This article reviews how Italian National Health
Service (NHS) pediatricians have tried to fulfill the obligations of
modern primary care providers in a managed care environment, with
special reference to the experience of the Veneto region in Italy and compares this situation with the present changes of the health system
in the United States.
Italian NHS primary care pediatricians work independently in their
offices, providing acute and chronic patients to all children 0 to 14 years old: NHS primary care physicians, including 7000 pediatricians,
contract directly with the government for the care of patients through
a capitated reimbursement system.
Twenty-nine independent associations of community pediatricians have
been formed with the primary goal to pursue research and education in
primary care pediatrics, in addition to traditional care. Several
multicenter collaborative research studies at the national level have
been organized and four university residency programs are training
their residents in community-based pediatricians' offices also, giving
priority to activities specific to ambulatory practice and follow the
suggestion of an Italian work group on ambulatory pediatric training.
The NHS has allowed the Italian pediatrician to focus on patient care
and education rather than business. Computerization has been applied to
the practice of medicine through the development of electronic medical
records, particularly in the Veneto region. This technology allows
combining effective clinical care with outcome researches and
facilitates continuing medical education and residents' training
programs.
Italian primary care NHS pediatricians have tried to identify and
address patient's needs as well as the needs of a primary care
provider in a managed care system. Recent and possible future modifications in the health system in the United States and in Italy
need to be examined to learn from similarities and differences. primary care, network research, managed care, national health care, education.
This proposal was approved by both the SIP and FIMP Veneto
sections, and obtained support from the ACP National Council. Formal acceptance also by the national executive boards of SIP and of FIMP is
anticipated. This acceptance would lead to ambulatory pediatrics
preceptorship in the primary care pediatrician's office being
officially introduced into most pediatric residency programs.
BACKGROUND 
Since 1978 the Italian National Health Service (NHS) has provided
pediatric primary care to children through the use of community-based pediatricians (pediatra di base). This article describes this system,
with special emphasis on the activities of the NHS pediatricians of the
Veneto region, and compares the Italian system to the changing health
care system in the United States.
The Italian NHS requires that all children have an identified primary
care provider, either a pediatrician or a family practitioner, depending on the patient's age. Italian NHS pediatricians work in
their own private offices, providing primary care for patients from
birth to 14 years of age and are compensated under a capitation system.1 The NHS pediatricians are usually the sole patient entrance to NHS secondary and tertiary care in the 0 to 6 age range,
while parents can choose between a pediatrician or a general practitioner for their children's care between 6 and 14 years of age.
Over 10 years ago Italian primary care pediatricians recognized the
necessity of adapting their practice to the needs of a changing health
care system as well as the new morbidity of childhood illnesses as
described by Haggerty.2 In responding to these needs, 29 associations of practicing community pediatricians, mostly unaffiliated
with academic institutions, were independently created with the mission
of research, teaching, and continuing medical education.3
This was based on the concept that all these areas, in addition to
traditional clinical care, should be included in the activities of a
modern practicing pediatrician.
The following sections describe the main characteristics of clinical
care, research, and education in the Italian pediatric primary care
system. The "Comment" section will examine the integration of these
different activities and address the relationship between the Italian
NHS and the United States health system with regard to pediatric care.
CLINICAL CARE
In Italy there are almost 6000 NHS primary care pediatricians
(1994 data) taking care of more than 4 million patients from birth to
14 years of age, the majority of these patients are less than 6 years
old.4 The Veneto region in Northern Italy, where the
Italian authors practice, has approximately 4.3 million inhabitants. Of
these, 562 000 are less than 14 years old and 233 000 are less than 6 years old. In this area there are 435 practicing pediatricians. In the
0 to 6-year-old age group 85% of patients are under a pediatrician's care. The remaining 15% live in rural and mountain areas where only
NHS family physicians are available, as most of the pediatricians are
located in larger towns with more than 5000 inhabitants. The pediatric
coverage drops to 54% in the total 0 to 14-year-old age group in the
Veneto region and 44% in Italy; as in the United States, parents tend
to use more general practitioners as primary care providers for their
children after 6 years of age.
