Health payback, what it is and why it risks destroying public health – Corriere.it

Respirators, mammography machines, scalpels, syringes and gowns. Over 1 billion euros to be repaid to the Regions. Since in 2015, as part of the spending review requested by the European Union, the Renzi government (Minister of Health was Beatrice Lorenzin) introduced the law, the health payback is a sword of Damocles hanging over the head of an entire sector, that of the supply and distribution of medical devices. And that threatens to deal a mortal blow to a public health service already heavily tested by the reduction in public spending and investment.

From Renzi to Draghi, from Draghi to Meloni

Never applied and passed from hand to hand for four governments, the hot potato of health payback finally it fell to the Draghi government, which implemented it in the summer of 2022 with the “Aiuti bis” decree. Since then, from extension to extension, companies and workers have alternated sighs of relief with the hope of a further postponement of the payment deadline. On June 16, with an amendment to the “Bodies” decree, the date was postponed from June 30 to July 31. From that day on, companies that supply medical devices to the public service will have to pay a total of 1.1 billioncontributing to the settlement of the exceeding of the regional spending ceiling for purchases in the four-year period 2015-2018.

On 27 June the technical table convened by the ministry

The deadline, in principle, was April 30 and there were 2.2 billion, but with the “Bills” Decree of March 30, the government in office decided to halve the amount of the requested contribution, asking companies in exchange to waive the appeals presented to the Tar. On June 27, the Ministry of Health will convene a technical-ministerial table with the aim of discussing the critical points of this provision together with the parties. Meanwhile, the extension to July 31 does not erase any doubts. It could be a way to buy time in view of a cancellation of the payback – he explains Massimiliano Boggettipresident of Confindustria medical devices – or simply an extra month granted to the Regions for technical reasons.

Confindustria: Distributors will avoid public tenders

For Boggetti, and for all the companies in the sector, the problem remains: if the medical device market is worth 6 billion in turnover a year, the request to pay over 1 billion into the coffers of the Regions can only generate an avalanche effect on the whole system. At least a thousand businesses go bankruptwarns, they will close all those smaller realities that are located downstream of the supply chain, i.e. the sellers, the distributors. On the other hand, Italian and foreign producers are located upstream, which would suffer the impact of the payback to a lesser extent but which would inevitably be affected by the compression of the market.

The risk of having obsolete technologies and tools

In essence, there would be a flight of investments for the benefit of more attractive contexts, with disastrous consequences also for the NHS and universal access to care. In fact, public structures would not only have a problem with the supply of essential devices, modern enough to function properly, but also with maintenance and training on the use of the machinery. And the doctors? How many would remain in the public service working with obsolete technologies, with all the risks that this entails? asks the Confindustria president.

The inconsistencies of health payback

The payback standard also contains another peculiarity. An overall calculation is made on the deficit of the regional budgets, without distinction between the items of expenditure: this means that whoever produces or distributes surgical scalpels, for example, called upon to remedy an overrun of the expenditure ceiling caused by an excess in the purchase of heart valves . An aspect, judged to be at least controversial, which prevents supplier companies from making forecasts on the costs to be incurred and therefore on profitability. If we consider that the tenders announced at regional level concern multi-year supplies (usually between 5 and 7 years), the consequences are easily imaginable, concludes Boggetti: To escape the payback trap, distributors will stop participating in public tenders and direct sales abroad, or towards private individuals. Considerations that sound familiar, to put it mildly, to many of the 1500 companies that distribute in Italy.

The ab medica case: Until 2026 we can’t resist

Together with the extension to July 31, a second amendment to the Entity Decree introduced the possibility of reviewing the management of the expense of medical devices by 2026. But in three years we will either have reinvented ourselves, distributing abroad, or we will have sold the company to a fund. Francesca Cerruti, CEO of ab medica, is clear in asking for the cancellation of the law. The impact of the payback on your company would exceed 20% of turnover. For the four-year period 2015-2018 we would have to pay 19.8 million euros and for the following four-year period we have no idea what the costs might be.

Ab medica, which in recent years has also become a small producer, remains mainly involved in distribution, 70% of which is destined for the NHS and the remaining 30% to private individuals, including those affiliated with the public system. Among the suppliers from which ab medica procures itself there are over 40 foreign entities. With the exception of some Italian excellence, the producers in this sector are mostly foreign. They are well aware of the quality of the Italian distribution network and also thanks to this that our healthcare enjoys certain electromedical excellences. The risk, observed by those who know the supply chain in detail, that the multinationals are waiting for the fateful 2026 to decide whether or not to re-enter the market and that, in the meantime, they decide to close their Italian branches. Personnel cuts already exist – underlines Cerruti – And a branch to all intents and purposes is an Italian company, which has its own managing director and up to 150 employees in the area.

In short, foreign operators able to go elsewhere and invest far from Italy will be saved. Private healthcare will benefit, on which excellent products and medical personnel fleeing the public will converge. Banks and financial institutions will be called upon to open credit lines at subsidized rates, in favor of companies that would otherwise go bankrupt: representatives of Abi and Sace were present at the table on June 14, with the Ministry of Health. But once the deadline has expired and in the absence of adequate solutions, all the others will lose out: companies, professionals, citizens. In a country where, today, the per capita expenditure on medical devices is about half the European average.

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