The recent draft decree framework for updating the Essential Levels of Care “Presidential Council Decree Scheme Containing modifications and additions to the decree of the President of the Council of Ministers of January 12, 2017, on the Essential Levels of Care (LEA)” represents a necessary step forward, but according to the analysis by Salutequità presented in a hearing before the Social Affairs Committee by its president Tonino Aceti, persistent structural obstacles continue to directly affect physicians’ work and the patient journey.
Out of 370 integration proposals received by the Ministry, only 91 were accepted, leaving gaps in areas of high epidemiological significance.
Exemptions and Chronicity: the “black holes” of dermatology and pain
For clinicians, managing the chronic patient clashes with the absence of financial protections for high-burden conditions. Salutequità highlights three emblematic cases:
- Chronic primary headache: despite being recognized as a “social disease” under Law 81/2020, there is still no specific exemption code.
- Atopic dermatitis and severe plaque psoriasis: remain excluded from exemption codes (such as 045), limiting patients’ access to the monitoring and treatment pathways needed to stabilize the clinical picture.
Oncology: the paradox of diagnostic tests
One of the most critical points for precision medicine concerns diagnostic tests necessary to access innovative drugs. If, on one hand, the new decree includes essential services, on the other there is a timing misalignment: the Italian Medicines Agency (AIFA) approves targeted molecules more quickly, but the National Health Service (SSN) lags in adopting and reimbursing the tests needed to identify beneficiaries.
The risk for oncologists is to have the therapeutic tool but not be able to use the reimbursed diagnostic targeting system.
Mental Health and Dentistry: undercounted resources
The analysis also stresses the inadequacy of the ten psychoeducational therapy sessions planned for eating disorders, a number deemed insufficient given the complexity of the required clinical management.
Similarly, dentistry remains almost entirely outside the public perimeter, making it difficult to integrate oral care into overall health pathways.
The tariff issue and implementation uncertainty
The cancellation of the Tariffs Decree by the TAR Lazio places a mortgage on the future of the LEA. Without a new tariff agreement by September 2026, the risk is that the new services will remain unimplemented, Aceti warned.
The concern also extends to financial coverage: the costs estimated in the technical report might not align with the tariffs that will be redefined, opening new grounds for disputes and further slowing the delivery of services.
Governance: toward an Independent Authority for the LEA
Salutequità proposes overcoming bureaucratic inertia by establishing a permanent and independent Authority (modeled after AIFA) for the continuous updating of the LEA. The aim is to swiftly align the portfolio of services with the latest scientific evidence and technological innovations.
Concurrently, the current monitoring system is criticized: assessing LEA compliance through only 27 performance indicators for over €142 billion transferred to the Regions is deemed insufficient to guarantee uniform care across the country.
From reimbursement-for-service to Value-Based Healthcare
The most impactful reform proposal for medical practice concerns the financing model. Salutequità calls for moving beyond mere fee-for-service reimbursement and instead incentivizing:
- Funding of PDTA to value the entire diagnostic-therapeutic-care journey.
- Focus on outcomes to base the allocation of resources on the health results actually achieved.
- Strategic vision to close the gap left by a National Health Plan that has stood still since 2006, ensuring real and sustainable care for chronic and rare patients.
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