Italian
Gino Gerosa is the Health and Health Planning Councillor of the Veneto Region. He was a Full Professor and Director of Cardiac Surgery at the University Hospital of Padua. Author of over 600 scientific publications, he has performed pioneering surgeries such as the first total artificial heart implantation in Italy and innovative heart transplants, including the fully beating heart transplant and the transplant from a donor with a still heart. A Grand Officer of the Order of Merit of the Italian Republic, Gold Medal for Merit in Public Health, and honorary citizen of Padua, he is among the leading figures in Italian and international cardiac surgery.
From the Scalpel to Health Policy
Councillor, after a brilliant career in the operating room, you chose to put aside the scalpel to lead the healthcare system in Veneto. What was the strongest motivation behind this choice?
The main motivation lies in the possibility of giving substance and concreteness to a series of projects that I previously directed strictly towards the cardiac surgery field, while now I can direct them towards a broader area, that of public health: it is a great opportunity.
Veneto is often referred to as one of the most efficient healthcare systems in Italy, the so-called “Veneto model.” What model is it trying to build and what innovations could be replicated at the national level?
Veneto is a national reference healthcare system, but that doesn’t mean we can’t do better — on the contrary, we must do better. Clearly, when the bar is already quite high, it becomes difficult to raise it further, not least because of the “ceiling effect.” We must consider that the demographic pyramid has completely inverted in the last 20 years, with a decline in birth rates, but especially with the aging of the population. It is important to note that Veneto has one of the highest aging indices in Italy; it is one of the oldest regions along with Liguria and Sardinia. We are a region where the elderly are predominant, and in the next 15 years, the number of people over eighty will increase further, by almost 40%. My intention is to make Veneto the international laboratory for healthy aging.
What does this mean in practice?
Life expectancy in Veneto is 84.3 years, compared to the Italian national average of 83.4. The national average for healthy life expectancy is around 58 years, while ours is 60 years. So we have one year of life expectancy and two years of healthy life expectancy more than the national average: this reflects the fact that the Veneto Healthcare System is naturally a system of excellence, a reference point. However, there is still a gap of almost 25 years between healthy life and life expectancy. Therefore, by making Veneto the international laboratory for healthy aging, we would like to close this gap — or at least reduce it, because closing it completely is almost impossible — and thus have more years in good health, because as Rita Levi-Montalcini said, we “do not want to add years to life, but we want to add quality of life to years.”
The challenge of aging
Regarding the demographic pyramid, as we said: fewer young people, more elderly. How do you “engineer”, to use your expression, a healthcare system that can still ensure quality and universality of care?
This is an excellent point, as the OECD tells us that a universal healthcare system like ours is not sustainable with just taxation. Therefore, if we want to maintain a public, fair, and solidarity-based healthcare system like ours, we must necessarily re-engineer the system. In this case, the DM77 – 2022 helps us, as it allows us to shift from a hospital-centric healthcare reality to a territory-centric healthcare reality: we move from a healthcare system that worked in silos (a model where different areas, functions, or departments operate as “separate compartments,” with little communication and collaboration between them) to a healthcare system that works horizontally.
Being a company with many elderly people, who by definition are fragile and have chronic diseases with multiple associated pathologies, we must avoid acute episodes. Therefore, we shift from reactive medicine, which intervenes when one falls ill, to predictive medicine: we must anticipate exacerbations, because exacerbation naturally leads to hospitalization while it is in the patients’ interest to remain at home in their communities, as this ensures a better outcome.
We therefore need to develop a territorial healthcare system where Community Houses and community hospitals become essential to ensure the health level of an extremely fragile population.
Territorial Medicine
We already have several Community Houses active in the area, from Codognè to Conegliano, from Farra di Soligo to Vittorio Veneto, which ensure unique access, a multiprofessional team, primary care as well as specialist and preventive care. So, can this really help improve proximity care? What is the true innovation in this transition?
There are three moments of innovation. The Community Houses, let’s clarify, are a dynamic process: they have been opened, but then each Community House will essentially need to map the territory and see what the health needs of the citizens in that area are.
For example, if there is a predominance of diabetic patients in an area, there will be a specialized presence focused on endocrinology; where chronic obstructive pulmonary disease prevails, greater emphasis will be placed on the presence of the pulmonologist. It is a tailored healthcare designed to meet the health needs of the territory.
The other major expectation we have from the Community Houses is to reduce emergency room visits: currently, 40% of emergency room visits are white codes, and we would like to intercept that need in the Community Houses to clearly avoid overcrowding in the emergency room.
Another fundamental step is to manage to network the doctors working within the Community Houses, because until now the general practitioner was essentially alone in their office, so there was no comparison with other professionals; in this case, of course, within the Community House they can compare themselves with other general practitioners, but above all they can engage with specialists, and this amplifies the knowledge of the doctor themselves and the possibility, in the comparison, of finding multidisciplinary solutions, thus involving different professionals who take — not in charge, but in care — the patient.
