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From Riccardo Asteggiano, member of the Nucleus of the Council for Cardiology Practice

Date : 09 Nov 2009

The Italian Health System

The National Health System (NHS) in Italy is based on a multi-functional unit called Azienda Sanitaria Locale (Local Sanitary Company - ASL), responsible for the Health System in a community varying from about 100,000 to 500,000 inhabitants and on a territorial extension from a large town to about one third to one fifth of an Italian Region. The ASL is responsible for the organisation and the economic management of the entire population’s care in that geographic area. All medical structures, from General Practitioners to Hospitals, are under the supervision of the ASL.

All Italians are covered by the NHS. Everyone has the reference of a GP who is responsible for prevention, care and all medical activities regarding his patient's health. The patient consults the GP in his practice or alternatively can be examined at home. In the case of complex medical interventions, GPs collaborate with specialists and nurses in domiciliary care. A well organised system of medical Emergency Care intervenes in case of dangerous situations. This applies to all the national territory with the telephone number "118".

The area of specialised medicine is much more complicated. In every Italian ASL there are public out-patient clinics with multiple services such as centres for blood examinations, administrative offices and medico-legal consultation. These clinics also centralise many specialists in different branches of medicine (“Specialisti Ambulatoriali” – Practising Specialists). Obviously private-practice cardiologists are one of the most important components of these services. These structures act as a “bridge” from GPs to specialised hospital divisions, as a filter to hospitalisation and as a reference for out of hospital specialised medical activities. The majority of the public hospitals are dependent on the ASL economically and managerially. Only university hospitals and very large hospital structures are independent and are considered “autonomous companies”.

Cardiology Divisions are wide spread over the national territory, and generally they have a Coronary Care Unit and a Hemodynamic Service, often active 24 hours/day, 7 days/week for primary PCI. The standard of care in cardiology divisions is quite satisfying and one example is the activity of the well known "GISSI" network of investigators (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarcto Miocardico). Together with the completely public organisation there is a network of private hospitals and out-patient clinics where patients can obtain specialised care. These structures are reimbursed directly from the NHS, through the ASL, providing they satisfy specific criteria (called “Accreditato").


The patient is completely free to choose a public or a private structure of this kind. GPs send patients with a referral schedule valid for both public and for private “accreditati” centres to a reservation office. GPs can also identify the priority of the consultation or of the required exam, classifying it as I) urgent II) can be delayed or III) control; the patient is added to an agenda according to these criteria. Unfortunately this procedure of reservation is not activated over the entire Italian territory and in many situations the waiting lists are not managed satisfactorily.

Patients participate to payment of the medical activity (so called “ticket”), varying in the case of cardiology from 11.65 Euros for an ECG to a maximum of 70.00 Euros for an Echocardiogram, or a Stress ECG, or Stress ECO, or Scintigraphy. Patients aged over 65 and with an economic threshold of less than 36.151,98 Euros per year, and patients with specific pathologies identified in a list, are excluded from payment of this tax. Admission to hospitals, both public and private, is free of charge. Moreover high class populations, and to a lesser degree the middle classes, also have private medical insurance and can obtain assistance from completely private structures. These are mainly completely private practice specialists, often organised in out-patient clinics, and very rarely in private hospitals. However the situation varies greatly between Italian regions regarding the distribution of completely public, “accreditati” and completely private centres, and in the percentage of the population that uses each system. This depends on the quality of the NHS offered in that region, on the waiting lists for procedures and on the economic level of the population in that region.

Who are Italian Cardiologists?

According to the complexity of the NHS, with completely public, “accreditati” and completely private structures offering their care to cardiologic patients, in Italy we have the following "kind" of cardiologists:

  1. Cardiologists working only in public hospitals
  2. Cardiologists working only in university hospitals
  3. Cardiologists working in private hospitals with reimbursement by the NHS (“accreditati”)
  4. Cardiologists working in completely private hospitals (very few in recent years)
  5. Cardiologists working in public offices in cardiology practice but paid directly by the NHS (“cardiologi ambulatoriali”)
  6. Cardiologists working in private offices in cardiology practice paid with reimbursement by NHS (“accreditati”)
  7. Very few cardiologists working only in private offices in private practice
  8. Many cardiologists working in public hospitals or offices are doing true private practice for some time in "intramoenia" (public structures) or in "extramoenia" (private offices) conditions. They are paid by patients, but in accordance with rules of the ASL or the hospital where they are working (they receive a percentage of the fee).


Cardiologists in public or university hospitals may choose full time or part time contracts with a different timetable and different economic retribution.

Cardiologists working in private hospitals or in private out-patient clinics reimbursed by the NHS or completely private have work contracts based on the number of medical activities performed i.e. a percentage of the reimbursement from the NHL to the structure.
Cardiologists working in out-patient clinics managed directly by the ASL have payment according to the number of hours worked, with a maximum of 38 hours per week, increased by fees for home calls or particular activities like diagnostic exams (Echocardiograms, Holter Monitoring, etc.). So a practice cardiologist (“cardiologo ambulatoriale”) can have better economic treatment than a hospital cardiologist, depending on accessory payments for extra activities. A full time cardiologist in NHS practice may earn more than 100.000 Euros per year. Taxes account for about 50% of this sum.

