Mediobanca Research Area, updated the report dedicated to the main healthcare providers in Italy
L’Mediobanca Research Area has released an updated report on largest private healthcare operators in Italyfocusing on groups with a turnover greater than 100 million euros. The study also provides an analysis of the latest trends and future prospects of the Italian healthcare sector, accompanied by a comparison with the international panorama.
Turnover growing compared to pre-Covid levels, but profitability drops and the net result is negative
From the research it emerges that in 2022 the 31 private healthcare providers surveyed scored revenues of 10.6 billion euros. The turnover, therefore, grew by 2.7% compared to 2021 and 8.7% compared to 2019. Instead, in 2020 there was a decline of 6.6%, due to the partial suspension of healthcare activities, and in 2021 there was a rebound of 14.5%. The recovery, however, was not homogeneous. Compared to 2019, the medical diagnostics recorded an increase of 22.3%, thanks to the exceptional demand for swabs and molecular tests during the pandemic, the solution of which in fact produced a drop in revenues of 8.1% compared to 2021.hospital care grew by 10% and the residences for the elderly by 4.1%. RSA managers benefited from the increase in the occupancy rate of beds in residences (on average above 90%) and from the opening of new facilities which continued even during the pandemic. There rehabilitationhowever, is still decreasing (-0.4%).
There profitability not only is it still lower than pre-pandemic levels but it suffered a further setback in 2022, affected by inflation. The net operating margin (MON) contracted by 60.4% on 2019 and by 49.7% on 2021 and theEbit margin it fell to 1.8% from 3.8% in 2021 and, above all, from 5.3% in 2019. With reference to individual specialties, hospital care and rehabilitation closed 2022 with a negative current result, in more marked measure for the second (-6% against -0.3%). Diagnostics, despite sharing the contraction in margins, achieved the greatest Ebit margin (11.1%). However, this sector is affected by the consequences of Decree of the Ministry of Health of June 2023 which regulates the new nomenclature for specialist outpatient and prosthetic care, with expected average cuts on the tariffs of the main services of around 30%. The entry into force of the decree, initially set for April 2024, has been postponed to January 2025.
L’last line of account the aggregate economic performance of the 31 operators is negative by 38 million, bringing the number of businesses in the red in the four-year period to two (after -53.9 million in 2020). There are 14 groups that closed 2022 with a loss (there were five in 2021). The Aggregate ROEalready decreasing from 5.9% in 2019 to 4.1% in 2021, falls further to -0.8% in 2022. The best net profitability is recorded by: Medicine Center (22.2%), Humanitas (13.4%), Eurohealth (9.5%) e GHC (8.3%) in hospital care, Synlab (39.2%) in diagnostics and San Raffaele of Rome (36.3%) in rehabilitation.
There capital structure in 2022 it appears solid and partially improving compared to the previous year, with financial debts equal to 104.5% of equity (112.7% in 2021 and 120.8% in 2019). The most solid financial positions are those ofIEO, Italian Auxological, Hello, Monza Polyclinic, Humanitas And Don Calabria Institutewith financial debts substantially absent for the first and around 20% for the others.
Expectations for the sector
The end of the health emergency in March 2022 marked the beginning of the gradual resumption of activities in the healthcare sector. In 2023, there was a return to full operation in rehabilitation andhospital care, despite some persistent critical issues. Among these, the failure to recover the waiting lists, along with economic reasons, was a significant problem that led 4.5 million Italians (7.6% of the population) to give up tests and medical visits in 2023.
The long waiting lists induce not only those who are able to bear the costs, but also the subscribers of private insurance and the beneficiaries of company welfare, to go outside the NHScontributing to growth in private health spending. It is therefore reasonable to expect, in the near future, an increase in the weight of private healthcare operators whose turnover in our country can already be estimated at approximately 70 billionequal to 40% of the overall numbers in the sector.