In addition, in the Community House there is the PUA – Single Access Point, with the possibility of also using home nursing care and more, precisely to respond to the health needs of citizens, allowing them to stay at home.
So this resolves the issue of the emergency room regarding white codes, in terms of organizational level… but is there also a cultural issue? The tendency to go to the emergency room even for situations that are not real emergencies.
It is also a cultural issue, because in the Community Houses we have planned to establish rooms for the “aware citizen”.
We want to create within each Community House the room for the aware citizen, using immersive reality and headsets to provide information and training to citizens: for example, on lifestyles, on reducing risk factors, to encourage responses to cancer screenings — breast cancer, as well as colorectal cancer, uterine cancer, and prostate cancer. And then, for example, for adolescents, knowledge of sexually transmitted diseases: at this moment we have an increase in HIV infections because no one is talking about it anymore, and young people, if not informed, naturally do not take their precautions. Therefore, the house of the aware citizen serves to provide information and thus training.
The international comparison
Looking at the best healthcare systems in the world, which model do you consider closest to the direction that Veneto should take? For example, Singapore for efficiency, Japan for prevention, Denmark for digitalization, or the Netherlands for community medicine?
Of course, the correct answer would be to implement all these specificities. For example, in the Netherlands for primary care: in the Netherlands, Emergency Rooms are essentially deserted because it is the general practitioner who sends the patient to the Emergency Room, unlike in Italy, where the patient goes directly to the Emergency Room precisely because they do not find an alternative response, which they should instead find in the Community House. South Korea and Japan share with Italy a significant aging population, having a very high old-age dependency ratio as well. South Korea has already developed, starting from the 1960s-70s, the KAIST, the Korean Advanced Institute of Science and Technology, where it sought to develop technological solutions — for example, using robotics — to address the shortage of nursing staff that they had anticipated, which, especially regarding the nursing aspect, becomes essential to safeguard elderly individuals. But we must not forget that we have a strong humanistic component, and therefore we must succeed in combining technology and the humanization of care, because the human being must be at the center of the care pathway, as Pope Leo XIV reminds us in his latest encyclical “Magnifica Humanitas.”
Japan invests heavily in prevention, with regular check-ups and widespread screenings. Do you believe that it is also time for Veneto to transition definitively from a medicine that treats to a medicine that prevents?
Exactly. We mentioned earlier that taxation alone cannot sustain a universal healthcare system, and we must therefore re-engineer it: we absolutely need to invest in prevention, as it becomes essential. If prevention was once considered a luxury, today we must see it as a must, a duty because the ability to prevent diseases allows us to drastically and significantly reduce the cost of treating diseases in a universal healthcare system like ours.
Prevention
Prevention yields results in the long term, while politics is often tied to immediate consensus. How can this contradiction be overcome? How can citizens be made to perceive that there is a long-term vision?
This is the difference emphasized by De Gasperi, drawing on a concept developed by the Jewish-American theologian James Freeman Clarke in the 19th century: “a politician looks to the next election, while a statesman looks to the next generation.” Therefore, we must operate within the realm of the statesman, managing to provide information, because — as I have already had the opportunity to tell your colleagues — healthcare is not a monolith: healthcare is divided into produced healthcare, perceived healthcare, and narrated healthcare.
How does this division work?
The healthcare produced is what we talked about earlier: a life expectancy that is one year above the national average, two years more of healthy life compared to the national average. Clearly, these results are not random, but are the result of a healthcare system that produces health. At the same time, we have perceived healthcare, which is what the citizen sees when looking at waiting lists and says: “Wow, I have to wait,” or “I have to call the CUP and the CUP doesn’t respond” — this is the perceived healthcare that usually creates disvalue.
So you can have excellent quality healthcare, but then you face a perceived healthcare where the perception of the health outcome you provided is undermined. And then there is the healthcare narrative, the one told by the media — you teach me that bad news is much more appealing than good news, that negativity attracts much more than positivity from a media perspective.
It is necessary to ensure that the healthcare portrayed and the healthcare perceived are equal to the healthcare produced, and then the citizen can understand that the result is not immediate, but is a result that is gathered over time.
As for healthcare perceived in relation to waiting lists, we are preparing solutions that allow citizens to leave their general practitioner’s office without having to contact the CUP, but instead being directly contacted by the CUP with the assignment of the appointment date or the instrumental exam. Let us remember that we do not want to provide services but health, because according to Roemer’s law of induced demand, if I need 30,000 services and provide 32,000, immediately after 40,000 would be needed. But we do not want to provide services; we want to provide health: it is a subtle shift, it may not seem so, but it is important.
The other goal, regarding chronic conditions, is to do what already happens with oncological diseases: that the chronic patient is taken care of by the regional healthcare system throughout their journey, so that follow-up visits and subsequent tests do not have to be booked by themselves, but the system will contact them and inform them: here is the date of your follow-up visit and the necessary tests.
Artificial Intelligence
It’s a great thing: so there will be support from algorithms as well, so from technology?
