided by outpatient health units or either public or private accredited hospitals; patients can choose which hospital they would like to receive their care at, but they cannot choose which specialist they see (Donatini, 2018). As part of the public system, the wait times to see a specialist may be long. If able, the patient may choose to pay for a specialist through the private sector which typically would result in faster treatment. Italy has a prominent focus on prevention through the healthcare system. The lifestyle and diet of the Italian culture is used as a focus on preventing disease rather than only utilizing the healthcare system as a way to treat disease. Long wait times are a concern for people needing care quickly, if an individual or family is not able to afford the private insurance fees to expedite the treatment process, accessing care through the public system is the only option. This can be a frustrating aspect of the healthcare system for many Italians.

            In America, Healthy People 2020 has set a goal to improve the access to comprehensive, quality health services for American citizens (ODPHP, 2018). It is recognized that having access to health services is important for the promotion of health and prevention of disease.  Access to care is based on gaining entry into the health system typically through private insurance coverage or if eligible through Medicare or Medicaid (ODPHP, 2018). Patients must find a location that the needed services are provided and are covered by their health insurance; they are able to choose their general practice doctor and their specialists for the care that is needed. An emphasis is placed on choosing a doctor that the patient trusts and can communicate with and build a personal relationship to work together during the care process (ODPHP, 2018).  The Office of Disease Prevention and Health Promotion (ODPHP) (2018), recognizes several barriers that Americans face when finding health services, these include the high cost of care, inadequate or no health insurance coverage, lack of services in the required geographical area, and a lack of culturally competent care. These barriers then lead to health needs not being assessed, delays in receiving care, financial burdens, and hospitalizations that could have been prevented through appropriate preventative services (ODPHP, 2018).  Through the implementation of the ACA, 20 million people gained health insurance coverage, but millions of Americans still lack healthcare insurance. The Healthy People Midcourse Review shows significant disparities in access to care by age, sex, race, income and education level (ODPHP, 2018). Government officials know that efforts need to be focused on increasing coverage, better distribution of care, focusing on primary care models and patient-centered care, as well as preventative care and cost of receiving care in America (ODPHP, 2018). 

Healthcare Provider Roles and Advanced Practice Nursing

            Traditionally, Italian General Practitioners have worked in a solo practice, more recently there has been a push to develop multidisciplinary practices to integrate health and social care services (Donatini, 2018). General practitioners typically oversee patient care and take responsibility for patient outcomes. In July 2014, a Pact for Health was signed to work towards care integration and involving GPs, specialists, nurses and social workers to work interdependently to care for the patient (Donatini, 2018). The family also plays a very important role in the health care of family members. Caring for a loved one, assisting in the delivery of the care and decision-making would be an integral part of the family culture in Italy. 

            A notable difference in the Italian healthcare system is the lack of the Advanced Practice Nursing profession. The Advanced Practice Nurse (APN) role continues to be developed in Italy. Legislation is 2006 created a nationally recognized title of the Nurse Specialist and laid out educational requirements to be in this role (Kruth, 2015). However, the implementation of this role continues to be under development. As of 2015, there was no legal separation between the scope of practice of the RN and the scope of practice of the Nurse Specialist due to resistance to advancing the role of the nurse (Kruth, 2015).  This is unfortunate for the Italian community. The APN can provide a multitude of skill to the medical community and work alongside GPs to enhance the whole patient experience, decrease costs and improve patient outcomes.

            In the United States, the APN plays a vital role in the health system and delivery of patient care. The APN is a registered nurse who has received a graduate degree with a master’s or doctorate level preparation. APRNs are prepared to assess, diagnose, manage, treat and prescribe medications to all types of patients both in hospital and clinic settings (NCSBN, 2018). Evidence has shown that APNs provide significant contribution to the improvement of patient care and outcomes, help to decrease readmission rates and lower hospital costs (Parker, & Hill, 2017). In the US, APN’s practice is different depending on which state they live in. Research has shown us that having Advanced Practices Nurses practicing to the full extent of their scope of practice is beneficial to the hospital organization, to the community and most importantly to the patients in which they provide care for. The APN is well-equipped to care for complex cases and has the capacity required to meet the care needs of their communities (Parker, & Hill, 2017).

Conclusion

            As we have learned, there are significant differences in the way the Italian healthcare system functions compared to the American structure. There are pros and cons of each system. Italians have access to general care, specialized care, medications and treatments at little to no cost; however, there may be long wait times or additional feels for non-emergent needs. Americans on the other hand are feeling the heavy burden of increasing medical fees, restrictions on insurance access and a decrease in preventative services. Italy’s culture places focus on family, community and prevention; with the thought process that if chronic illness can be prevented through diet and lifestyle choices, less money will need to be spent on care and treatment for the disease. America’s medicine is more reactionary, and a lot of money is spent every year on treatment of chronic illness and disease. However, wait times to see a specialist are not as long, you can choose the physician you would like to see for treatment and the system provides exceptional health services to everyone – but many are left wondering how they are going to pay those bills. Nursing as a professional practice is viewed with more autonomy in America. Nurses with advanced degrees are allowed to practice independently and within a broad scope of practice in the United States. Italy has been working towards an advanced practice nurse but has not seen much headway in several years. As research has shown, the advanced practice nurse can provide exceptional care, decrease costs and improve patient outcomes. This role could be very beneficial to the health care practice in Italy as well. Overall, America has a lot to learn from the Italian culture, shifting focus from individual needs to a community-based thought process could help to serve so many more individuals. Good food, close family, disease prevention are the cornerstones of the Italian community network which leads into the Italian healthcare system and provides a strong basis for a long and healthy life.

References:

Bezzone, F. (2018, May 10). Italian health care system vs. the US healthcare system. [Blog post]. Life in Italy. Retrieved from https://www.lifeinitaly.com/lifestyle/medical-system

Donatini, A. (2018). The Italian healthcare system. The Commonwealth Fund. Retrieved from https://international.commonwealthfund.org/countries/italy/

Kruth, T. (2015, March 3). Advanced practice nursing in Italy. International Advanced Practice Nursing. Retrieved from https://internationalapn.org/2015/03/03/italy/

National Council of State Boards of Nursing. (2018). APRNs in the US. Retrieved from https://ncsbn.org/aprn.htm

NationMaster. (2018). Health Stats. Retrieved from https://www.nationmaster.com/country-info/profiles/Italy/Health

Office of Disease Prevention and Health Promotion. (2018). Access to health services. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Parker, J.M., and Hill, M.N. (2017). A review of advanced practice nursing in the United States, Canada, Australia, and Hong Kong Special Administrative Region (SAR), China. International Journal of Nursing Sciences 4(2), 196-204. Doi 10.1016/j.ijnss.2017.01.002

Salvadori, P. (2018). Primary care in Italy. European Forum for Primary Care. Retrieved from http://www.euprimarycare.org/column/primary-care-italy

The Commonwealth Fund. (2018). The U.S. healthcare system. Retrieved from https://international.commonwealthfund.org/countries/united_states/