Acute, chronic, and preventive care, through both office and home
visits, are provided by the pediatricians, who are reimbursed under a
capitated system that pays about $8.50 a month per patient. The NHS
pediatrician cares for an average of 700 up to a maximum of 1000 patients, is available for patients from 8 AM to 8 PM, Monday to Friday and 8 AM to 2 PM on Saturday and, performs 4000 to 4500 visits a year. In
addition to acute ambulatory and home care, responsibilities include
coordinating the care of chronically ill patients, consulting with
subspecialties, performing well baby health checks and all
certifications for school activities, parent's absence from work,
indemnities, and social welfare. Pediatricians, as well as general
practitioners in the Italian NHS, are not allowed by law to take care
of their patients during hospital admissions. Solo practices, mostly
without nursing or secretarial staff, account for 95% of pediatric
primary care practices and the pediatrician's expenses are mostly
limited to telephone and office overhead in addition to travel expenses
for home visits. Immunizations are usually performed by a different NHS
community service. The NHS provides night and weekend phone coverage as
well as urgent home care to all patients, using moonlighting
nonpediatrician physicians. Both these services are provided to all
patients free of charge.
The major advantage of this system for the community is that health
care is available to all children without any out-of-pocket expenses:
health care costs are paid by tax money with a levy on gross income
from 5% to 10%, paid principally by the employer with some employee
contribution. Functionally, because all health care is funded through
the government, the Italian NHS is a single payor system. This allows
patients to choose their primary care physician/pediatrician, in
contrast to the United States, where the employer may direct that
choice. However, there is some restriction on the parents' choice of
primary care providers for their children, due to the NHS limitation,
by law, of a maximum of 1000 patients per pediatrician and a relative
shortage of community-based pediatricians. Over the years, this system
has been instrumental in building a trusting therapeutic relationship
between parents, children, and their pediatrician. In the first patient
satisfaction survey performed in Italy in the Veneto region,
pediatricians in the system scored highest among all other NHS
services.5
The Italian NHS, which accounts for approximately 8.5% of the gross
domestic product (1994 data), is trying to control the increasing costs
of health care by limiting physicians' reimbursements and applying
copayments to laboratory tests and NHS subspecialty consultations. This
has been done without offering incentives for cost saving to
physicians, which may negatively affect the patient-physician
relationship. As in the United States, it is anticipated that in the
future the NHS will also implement quality assurance standards using
outcome assessments in primary care. As it currently functions,
however, the Italian health care system has resulted in a perinatal
mortality of 9.5/1000 births, a neonatal mortality of 5.9/1000 live
births, and an infant mortality of 8.1/1000 births.6
RESEARCH
The following national pediatric associations are involved in
research in Italy: the Italian Society of Pediatrics
(SIP-Societá Italiana di Pediatria) is the predominantly
academic society; the Italian Federation of Pediatricians
(FIMP-Federazione Italiana Medici Pediatri) is the trade organization
of community-based practicing pediatricians, responsible for the
development and evaluation of continuing medical education programs for
its members; and the Pediatric Cultural Association (ACP-Associazione
Culturale Pediatri), formed by community primary care pediatricians and hospital and academic pediatricians, who focus on research and education in general pediatrics.
To address issues that face primary care child health providers in
Italy, the previously mentioned 29 local associations of primary care
pediatricians (affiliated with the ACP) have undertaken multicenter
collaborative studies7 and developed practice guidelines through generalist/subspecialist discussions.10 These
studies have focused on common pediatric problems not usually addressed by research based in academic centers. For example, projects
independently organized by Veneto's community pediatricians, include
organizational issues of the pediatric practice, quality assurance,
pharmacoeconomics of antibiotic therapy, practitioner education
concerning counseling and structured paper medical
records.11 All of these studies have been funded by the
primary care pediatricians' associations, either at the regional or
national level, with one exception that was partially funded by
Veneto's Department of Health.