The hours worked by cardiologists in hospital and in public practice clinics, and those doing true private practice, vary from a few hours to 20 hours per week. With the recent economic restrictions, there has been a reduction in the number of private consultations.
The reimbursement of cardiologic activities by the NHS to the ASL and to the structures “accreditate” is listed in Table 1. As shown, the sums reimbursed vary between Italian regions.

Table 1. Reimbursement of cardiologic activities from the NHS

  Range of reimbursement in Euros
Electrocardiogram 11.82 - 13.70
General examination 18.91 - 30.00
Echocardiogram 52.53 - 71.80
Stress- Echocardiogram 56.73 - 109.50
Supra-aortic branches Echo 44.65 - 51.65
Limbs Echo 44.65 - 51.65
Stress Electrocardiogram 56.73 - 67.15 (Treadmill)

56.73 - 65.65 (Cycle)

Holter ECG Monitoring 63.02 - 72.95
Pace-maker electronic control 23.64 - 28.45
AICD Electronic control 45.45
Ambulatory blood pressure monitoring 42.02 - 48.65

In Italy, in private practice, the cost of an ECG is between 15 to 50 Euros and a complete consultation costs between 60 to 500 or more Euros! This great oscillation depends on the reputation of the specialist and also on the geographic area of Italy.

How many Cardiologists are working in Italy?

Nobody knows with a good approximation how many cardiologists are working in Italy.
Cardiologists working in public hospitals are assigned to the ASL and it would be necessary to contact every Italian ASL to have this data. Some cardiologists working in public structures assigned to the ASL but work in different ASLs.
To know how many cardiologists are working in hospitals or in offices in the “convenzionato” regimen, it would require contacting each of the very numerous structures in Italy, and moreover many cardiologists are working in different structures.
Another way to count the number of cardiologists could be by the lists of specialised doctors of a local provincial Medical Association (“Ordine Provinciale”), but it is not mandatory to notify the obtention of a specialisation and many doctors omit to do so.

The number of cardiologists registered in a retirement system could be an indicator but professionals are registered as General Practitioners or as Specialists with no mention of the kind of specialisation. Moreover there is a good percentage of retired doctors who continue to work in private practice.

The analysis of member lists of scientific cardiology societies does not provide good results. Every kind of cardiologist has a scientific society that represents his particular situation (ANMCO for public hospitals, SIC for university hospitals and so on) but every cardiologist can be a member of many different scientific societies, just by working in a hospital and in private practice!
So, in conclusion, it is practically impossible to know how many cardiologists there are in Italy!

Specialisation School in Cardiology

Having graduated in Medicine after a study course of six years, an Italian doctor wishing to specialise in Cardiology spends five years in a University Specialisation School in Cardiology, consisting of an internship in the Cardiology Departments of both University Hospitals and of the NHS hospitals classified as “accreditati” (apt for specialist training) by the Council of the University School according to the annual volumes of activity of these structures (at least 600 admissions, 250 cardiac catheterisations, 500 Echocardiograms etc.). Annual admission to the internship is made through a national public application. Every year the number of vacancies is defined by the NHS and by the University Ministry on a presumed evaluation of vacancies for specialists. This evaluation was introduced in recent years and there is a certain unbalance between southern and northern Italy. Also cardiologists, along with other professionals, are suffering today from immigration in the country and are leaving southern Italy to work in northern Italy where there is increased need of qualified personnel.

For 2009 the defined number of vacancies is 261 places.
The internship consists of :

  • Clinical cardiology with active involvement in the management of at least 400 patients with cardiovascular disease.
  • Intensive Cardiac Care with management of at least 100 patients.
  • Conventional Electrocardiography (at least 300).
  • Stress-ECG (at least 100).
  • ECG Holter Monitoring (at least 100).
  • Echocardiography (at least 100)
  • Coronary angiography (at least 30)
  • Cardiac catheterisations (at least 30)
  • Electrophysiology, Pace-maker implantation, Cardiac CT, Cardiac MNR, etc. (not clearly required).

Every cardiologist has to achieve 300 formative credits during the five years and pass exams on specific training courses. At the end of the course in specialisation every cardiologist has a final test, the discussion of a “specialising thesis”.

Continuing Medical Education

Health authorities have defined for all medical personnel the acquisition of 150 CME credits for the period 2008-2010. These CME credits have to be acquired during national or local congresses or courses, organised from scientific societies or from NHS structures (such as the ASL). The possibility to acquire CME through E-learning has recently been introduced. All CME activities have to be validated by the NHS Ministry, and, for example, the CME credits acquired during ESC Congresses are not recognised.