Sure, artificial intelligence — which I would call “artificial intelligence,” because artificial gives the sense of the lack of awareness of artificial intelligence compared to human intelligence, which is our creative intelligence, while that is a generative intelligence.
So the human factor remains extremely important. I think of the transplant from a donor with a still heart: if we had asked artificial intelligence whether it was possible to perform a transplant from a donor with a still heart after 20 minutes of cardiac arrest to confirm death, being generative it would have scanned all the literature produced and would have answered “no, it is not possible.” The human factor, however, said “yes, it can be done” — and indeed it could be done. This is why the human factor remains crucial, even though artificial intelligence, regarding the creation of algorithms and more, is certainly fundamental.
Artificial intelligence also promises predictive analytics, capable of early identification of at-risk patients.
Exactly, so as to identify possible diseases early. With artificial intelligence, there is the possibility to predict adverse events, and this applies to other areas as well, precisely because of its predictive capability — because artificial intelligence can process millions of data points, something that human intelligence cannot do, and thus it can categorize a whole range of information.
But how much is artificial intelligence already being used, for example?
In the response, for example, to radiological imaging exams, rather than in pathological anatomy.
And what about Veneto, in particular, which of these applications has already been implemented?
Artificial intelligence is already being used in pathological anatomy. There are others that could be promising, which could improve the algorithms I referred to for enhancing the booking of treatments and exams, or for patient care. Surely, there are several innovations on the way.
Economic resources
At the state budget level, healthcare is the second largest expense after pensions and social security. In Veneto, however, it is the largest item of programmable resources: 80% of the budget.
Exactly, 80%, equal to 10.4 billion euros.
The real challenge today, in your opinion, is to find new resources or to better optimize those that already exist?
It is clear that talking about an increase in resources means discussing an increase in the allocation of the National Health Fund, and this depends on the choices of the central Government regarding how much is currently allocated to healthcare.
What is instead the responsibility of the Regions is to make the best use of the available resources, improving the efficiency of the system. Veneto, in this sense, starts from a virtuous position: we are a Region that is not subject to a recovery plan and can therefore use this condition to accelerate the reorganization processes.
An important element is represented by the increase in DRG rates (prices set to pay for hospital admissions based on illness) at the national level, which has generated over one billion euros in additional resources for the healthcare system. For a Region characterized by high-performance healthcare but under pressure from an aging population, this represents a strategic opportunity to further optimize the regional healthcare service.
The path goes through some fundamental pillars. First of all, strengthening the role of Azienda Zero, through greater operational centralization and more effective control of spending processes. Improving the management of SDOs (hospital discharge forms) to properly value the services provided and recover all the resources that belong to the system.
Another central element is the monitoring of spending levels, along with greater integration between hospitals and the community: I am thinking of community hospitals, protected discharges, and all those services that allow for supporting the citizen outside the hospital and ensuring continuity of care.
We then need to work on reducing waiting lists, also through a more effective use of the purchase of services, on personnel management, and on technological investments.
In summary, the challenge is to optimize the financial resources we have available, because the sustainability of the healthcare system depends not only on how many resources we invest, but also on how we use them.
Healthcare personnel
Many young doctors continue to choose private practice or go abroad, but there is also good news: 176 new General Medicine doctors have just joined the National Health Service in Veneto. This is the beginning of a journey that is set to continue, with new hires also expected in other areas of public health?
This is an initial result of the path initiated by the Region, which has decided to increase investments in training grants for general medicine.
In the past, there was an economic difference that pushed many young people towards specialization schools compared to the path of general medicine. We have sought to rebalance this situation by increasing support for the training of future family doctors, with the aim of making this choice more attractive.
However, there remains a national problem: Italy trains highly skilled professionals, but often fails to retain them. And it’s not just an economic issue, even though the financial recognition of healthcare professionals abroad is significantly higher than that in Italy. It’s also a matter of career prospects, professional recognition, and opportunities for growth.
A systemic reform is therefore needed, not only at the regional level but also nationally, to retain the skills we develop. Our young doctors and nurses, when they go abroad, demonstrate that they have excellent training: this means that the problem is not the quality of education, but the ability of our country to value it.
We must restore economic and social dignity to health professionals. This is also demonstrated by unacceptable phenomena such as assaults in emergency rooms: it is not only a security issue but also a cultural problem, related to the respect for roles and professional expertise.
It is an issue that concerns many fundamental categories of our society, from healthcare workers to teachers. We must return to recognizing the social value of these professions.
After a lifetime spent saving individual patients in the operating room, today he finds himself having to “operate” an entire healthcare system. What result, by the end of the term, would make him say that it was worth leaving the scalpel behind?
If we manage to implement all these projects, and in particular to make Veneto an international laboratory for healthy aging, this would be an extraordinary achievement.
The real challenge is to reduce the gap between life expectancy and years lived in good health. It’s not enough to live longer: we must ensure that people can maintain autonomy, well-being, and quality of life.
But, beyond the technical and organizational results, if at the end of my term I can say that I have contributed to improving people’s lives, then it will have been worth embarking on this journey.