Because all pediatric primary care in Italy functions under a capitated
system with a single payor, Italian community pediatricians have
neither had the need for sophisticated accounting and billing systems,
nor, due to reduced needs for office staff, high overhead costs and
administrative commitments found in the United States. In the Veneto
region this situation has allowed information systems experts,
community pediatricians, and members of the Associazione per la Ricerca
e Formazione in Pediatria (APREF) the ability to collaboratively focus
on the development of an electronic medical record system for pediatric
primary care, that serves as a powerful data collecting instrument. To
assess the impact that NHS-imposed demands has had on practicing
pediatricians, this electronic system will link affiliated practices in
the near future. Using statistical analysis modules developed by the
same research group, data will eventually be gathered to measure and
analyze the quality of services provided. It is anticipated that
similar systems will be implemented elsewhere in Italy.
EDUCATION AND TEACHING
The process of becoming a pediatrician and selecting a career path
in Italy begins with a university-based residency program in pediatrics
(currently 4 years long, and as of next year, 5 years long) following
common national requirements published by the Italian Department of
Education. Residents must take yearly examinations and develop a
research project that is presented at the end of the residency to
become fully certified. This university certification (Diploma di
Specialita) is valid nationwide. There is no national board
examination. When fully certified as a pediatrician, one can apply for
a job in a hospital (NHS), at a university, or as a primary care
pediatrician (NHS). This process involves presenting a curriculum
vitae, certifications of postgraduate training, and proof of working
experience (locums, etc). Hospital and university positions, which
require a copy of all publications as part of the application, are
filled by a vote of committees from the respective institution. With
regard to NHS primary care positions, there is a list of available
pediatricians published yearly by the Health Department of the Regione
and a list of possible (theoretical) vacancies published twice yearly.
These possible vacancies are calculated considering the number of
children living in the area. A pediatrician can apply for each vacant
position and the local health authorities must call the pediatricians
who have applied according to their rank in the regional list. They cannot select, but only ask if the next pediatrician is available to
take the job.
Continuing Medical Education (CME) is required by the NHS contract for
primary care pediatricians. Each regional Health Department is
responsible for the creation its own CME programs and must collaborate
with the FIMP. This process usually includes the regional academic
institutions. For the first time in Italy, the Regione Veneto
Department of Health has designated the organization CESPER (Centro
Studi per Ricerca e Formazione in pediatria territoriale), that
represents both the Veneto-based primary care pediatricians' associations and FIMP, as the only entity for accrediting CME activity
for community primary care pediatricians.
Italian pediatricians read the Rivista Italiana di Pediatria
(Italian Journal of Pediatrics [SIP]), which focuses on
subspecialty pediatrics; Medico e Bambino (Doctor and Child,
ACP), which is mostly practice-oriented and subscribed to by
pediatricians and family physicians; the Italian translation of
Pediatrics (which is a condensation of two issues into one
through a selection of articles made by two scientific supervisors);
and Pediatrics in Review, which is fully translated. In
addition, most pediatricians also read many of the foreign journals,
such as Lancet, the New England Journal of Medicine,
Archives of Pediatrics and Adolescent Medicine, and the
British Medical Journal in their untranslated form.
