Network governance forms in healthcare: empirical evidence from two Italian cancer networks.

BACKGROUND: This study focuses on the application of Provan and Kenis' modes of network governance to the specific field of public healthcare networks, extending the framework to an analysis of systems in which networks are involved. Thus, the aim of this study is to analyze and compare the governance of two cancer networks in two Italian regions that underwent system reconfiguration processes due to reforms in the healthcare system. METHODS: A qualitative study of two clinical networks in the Italian healthcare system was conducted. The sample for interviews included representatives of the regional administration (n = 4), network coordinators (n = 6), and general and clinical directors of health organizations involved in the two networks (n = 25). Data were collected using semi-structured interviews. RESULTS: Our study shows that healthcare system reforms have a limited impact on network governance structures. In fact, strong inertial tendencies characterize networks, especially network administrative organization models (NAO). Networks tend to find their own balance with respect to the trade-offs analyzed using a mix of formal and informal ties. Our study confirms the general validity of Provan and Kenis' framework and shows how other specific factors and contingencies may affect the possibility that cancer networks find positive equilibria between competing needs of inclusivity and efficiency, internal and external legitimacy, and stability and flexibility. It also shows how networks react to external changes. CONCLUSIONS: Our study shows the importance of considering three factors and contingencies that may affect network effectiveness: a) the importance of looking at network governance modes not in isolation, but in relationship to the governance of regional systems; b) the influence of a specific network's governance structure on the network's ability to respond to tensions and to achieve its goals; and c) the need to take into account the role of professionals in network governance.

Models for governing relationships in healthcare organizations: Some empirical evidence.

Recently, most European countries have undergone integration processes through mergers and strategic alliances between healthcare organizations. The present paper examined three cases within the Italian National Health Service in order to determine how different organizations, within differing institutional contexts, govern an healthcare integration process. Furthermore, we explored the possibility that the governance mode, usually seen as alternatives (i.e., merger or alliance), could be considered as a separate step in the development of a more suitable integration process. Multiple case studies were used to compare different integration approaches. Specifically, three cases were considered, of which two were characterized by collaborative processes and the other by a merger. Semi-structured interviews were conducted with managers involved in the processes. Each case presents different governing modes, structures, and mechanisms for achieving integration. The role played by the institutional context also led to different results with unique advantages and disadvantages. Three main conclusions are discussed: (a) Alliances and mergers can be interpreted as different steps in a path leading to a better integration; (b) The alignment between institutional/political time horizon and the time needed for the organizations to achieve an integration process lead to a better integration;

Private health care expenditure and quality in Beveridge systems: cross-regional differences in the Italian NHS.

Private health care expenditure ranges from 15% to 30% of total healthcare spending in OECD countries. The literature suggests that there should be an inverse correlation between quality of public services and private expenditures. The main objective of this study is to explore the association between quality of public healthcare and private expenditures in the Italian Regional Healthcare Systems (RHSs). The institutional framework offered by the Italian NHS allows to investigate on the differences among the regions while controlling for institutional factors. The study uses micro-data from the ISTAT Household Consumption Survey (HCS) and a rich set of regional quality indicators. The results indicate that there is a positive and significant correlation between quality and private spending per capita across regions. The study also points out the strong association between the distribution of private consumption and income. In order to account for the influence of income, the study segmented data in three socio-economic classes and computed cross-regional correlations of RHSs quality and household healthcare expenditure per capita, within each class. No correlation was found between the two variables. These findings are quite surprising and call into question the theory that better quality of public services crowds out private spending, or, at the very least, it undermines the simplistic notions that higher levels of private spending are a direct consequence of poor quality in the public sector. This suggests that policies should avoid to simplistically link private spending with judgements or assessments about the functioning or efficacy of the public system and its organizations.

Italian public health care organizations: specialization, institutional deintegration, and public networks relationships.

The Italian National Health Service (INHS) has undergone profound changes over the past three decades. With establishment of the INHS in 1978--a tax-based public health care system with universal coverage--one of the underlying principles was integration. The recognition of health and health care as requiring integrated answers led to the creation of a single public organization, the Local Health Unit, responsible for the health status of the population of its catchment area. At the beginning of the 1990s, the scenario radically changed. The creation of hospital trusts, the development of quasi-market mechanisms and management control tools, the adoption of a prospective payment system for reimbursing health care providers--all were signs of deintegration and institutional unbundling. Two structural changes have deeply sustained this deintegration: patients' empowerment and the increased possibilities for outsourcing practices. In more recent years, a new reintegration effort has occurred, often led by regional governments and based on institutional cooperation and network relationships. However, the earlier structural changes require innovative approaches and solutions if public health care organizations want to retain their leading role.

[Cardiac sudden death in Italy. Dimensions, perceptions, policies and economic/financial impact]. / La morte cardiaca improvvisa in Italia. Dimensioni, percezioni, politiche ed impatto economico-finanziario.

This study is based on the consideration that sudden cardiac death (SCD) incidence is increasing in today's society and, despite the efforts of clinicians, there is great lack of awareness and focus for its prevention on behalf of society and institutions. During 2006 a research project on SCD was initiated in Italy by the CUSAS (Centro Universitario di Studi in Amministrazione Sanitaria) and the Institute for Internal Medicine and Cardiology of the University of Florence with the intention to: estimate the dimension(s) of the SCD phenomenon in the general population; underline the economical consequences of SCD; identify the causes for the lack of interest in SCD; evaluate the degree of use of biomedical technologies for SCD prevention, and compare the actual scenario with the ideal one (driven by treatment guidelines implementation); the last part of the study analyzes economical sustainability of the implementation of the 2006 European Society of Cardiology new guidelines. We estimated an occurrence of SCD in young subjects (between 35 and 65 years of age) of roughly 9300 cases per year (approximately 17% of total): nearly one case of SCD in 5 afflicts young and still active individuals. Causes of the phenomenon vary greatly: in older subjects the pathology that most frequently causes SCD is ischemic heart disease, whereas in younger subjects it is more often related to heart failure. The most optimistic hypothesis is that each year SCD causes the loss of nearly 600 000 life years. We came up with a first estimate of the socio-economic impact due to life years lost each year to SCD, using net individual work salary for the basis of the calculation. Results are extremely variable (between 6.482 and 12.216 millions of euros each year). Considering that half of the events occur in patients in whom SCD can be accurately predicted, due to their high risk factor, it is possible to estimate the financial investment necessary to prevent SCD in at least these individuals. The DRG tariff is used as a proxy for the economic calculation of the procedure costs. An additional investment of 310 million euros would have been necessary, which represents only 0.33% of the national health budget for that same year. We strongly believe that preventing SCD is not only financially feasible but very beneficial from the societal perspective.