Folks still wonder why we live here
‘Singin’ to the choir’, I said when I saw this article on the internet.
(Tessera Sanitaria, Government-Issued Health Care Card)
The Italian health care system is now considered the third most efficient globally, as judged by Bloomberg Rankings. In the last year, the universal health care system has moved from 6th to 3rd place. Recognizing that an efficient health care sector is vital to the longterm fiscal health of a nation, this is good news for Italy and her citizens who are universally covered. The average annual cost per capita of health care in Italy is $3,032 (9.0% of GDP) compared to Singapore that placed 1st at $2,426 (4.5% of GDP). For the full results click here. As a side note, Italy has one of the highest life expectancies in the world at 82.5 years.
So how does health care work in Italy?
The central Italian government controls the distribution of tax revenue for publicly financed health care (Servizio Sanitario Nazionale, or SSN) and defines a national minimum statutory benefits package to be offered to all residents in every region – the “essential levels of care” (livelli essenziali di assistenza, or LEAs). The 19 regions and two autonomous provinces have responsibility for the organization and delivery of health services through local health units (LHUs). The regions enjoy significant autonomy in determining the macro structure of their health systems. LHUs are managed by a CEO appointed by the governor of the region, and deliver primary care, hospital care, public health, occupational health, and health care related to social care.
The SSN covers all citizens and legal foreign residents. Coverage is automatic and universal. Since 1998, illegal immigrants have been granted access to basic services. Temporary visitors can receive health services by paying for the costs of treatment. Modeled after the British National Health Service, the SSN replaced a Bismarckian system of health insurance funds in 1978. Complementary and supplementary private health insurance is also available.
Martha writing again.
The important sentence to note is ‘regions enjoy significant autonomy’. From FaceBook groups that I am part of, I know that not everyone has a good experience with the health care system here. And I believe that here in Italy, just as anywhere else, you only get the quality of healthcare that you ask for/advocate for. I feel like sometimes you might have to be aggressive in getting good healthcare. But I rarely have to be pushy here in Tuscany, specifically the Arezzo region which we are part of. I think we have a well run system and our experiences for over seven years are what I base those beliefs on.
This summer we had more than our share of contact with Italian healthcare. In July, Ben made a Saturday night ambulance ride with emergency room visit and over night stay. Which was followed by a visit to our family doctor on Monday morning for an urgent referral to the diabetes clinic, who saw us on Tuesday and changed his medication and gave him a blood monitoring kit and supplies. And set up him to receive supplies at no cost on a regular basis.
Now while all that is condensed down to a few sentences what really was involved was on Monday morning I had to go to Monte San Savino to see our family doctor and explain what happened. (Sit and wait to see the doctor.) Then I had to go to Arezzo to the diabetes clinic to give the referral and get the appointment. (Sit and wait to get the appointment.) The day of the appointment Ben and I went. (Sit and wait to see the doctor.) The diabetes doctor wrote up her recommendations, gave us the blood testing kit and told me where to go to register to get the supplies, the office of Protesti. This is an extremely hard place to find. It is tucked in a section of the hospital grounds that must date from the 1940s. There are a lot of trees and crooky, winding lanes so you can’t really see all the buildings or any signs without walking up to each one. Several years ago I had been to this office. So I did have vague ideas about where it was, but still it took me a good 15 minutes of walking around (in the heat) to find it again, take a number and sit and wait to see the lady, Sandra, who runs the show. She got us hooked up. And then she started chatting. Sandra has relatives in the US. She loves the US. She loves speaking in English. And she clearly loves her job. But all that is not the point of the paragraph. The point is that unless you know how the system works, the steps that have to be taken and in what order and you are smart enough to bring some reading material for all the time you spend sitting and waiting, then it will feel like a frustrating, inefficient experience.
While I was there chatting with Sandra, I remembered that we had come to this office before about getting a cane for Ben. It sounded like such a process that we just bought one. But clearly she was in charge of wheel chairs too. Now, Ben can walk. But not for far and not for long. And any small change in grade, steps, holes, rocks, cracks in sidewalks can send him tumbling. Even after many falls he remains relatively fearless. Not the case for me. Imagine the sight we make, Ben swinging and tapping along with his long walking sticks that he uses instead of his canes when we are outside the house, slowly progressing and lurching from side to side, usually with his headphones on listening to a book on tape and sunglasses on too. So he can barely walk, he can’t hear and is half blind. And I am behind him, to catch him if he falls, opening and shutting doors, moving furniture out of the way and then back again, all with my purse and his bag slung on me, carrying medical records, or shopping. Usually I am stressed and looked stressed. And I wonder why all of Monte San Savino knows us?
Several weeks later, considering a vacation, with Ben using a wheel chair so that it is a vacation for me too, I spent hours on the internet trying to rent a wheel chair in various locations. Because of Ben’s size he is just over the weight limit for wheel chairs that are available for rental. I consulted our pharmacist. (In Italy the town pharmacist is a very good resource for many things.) He said, ‘get your doctor to write a prescription and get it from the health people.’ Well, it was worth a try.
So in late July, early August, I asked our doctor about getting Ben a wheel chair. This is when he told me to go to Medicine Legale, it is in Arezzo, in the old children’s hospital. (like I have lived here all my life and was born in the old children’s hospital and know exactly where it is) Seeing that I wasn’t go to get anywhere else with him I remembered our friend Sandra, in charge of wheel chairs. Why not go straight to the source? So back to the hidden office in Arezzo. (sit and wait to see the lady) She wrote for me a list in Italian of the steps that I had to take to get a wheel chair.
Step 1 Fill out the paperwork listing Ben’s limits
Step 2 Take this paperwork to the ‘social services’ office, then wait for an appointment for step 3.