Although primary care is clearly the critical base of any health care
system, relatively few studies have addressed the information needs and
concerns facing the practicing pediatrician with regard to the changing
health care systems.16,17 These issues ultimately require
incorporation into the education of pediatric residents and
practitioners. In Italy there is not a formal regulatory organization corresponding to the Residency Review Committee in the United States; a
committee of academic physicians provides general guidelines for post
graduate training to be approved by the Italian Department of
Education. The requirements for pediatric training in Italy recently
published by the Department of Education do not include community-based
primary care experiences and unlike the Residency Review Committee
guidelines, encourage only in-hospital training experiences.18 Because of its intrinsic structure, the
medical education system in Italy, based in hospitals and universities, may encounter some difficulty in effectively training residents for
their future careers as competent, community-based, general pediatricians.19,20
Presentations given by community-based primary care pediatricians to
pediatric residents at the University of Padova created an impetus for
an educational pilot study involving primary care pediatricians and
residents of the Universities of Padova, Verona, Trieste, and
Milano-Monza.21 In these institutions, residents have been
placed in primary care pediatricians' offices for a month long
rotation. A formal faculty development program to enhance the teaching
abilities of the practitioners has also been organized.
After these initial activities, a work group in pediatric primary care
education produced a proposal for future primary care training in
pediatric residency programs in Italy.22 This training document suggests that in Italy:
- The resident should attend the primary care pediatricians'
offices once a week beginning in the second and/or third year of the 5 years of postgraduate training;
- Clinical problems that have a unique primary care dimension
should be discussed in seminars scheduled throughout the program and
require the participation of all residents and primary care preceptors;
- A teaching/learning plan and educational methodology should be
developed through a process of evaluation and feedback, that could
provide structure for the community experience and serve as a powerful
method of ongoing improvement for the resident, the preceptor, and the
residency program itself.
COMMENT
The challenge of managed care, which is producing major anxiety
and debate among United States' health providers,23,24 has
already been faced by Italian pediatricians, who have taken the risk in
providing a service with a prepaid fee and almost unpredictable costs,
contracting directly with the payer.
For the Italian primary care pediatrician, the NHS capitated system has
allowed for a focus on patient care, research, and education rather
than on cost and profit. The Italian pediatrician has a relatively
stable income, independent of patients visits, but does depend on the
number of patients enrolled in their panels. With health care consuming
a significant percentage of the gross domestic product, as it does in
the United States, there is concern about the ability to fund the NHS
at current levels. There is a general feeling of being underpaid due to
the significant patient overuse of the services and some uncertainty
about the role of the government in financing health care in the
future. There is also limited autonomy and decreased incentives for
entrepreneurship and quality of care as many pediatricians have reached
the maximum number of possible patients and competition is limited by
the restricted ability to increase patient numbers. However, as in most
systems, patients can pay privately for any medical service, primary
care or subspecialty, as long as it is not performed by the patient's
identified NHS primary care provider.
Starting from opposite ends of the health care system spectrum,
pediatricians in Italy as well as in the United States are experiencing
pressures to change dramatically the practice of primary care
pediatrics.25 Italian pediatricians will have to start
pursuing other funding sources, such as private insurance, and solo
practices, which account for 95% of pediatric primary care practices,
might have to be aggregated into group practices. This evolution may be
necessary to allow pediatricians to offer services which, in the
future, may not be covered any longer by the Italian NHS. In contrast,
the pediatrician in the United States, who has traditionally received
payment from private insurance in a noncapitated system, is learning to
practice in an increasingly capitated environment, where providers
rather than insurance companies bear the risk. Similar to the Italian
situation, solo practitioners in the United States are moving toward
groups. In both systems physicians need to learn how to assume a
leading role in direct negotiations with purchasers.
From a research and education perspective, community-based Italian
pediatricians, in analyzing practical issues of actual concern to
themselves and their patients, realized that the majority of academic
institutions as well as the Italian Society of Pediatrics, mostly
representing university and hospital staff, were unable to address
these issues. In Italy there is no national research network, such as
Pediatric Research in Office Settings, sponsored and staffed by the
American Academy of Pediatrics nor an academic generalist organization
such as the Ambulatory Pediatric Association. Instead, independent
groups of practicing pediatricians have developed in most regions to
pursue research and teaching in ambulatory settings. These groups'
enthusiasm in research and education in primary care settings has
allowed several research projects to flourish and multicenter studies
have been coordinated by the ACP research committee.
