Chapter 2

formance, implying an increase in average cost per standardized hospitalization; a 1%
increase in the share of “other personnel” implied an increase in total cost per DRG point
of 0,010% in 2002 and of 0,133% in 2003. Finally, it seems interesting to note that more
complex hospitals have, on average, lower mean costs per standardized case. The
explanation may lie both in the fact that greater clinical complexity is correlated with better
organization of services and that the present tariff system overestimates the cost of
major interventions (with a weight greater than 2,5).
3.2.6 Conclusions
The econometric analysis aimed at evaluating the (in)efficiency of public sector hospital
organizations makes it possible to state with sufficient conviction that there are significant
problems in the Italian system of publicly funded hospitals on both the financing
side and on that of efficiency.
Though doubts remain as to whether the accounting data are fully comparable – and the
quantitative importance of such doubts cannot be inferred at the present time – some
indications emerge regarding the inadequacy of the present tariff system based on DRG.
Organizations with a single specialty are penalized (at least on paper, though in many
Regions they receive additional financing), whereas those with significant proportions of
highly complex hospitalizations could in some way be favoured.
This last suspicion might, however, be due to the greater efficiency of such organizations
over those with a lower intensity of care; one should also remember that in some
Regions all (or most) hospital organizations enjoy autonomy, independently of their complexity.
There also seems to be a clear demonstration of the existence of problems of
technical inefficiency, both from the statistical association of higher levels of productivity
with lower levels of cost, and from the high residual variance both within individual
Regions and at the supra-regional level which cannot be explained by structural factors
or those relating to the nature of the data used (accounting and DRG) tariff data.
Furthermore, the size of the differences (a difference of about three times between the
most costly and the least costly organization and one that is also growing in time) itself
makes it impossible to believe that they depend only on accounting factors or tariff distortions.
The foregoing therefore refocuses attention on the technical efficiency of the
hospital system at the centre of attention of health policies.
The DRG have certainly been an incentive for greater productivity, and our estimates
indicate that this has been at least partially transformed into greater efficiency.
Nevertheless, the single tariff fixing criteria for all autonomous hospital organizations
reveal aspects that can be strongly criticised. To provide better incentives for virtuous
behaviour by hospital organizations, it would be better for tariffs to be set by type of
organization, taking account of additional factors such as clinical complexity.
One also finds serious problems in the sphere of structural modifications to the “production
organization”. Balanced or unbalanced staffing seems to be of truly crucial
importance for the efficiency of the organizations.
At present, regional financing systems make up for the intrinsic limitations of the present
tariff system, providing additional financing by function, or simply as required. The risk
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CEIS Health Report 2006