Supply does not rhyme with consumption: the unequal geography of outpatient specialist care

Territories with a more widespread presence of outpatient clinics and laboratories are not those that receive more care. A chapter of the Rapporto OASI 2025 (in Italian) shows, using national data, that the capillarity of supply does not automatically translate into greater value or higher service utilization. On the contrary, in macro-areas where the network is more fragmented, and particularly in the South, the overall value of outpatient specialist services delivered is lower than their demographic weight: the South and the Islands account for 34 percent of residents but only 27 percent of the value of specialist services provided, despite hosting 54 percent of service delivery points.

The variability of services delivered under the National Health Service (SSN) across different health authorities is a constant, regardless of the examination or visit considered: for musculoskeletal MRIs among those over 65, the national median is 2.5 exams per 100 inhabitants (average 3.1), with a minimum of 0.9 and a maximum of 5.4. For abdominal ultrasounds, variability is even more pronounced: a median of 7.7 per 100 inhabitants, with regional averages ranging from 4.7 to 16.1. Laboratory services, which account for more than one thousand procedures per 100 inhabitants, range from a national minimum of 283.2 to a maximum of 1,481.1.

If variability in SSN utilization is a structural fact, the focus must shift from “how much is produced” to “how much is consumed.”

Variability without epidemiological basis

The chapter contributes to the international debate on “unwarranted variation,” launched in the 1970s, which showed how variability not explained by epidemiological factors poses a risk to equity and efficiency.

In the Italian context, attention has historically focused on hospital admissions. Today, the focus is expanding to territorial specialist care and residents’ utilization patterns.

The research aims to analyze residents’ utilization, standardized by age and gender, by addressing five questions:

• How wide is the variability in utilization across regions and across health authorities?
• Is it associated with population density or geographic location?
• Is it correlated with supply capacity (number of outpatient clinics and laboratories)?
• Is it linked to the organizational size of districts?
• What is the relationship between prescriptions and utilization?

Three services, one result

The data used come from the AGENAS performance evaluation model for territorial health authorities (110 Local Health Authorities), the Ministry of Health, and ISTAT. Three types of services were analyzed: musculoskeletal MRIs for those over 65; abdominal ultrasounds; laboratory tests.

The 110 authorities were grouped into nine clusters by crossing macro-area (North, Center, South) and population density (low, medium, high).

While for abdominal ultrasound the differences appear to follow geographic lines, for MRIs and laboratory services the picture is far more nuanced, with big local differences even among health authorities within the same Region.

The correlation between the number of outpatient clinics/laboratories per 10,000 inhabitants and utilization is weak or nonexistent; for abdominal ultrasound, the correlation is even negative, albeit modest.

The perhaps counterintuitive conclusion, consistent with findings reached in previous years for hospital facilities, is that more facilities do not mean greater utilization or better care. Fragmentation of supply may actually reduce productivity and value. Small-scale providers, with limited staff or outdated and inefficient equipment, do not represent an adequate standard in a field that—like hospital care—increasingly requires significant investment in specialized expertise, mechanisms for integrating professional knowledge, production scale, and technology.

A focused analysis of the Lombardy case confirms the strong local variability and shows that only 51.1 percent of prescribed visits and 56.1 percent of diagnostic services are actually delivered within the National Health Service. Evidence collected after the article’s publication, including in other Regions, suggests that an additional 10 percent may be delivered by the National Health Service through subsequent prescriptions and that private utilization accounts for roughly one-third of the total.

The gap between prescriptions and utilization also emerges as a widespread phenomenon that has so far never been thoroughly studied and is therefore rarely considered in the formulation of health policies and corporate governance tools. To date, these have focused instead on waiting lists, encouraging prescriptions and delivery volumes without addressing the fundamental question: how many services are already being used today by residents of individual territories? And, to properly frame the issue of unmet need: how many prescriptions not resulting in SSN utilization are fulfilled privately without any adverse consequences for the patient, who may have their own insurance coverage? Conversely, how many prescriptions are slow to translate into an actual service, generating delays and negative impacts on patients’ health, while also eroding the credibility of the SSN?

Greater access to data to allocate better

To govern the appropriateness of care and the reallocation of resources, health authorities should demonstrate the organizational and political courage to systematically make variability data available and, above all, to use them as a key tool to revitalize corporate planning and control mechanisms. Only in this way will it be possible to use utilization data—already theoretically available down to the individual patient level—to define priorities based on need rather than productivity targets.

Reflecting on prescribed and consumed services can in fact provide an objective ground for discussion for both clinicians and SSN managers, with the shared goal of bringing utilization closer across geographic areas and among patients with similar profiles. In some cases, it will prove necessary to undertake processes of reallocating supply across territories and specialties, with all the difficulties associated with altering established balances within complex organizations such as health authorities. Nevertheless, it is worthwhile to gradually but profoundly change the governance logic of outpatient specialist care. Undifferentiated productivity growth targets by geographic area and type of service risk, on the contrary, fueling overconsumption in certain areas and specialties while leaving uncovered those fields that currently suffer from underconsumption, with evident repercussions on health outcomes and equity.

Giulia Broccolo, Alessandro Furnari, Francesco Longo, Giordana Puritani, Alberto Ricci, “La variabilità dei consumi e delle prescrizioni nel SSN: un confronto inter e infra regionale.” In Rapporto OASI 2025. (In Italian).