In the Veneto region the above mentioned changes in health care have
stimulated APREF practicing pediatricians to focus on the use of
electronic medical records to monitor effective preventive care as well
as to manage information about outcomes and health care costs. The
importance of applying computerization not only to the business of
medicine but to the practice of medicine itself has also been
acknowledged26 in the United States. Recent reports have
shown how clinicians could use computerized clinical data more
efficiently, reducing medication errors,27 therefore
decreasing malpractice risks and hopefully liability costs. Future
research projects using electronic medical records could be focused on population studies to assess pediatricians' ability to provide high
quality care at a level that avoids high costs and poor outcomes. Regardless of the health system, these data could determine how changes
in responsibilities and activities could be linked to reimbursement
adjustments.28
Following trends developed in the United States regarding the structure
of postgraduate medical education, there are ongoing efforts to modify
future training in pediatrics in Italy to include more community-based
education. Such experiences could be a way to help define the
appropriate interface between primary and consultant care, a
delineation that is a major requirement in managed care environments
where primary care providers serve as gatekeepers for subspecialty
services.29 As in the United States, Italian pediatric
residency programs need to include practical experience in the context
of a community pediatric practice,30 particularly focusing
on primary care activities, such as relational skills and counseling
31 and on the relatively new concepts of quality outcomes
and measuring patient satisfaction32 in the outpatient
setting. Italian community preceptors should undergo one or more
preparatory training seminars within a formal community faculty
development program taught by experts with graduate training and/or
experience in adult and medical education.33 These
innovative programs not only enhance the education of future and
present practitioners, but could serve to return practitioners to the
mainstream of the educational process in Italian pediatrics.
In the Italian managed care environment it is unlikely that financial
remuneration for precepting will occur, although the NHS may accredit
precepting residents as an activity, which may fulfill part of the
continuing medical education requirement. Ideally, teaching should
become a highly rewarding experience in and of itself, where preceptors
are challenged by the presence of younger doctors, who stimulate them
to rethink about current diagnosis and treatment of pediatric problems.
SUMMARY
For the last 18 years Italian primary care pediatricians have been
working under the NHS in a capitated managed care environment. They
have CME requirements and are facing the potential of formal evaluations of their activity. However, as have many pediatricians in
other countries with different socioeconomic conditions and health care
systems, many Italian pediatricians have demonstrated a willingness to
participate in, and possibly stimulate, research and teaching.
As elsewhere, it continues to be necessary in Italian pediatrics to
evaluate new information, to measure new health outcomes, and to
address new issues in the educational process. This should be done in
part by trying to examine, compare, and share experiences from
different health systems in different countries.
The goal of primary care pediatricians all over the world has
been to provide preventive care, to treat everyday and chronic illness,
and to serve as advocates for their patients without regard to cultural
or social status. Dimensions of this common goal have been achieved in
various ways in a variety of national health care systems. Analysis
about failures and successes of these different systems in a
collaborative, informed, and international manner should help to meet
the needs of our world's future, the children.
Address correspondence to: Thomas G. DeWitt, MD, Division of
General and Community Pediatrics, Children's Hospital Medical Center,
3333 Burnet Ave, Cincinnati, OH 45229-3039.
We thank Drs Paul S. Bellet and Richard M. Ruddy for their
critique of the manuscript. The authors wish to thank Roberta Luchelli for her dedication and commitment as first and now past president of
the Associazione per la Ricerca e Formazione in Pediatria (APREF). Without her effort and enthusiasm many of the initial research and
teaching projects would not have been completed. We also want to
express gratitude to all APREF members who participated in our common
endeavors, as evidenced by their willingness to share their invaluable
experience and their precious time.
NHS, National Health Service.
SIP, Societá
Italiana di Pediatria.
FIMP, Federazione Italiana Medici Pediatri.
ACP, Associazione Culturale Pediatri.
APREF, Associazione per la Ricerca e
Formazione in Pediatria.
ABSTRACT
