An American gets total knee replacement in Italy’s health system

By JoAn Ferguson

When my husband and I started seriously considering moving to Italy, we investigated the Italian health system. It is as different from America’s as you can get. The Italian constitution states that “The Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent.” And we learned that Italy has a highly rated medical system – second in the world, according to Wikipedia!

This article shares my personal experiences with the medical system, including my recent total knee replacement surgery. As a bit of background, my husband and I are from the United States of America, both 63 years old and have lived in Lucca for two years.

Private Medical Insurance

We applied for Elective Residence Visas to allow us to move to Italy. One of the many requirements was to show that we had Private Medical Insurance because the Italian Government recognizes that there are many actions that must be taken before new immigrants are eligible to become part of the Italian health system. During a pre-move visit, we signed up for a plan that covered major and unplanned medical expenses – similar to what we would call catastrophic coverage in the USA. The coverage values seemed low to us (€30000 each) but our lawyer said that it should be adequate. The annual cost was less than €2000 for both of us. We expected not to use the insurance, but unexpectedly my husband needed surgery. We had to pay all costs at the hospital but the insurance reimbursed us for all of it! Because of COVID, we still weren’t able to sign up for the Italian medical system and our insurance was getting ready to expire. We renewed the policy and used it one other time, with the same results – all costs covered with no deductibles. During this period, we paid the full cost for our prescription medicines, but they cost us less than half of the co-pays that we had in USA with our health insurance.

Participation in the Italian Health System

Once we became official residents, we were able to sign up for the Italian Health System and receive our coveted Tessera Sanitaria cards. Tony, a local Italian who helps many expats with bureaucratic tasks, guided us through the process: go to the Post Office and pay for insurance, bring him the receipt and copies of several documents (passports, codice fiscale, permesso di soggorno, and documents showing income level). A few weeks later, we had the cards in hand. 

We had read many places that this insurance is “free” but also read that there were costs involved. It turns out that the Constitution and the laws state that it is “free” but with the kind of visa that we have, we were required to make a voluntary contribution for the insurance. The first of many bits of confusion regarding the Italian Health System. We pay more than €2000 per year for this “public” insurance but the coverage is comprehensive.  We selected a primary doctor that speaks some English and has an office close by.

Working with our primary doctor

I don’t actually visit our primary doctor frequently. After my initial visit and a review of my medical histories, he provided prescriptions for my regular medications and encouraged me to use WhatsApp to send further requests to him. So, whenever I need a prescription for medicine, a referral for a special visit, or a medical test, I simply send him a message with WhatsApp. He writes the prescription and leaves it at the pharmacy in his building and I pick it up that day or sometimes the next. Very easy and efficient but a bit impersonal! Many prescriptions cost nothing; some have a co-pay up to €20.

When it is time for a visit to our primary doctor, I send him a message via WhatsApp and he tells us when to come. Usually that day or the next. When you enter the waiting room for several doctors, you simply ask the group of people waiting “L’ultimo per Dottore Morotti” or “Who is the last person waiting for Doctor Morotti?” Someone should acknowledge that they are the last and you sit down and wait your turn; you need to remember who was last, so that you can enter the doctor’s office after that person finishes. When the next person enters the waiting room with the same question, you acknowledge that you were last and they now know where they fall in line. When the doctor is ready for the next patient, he simply appears at the door and says “Chi è il prossimo?” or “Who is next?” This sounds like a wonderful and informal approach, but seldom works as smoothly as it should. They typically are confused by my pronunciation and there are often disagreements about who is actually last or next. This approach is so characteristic of the Italian culture. I giggle to myself every time I watch it in action. (As of February 2022, I understand that Doctor Morotti is not taking any new patients.)

Once it is your turn and you are in the doctor’s office, you share your questions, requests, concerns, problems. There is no nurse, no unnecessary blood pressure readings or weigh-ins and frankly I can’t remember him actually examining me.  He fills out needed forms and prescriptions and hands them to you. At the end of any visit to a doctor, they give you a one-page summary of the results. You wait while they type and print it or simply hand write it. The doctor may keep some records for their patients but the expectation is that you maintain your own records. There is no charge to see your primary doctor. Once I needed to pay to have a specific form completed and I had to pay €50 for the administrative costs. He took out his credit card machine and I gave him a credit card… no billing department needed! A specialist visit typically requires a payment of around €30.

