Experience in an Italian Emergency Room

A week ago, Paula and I were out on a hike from Spoleto to Monteluco. When returning, there was a section of the pathway that was steep with a gravel base. Our shoes were flat sole tennis shoes and we didn’t have hiking sticks – we will probably not repeat this mistake. About halfway down, Paula slipped to the left and caught her fall on her outstretched left arm. This impact jar most likely created a tear in one of her shoulder’s rotator cuff tendons.

The next morning, Paula was unable to move her arm in certain ways that was consistent with the possibility of a rotator cuff tear. It seemed prudent to get an x-ray to rule out a fracture, so we decided to go to the pronto soccorso, aka hospital emergency room.

We got to the pronto soccorso about 11:00 a.m. We visited with a triage nurse about ten minutes later and were given a rating as to the urgency of her medical issue as well as our que number. They have five different ratings, color coded, that stratify patients on the degree of urgency. A poster on the wall of the waiting room detailed each urgency level and gave examples. There was also a TV monitor that showed real time status of how many patients were being treated at each urgency level, as well as how many were waiting to be seen, so everyone could keep track of how things were moving. It was about 3 hours later when she was seen by the ER doctor. He ordered an x-ray and referred her to the orthopedic surgeon’s office (also located in the hospital) to be seen as a walk-in patient.

We were escorted to the radiology department as the hospital was truly a maze of buildings that would make navigation difficult. Ten minutes later we were taken to the orthopedic surgeon’s waiting room and joined about half a dozen other patients. We had another wait of about an hour before being taken back to be seen. The orthopedist examined Paula and looked at her x-ray. He said it was likely she had either a partial or complete tear of the supraspinatus tendon of her rotator cuff which was superimposed on a chronic impingement issue. He aspirated her joint to confirm she did have a small intraarticular hematoma, then injected a local anesthetic as well as a steroid. Once the local took effect, Paula was able to move her arm much better, indicating that is was likely her tendon injury was a partial tear. 

He recommended a week in a sling, range of motion exercises, then a follow-up MRI and ortho visit after a few weeks. We are scheduled to return home about the time we’d need to do this. After the consult was completed, we went back to the pronto soccorso to complete the visit. It was about 5:30 p.m. when we left with an arm sling and a prescription in hand. We were also given a bill for the visit which was 25 Euros in total which is about $27.50 at the current exchange rate. I don’t remember what the medication cost, but is was under 10 Euros at the farmacia.

It was not until the end of the visit that I shared with my Italian colleagues and the staff that I was a physician. I didn’t want to do this at the beginning because I wanted to see how medical care was delivered without giving any potential bias.

What is my take on the medical care we received, from the perspective of a physician from the U.S.?

First, I think their delivery system for health care is designed to be organized and economical. Most health care is delivered at the local regional hospital where everything is centralized. We did spend about six hours that day, but that resulted in an ER visit, orthopedic surgeon consult, x-ray, joint aspiration and therapeutic injection, and sling. With normal health insurance in the U.S., we’d of probably had incurred a total expense of a few thousand dollars and this would have taken a few days or longer to schedule a non-emergency specialist consult. The total bill of 25 Euros was quite eye-opening.

I did notice a difference in the patient-physician interaction. In the U.S., the culture of this relationship is such that patients feel free to challenge the physician diagnosis or recommended treatment. U.S. physicians will tend to expect this and prior to proceeding with any treatment or procedure, provide detailed information so that the patient is clearly informed and a part of the decision process. In Italy, it seems that this patient-physician relationship is more like what was more customary in the U.S. many years ago, in which there is a high level of implicit trust given. When Paula had a joint aspiration and injection, she wasn’t asked if she agreed to the procedure. He just told her what he was going to do and proceeded to do it. No discussion, no consent form.

One thing that really stood out to me was the physical facilities. It was clear that the money allocated by the government for the provision of health care was not being prioritized for the physical building or facilities. This really was quite stark in contrast to what is usually present in the U.S., but that said, it didn’t bother me. I’d much rather have good health care in a sub-par building instead of having sub-par care in a shiny new building.

Data from 2202-2023 shows expenses of $3,674 per person for health care provided in Italy. The United States spends $12,555 which is the highest in the world. Despite this, most outcome indicators of care (life expectancy, maternal mortality, etc.) are not consistently better. Why are health care costs so much higher in the U.S.? I don’t have hard data to allocate what components are creating this, but I do know that multi-layered bureaucracy involving insurance companies is a huge part of this – as well as the pharmaceutical industry. The U.S. has high administrative costs that are not found in most other countries.

I’ve had multiple experiences where I was truly shocked at the expense of medications in Italy. Many drugs are a fraction of the cost because EU governments allow for pricing negotiations between the health care system and big pharma. For example, Wegovy is $1,300 to $1,500 a month in the U.S. In Germany it is $300 to $400 Euro.  Humira is over $6,000 a month in the U.S. versus 600 Euro in Italy. Other less expensive medications that are hundreds of dollars in the U.S. are around 25 Euro in Italy.

Why doesn’t the U.S. Congress produce legislation to allow for pricing negotiation of pharmaceutical medications? Perhaps it has something to do with the net worth of many legislators in Congress which somehow magically increases each year in an amount disproportionate to their salary. Term limits could help fix this, but most legislators adamantly oppose this.

Health care in Italy is primarily universal and is publicly funded with little significant out of pocket expense for patients. Quality of care seems to be equivalent to the U.S. It is true that nothing is for free, and the cost of this care is made possible by the much higher taxation rates in Italy versus the U.S. Also, there is more waiting involved when scheduling elective procedures. 

Despite these negative aspects, the trade-off of having the personal security of guaranteed good health care throughout one’s life, without the risk of disastrous financial implications, is truly huge.

So, in the context of this blog, does this impact our decision regarding moving to Italy? Personally, it provides reassurance that the care we would receive in Italy would be available and of good quality. The cost would be similar to what we pay in the U.S. since we are both covered under Medicare. Italy allows non-citizens on an elective residency visa to be admitted to the universal health care system for 2,000 Euro a year. We pay about the same amount in the U.S., as citizens, for Part B coverage, Part D coverage, and the supplemental Medi-gap policy. 

If we were younger and having to purchase standard private health insurance, the lower cost of health care in Italy would be a huge factor. Also, the security and peace of mind knowing that care would be provided without financial risk would be a huge plus.