Step 3 Attend a hearing to see if the request is approved
Step 4 Visit with a specialist who will decide what type of wheel chair is needed
Step 5 Get estimates of the cost from wheel chair providers
Step 6 Return to my friend Sandra, who will order it.
Of course there is an exact order which they should be done in but… some take longer to arrange than others. So she suggested that we complete steps 1 and 2 and then jump ahead to 4 while we wait for 3 to happen. Step 1 was to go back to our family doctor and get him to complete the paperwork to get the whole process started.
Before going to him, I wrote up a little summary of Ben’s abilities and limitations. So I went in to see him. (Sit and wait to see the doctor.) He looked at the list that Sandra had given me, looked at the summary that I had written up, heaved a great sigh, because it was now obvious to him that I was not going to give up and that he would have to do some work. Okay, he agreed. He would complete the form but I had to pay 61 Euros and return on Monday and he would have it.
Back, first thing Monday morning, our good doctor did have the form, took the money from me and gave me a receipt for it. Never before have I given him any sort of payment. So I was skeptical but he gave me a receipt. So I’m thinking that it is all on the up and up. While there, I get him to write the form that I need to get an appointment with the specialist. It is still early so I tootle off down the hill to the place where you make appointments (Sit and wait to make the appointment). Based on what our good doctor has written the appointment lady says I need to just go upstairs and see the local nurse. So I do that. I explain to her that we are trying to get a wheel chair and show her the steps that my friend Sandra has written for us. She just shakes her head. Writes out a new set of steps (which are more or less the same) and writes out EXACTLY what our good doctor needs to do. So back up the hill to see him again. (Sit and wait to see the doctor.) He writes a new slip for me. Back down the hill to the appointment lady. (Sit and wait to make the appointment). This time we get an appointment for a few weeks off. Then because it is still early enough, off to see the ‘social services’ folks. (Sit and wait to see them). Together the social services lady and I fill out paperwork. Ben needs to sign it. Ben is not with me because it really is hot and I did not want him sitting in the car for a long period of time. She and I agree that I will come back when they are open again, 2 days later.
Two days later after Ben has signed the documents, I tuck him in the car just in case they really want to see him and off we go back to Monte. I have his picture ID card which proves his signature with me but he is only a few steps away and they can walk outside if they want to see him. (Sit and wait to see them). Everything is in order, she accepts the paperwork and says we will be notified of a hearing.
While waiting for the hearing, we have our appointment with the specialist. (Sit and wait to see the doctor.) She writes up the prescription for the wheel chair. And we also have a follow up appointment with the diabetes doctor. (Sit and wait to see the doctor.) I casually mention that we are applying for Ben to get a wheel chair. “Oh,” she offers, “ You’ll need a letter from me about his condition.” (YIKES! Might have missed that) “Come back on Monday, I’ll have it for you.”
We are beginning to amass quite a file. The letter arrives scheduling our hearing for October 27 at 11:50 AM. Okay. Fearing that the hearing might be conducted by a bunch of ‘good ole boys’ who just might be a little intolerant of my poor Italian language skills I enlist the help of our diplomatic, courteous, well spoken friend, Richard. He meets us there. (Sit and wait to see them). Our hearing begins in a small, over heated room. There is a young man who conducts it and asks questions, Four older white guys, one of whom is shuffling papers and putting them into files and doesn’t really make eye contact and a younger woman who is over weight. There is an open discussion between three of the older white guys, all of whom could easily lose 10 pounds each, that Ben’s problems are all caused by weight and that if he had just pushed back from the table and on and on and on. All of this in front of Ben and the over weight woman. (And on this point I will agree that Ben has some fault in this but if you look at his heritage and genetics he has been fighting a losing battle since birth.) Together, Ben, Richard and I answer questions. The young man says we’ll make our decision and let you know in a month or so. We leave. Richard and I both understood the whole discussion about weight and were both totally amazed that it went on in such an insensitive manner in front of both Ben and the overweight woman panel member. (If the same thing happened in the US there would have been so many law suits…) Richard and I decided that she must be there to represent the portion of the population that is over weight.
Any way, my friend Sandra, from the office of Protesti, had said that after the hearing, don’t wait for the letter. Come to me and I can look it up. So, we wait a few weeks after the hearing and stop back in to see her. (sit and wait to see Sandra) . Yes, she finds us, yes, we are approved. Oh no, I have left a critical bit of paperwork at home. Next day, back again (sit and wait to see Sandra). Okay, she has it ordered, two weeks or so it will be here.
Two weeks go by. We check in with her. The wheel chair has just arrived. We can take it today. So what started in late July is finished on December 2. We go home with shiny new wheels. Ben says it does not match getting his first bike or his first car but it does give us both a feeling of security since we can now go places without as much fear of his falling.
This was a long process, but I will defend the system. If this had been an emergency situation where Ben could not walk, things would have moved much faster. And if we wanted to, at any time, we could have purchased a wheel chair. By going through what we did and seemingly endless times of sitting and waiting, the entire cost for us (including the July ambulance ride and emergency room visit and over night stay) was 61 Euros. Now, I did sign for it and assume responsibility for it so if it is stolen or damaged we will have to replace it. But at less cost than the open market. Would it have been smoother and faster in the US? Maybe. Would it have cost more? No doubt about that.
This is our friend, Sandra. She is just one of the many people who helped us along. It is a joy to see someone who is efficient and truly enjoys helping people.
Many times, Italy and its government are bashed/dissed for being slow, nonchalant, difficult to deal with. Not the case for us once we got the ball rolling. Really and truly that is not the case for us with the medical system. And folks still wonder why we live here and how long we’ll stay….