Working with a private orthopedic doctor

When my knee started hurting in November 2020, we still weren’t covered by the Italian Health System so I went to a private doctor. Once we were covered, I continued to see the same doctor as I had a lot of confidence in him. His office is run a little closer to an American doctor’s office. He has a receptionist who checks you in, accepts the payment, and schedules appointments. This doctor speaks some English and his receptionist speaks English very well.  During an early visit he reviewed my X-rays and MRIs and said that my right knee was in terrible shape. I would need a total knee replacement within a year or two. I was definitely in pain but had no idea that my knee was so bad. My husband had struggled for years with his knees and visited the same doctor. The doctor said that mine was much worse and I would “get to go first”. My initial visit was €130 and included a cortisone shot.

The cortisone shot helped a lot and I was back to walking the streets and wall of Lucca pain free. About six months later the pain started to return and we were getting ready for my son’s visit to Italy. I had plans for lots of fun activities and did not want to be in pain for his visit! I returned to the doctor and got a second cortisone shot (only €50 this time) and was pain free again. The doctor indicated that I should plan to have knee surgery in 2022. But the bad news was that the cortisone shot lasted only about a week… After an exchange of emails, we targeted February 2022 for the surgery.

Surgery – private or public insurance?

We had planned to use our private medical insurance because the doctor is a private doctor. But then we learned that we could not renew the same private medical insurance policy because we were now residents; that kind of policy is only for non-residents. So, we asked our insurance company for a similar policy for residents. Bad news, cost was higher and all pre-existing conditions were excluded. I had heard horror stories about people waiting many months for knee operations using the public insurance and was in too much pain for that. I visited my primary doctor to ask how long it would take to get a public orthopedic doctor and get the surgery scheduled. I explained my situation and he confirmed that my orthopedic doctor was the best in Lucca and said that he would certainly accept my Tessera Sanitara (i.e., the public insurance) for my surgery. Another moment of confusion – could my private doctor use the public insurance for the surgery??? I contacted my doctor and waited anxiously for the response. Of course, they would accept the Tessera Sanitara. Certainly no one would be expected to pay the full cost of the surgery! Confused but happy!

Time for surgery – total knee replacement

I won’t provide the full story of the surgery and recovery. If you are familiar with this surgery, you’ll know that it is particularly painful and a difficult recovery. Instead, I’ll provide a list of some of the similarities and differences between an Italian and American hospital visit:

Different – my hospital (Casa di Cura M.D. Barbantini) is a 9-minute walk from my apartment… if I could walk that far. It likely took my husband 12 minutes to drive there, including switching sides of via Del Fosso 3 times…

Similar – pre-surgical tests and meeting with the anesthesiologist scheduled a few days before surgery

Different – bring your own crutches, pajamas (no gowns provided!) and all toiletries

Similar – bland food. Even the pasta.

Probably similar – no visitors because of COVID-19

Different – minimal pain meds. I received intravenous acetaminophen (Tylenol) several times a day. When the pain got bad, I insisted on a stronger pain medicine and received “something like” morphine. Two times.

Similar – high quality staff (doctors, nurses, aides, therapists, etc.).

Different – 6 nights in the hospital versus 0-2 in America

Different – cost for doctors, surgery, hospital, Xrays, physical therapy in hospital, etc. was €0.

Recovery – total knee replacement

From the moment I heard the word “surgery” I started worrying about all of the steps in our apartment. We live on the 3rd, 4th, and 5th floors. There are two different sets of stone steps before reaching the elevator, then once you reach our apartment we have four more sets of stairs. Some have just a few steps… one has 12 steps. There are two ground-floor Airbnb apartments in our palazzo complex that are owned by our neighbors. We rented one of them for my first two weeks home from the hospital. The apartment was perfect for those initial weeks, including a front door that opened directly onto a paved street for my first walks. Although cobblestone streets are lovely to look at, a paved street seemed like a luxury after surgery.

Given that my knee would hardly bend, it was not easy to get into our small vehicle. My doctor referred me to Marco, a physical therapist who comes to your house. He came 3 days a week and I covered the cost of these sessions. After two weeks in the ground floor apartment, Marco walked me to my apartment and gave me instructions and tips for each set of stairs. 

Looking Forward

I have months to go before I am fully recovered but I feel very blessed by the good medical care that I have received and the many family members and friends that have supported me through texts, phone calls, visits and meals. And most of all the help provided by my husband all day and all night. Full recovery from a total knee replacement can take up to a year, but I look forward to spending this Spring working on my recovery on the streets and wall of Lucca. See you there!