The scenario that emerges is theflattening of the impact of public health spending on GDP, in the face of a growing demand for services due to demographic dynamics. Indeed, international statistics highlight the constant aging of the population: in the area OECDthe incidence of the over 65s on the total has gone from 7.6% in 1950 to 18% in 2022, with the forecast of reaching 26.4% in 2060. Italy, with 23.9%, has a well above the OECD average (behind only Japan with 29%), expected to rise to 33.4% by 2060. Again in the OECD area, life expectancy at birth grew by over 10 years between 1970 and 2022 and in Italy it stands at 82.6 years, with a birth rate of 1.25 children per woman, among the lowest values in the world.
For the 2023 a further one is planned 5.5% increase in overall revenues of the private operators examined. However, different variations are expected between the sectors considered: -4.0% for diagnostics, +4.1% for rehabilitation, +5.7% for hospital care and +14.0% for hospital managers facilities for the elderly, with the return to full saturation of Italian RSAs expected by 2024. The comparison between the 5.5% increase estimated byMediobanca Research Area and the +1.7% marked by the accredited expenditure detectable by the latest DEF, allows us to establish that the change in the aggregate turnover is driven by the increase in healthcare services paid out of pocket by citizens.
Size, geographic diversification and revenue composition
In 2022 it will be in first place in terms of revenues Papinianholding company of San Donato Group And San Raffaele Hospital in Milan (1,707 million), which precedes Humanitas (1,122 million), GVM – Villa Maria Group (840 million), A. Gemelli University Hospital (799 million) and KOS (683 million).
Some groups have one branched geographical presence on the national territory: KOS, Serene Horizons And Don Gnocchi they are operational in at least nine Italian regions, with a more marked presence in the North. Among hospital players they stand out GVM And GHC with activities in ten and eight regions respectively. Papinian And Humanitas are concentrated in Lombardy: the first is also active in Emilia-Romagna where it generates 4.3% of revenues, the second in Piedmont and Sicily (21% of turnover).
Instead, there are eight operators managing structures across the border, mostly with marginal presences. They are exceptions GVMwith 14 foreign facilities (including one in Ukraine) which generate 13% of revenues, and KOS with 51 RSAs in Germany for 4,423 beds which account for 28% of the total turnover. The international projection of Papinian it expanded in December 2023 with the acquisition, in partnership with the financial company GKSDfrom the American Heart of Poland, among the leading private healthcare providers in Poland. In turn, the Polish company reached an agreement in May 2024 to take over its compatriot Scanmed.
The breakdown between activities in accreditation and solvency highlights a varied situation in 2022. ICS Maugeri and the San Raffaele of Rome they see revenues from accreditation prevail with incidences equal to 96.0% and 94.4% of their revenues respectively. It is the opposite CDI whose diagnostic services are mainly intermediated by supplementary funds and insurance companies (41.5% of total revenues), by private individuals (20.9%) and by companies (10.7%). Among the other players with high revenues in solvency we note Lifenet (50.0%), IEO (35.3%) e KOS (35.0%).
Health spending: the international panorama and Italy’s position
At the end of 2022 the health facilities active in Italy were 29,354 (57% private and 43% public), an increase of 3,272 units compared to 2010. For OECD countries the average health spending per capita, the sum of the public and private components, amounted to $4,986 in 2022 and 9.2% of GDP. In an international comparison, the United States emerges with 16.6% of GDP ($12.6 thousand per inhabitant), followed by Germany (12.7%) and France (12.1%). Italy is below average both in per capita terms with $4.3 thousand and in relation to GDP (9.0%). To equal the incidence achieved in Germany, Italy would have to increase its healthcare spending 77 billion of euros, which they would become 65 billion taking France as a reference.
Relatively to alone public health spending, our country in 2022 will record 6.8% of GDP behind Spain (7.3%), the United Kingdom (9.3%), France (10.3%) and Germany (10.9%). In 2023, Italy stood at 6.3%, with a forecast of rising to 6.4% in 2024. In absolute value, Italian public health spending increased at current prices from 78.5 billion of the end of 2002 to 131.7 billion of euros in 2022 and, according to forecast data, has fallen to 131.1 billion in 2023. In 2022, approximately 79% of the total value originated from public structures and 21% from accredited ones. The expenditure disbursed by the latter shows a growth (+3.1%) higher than that of public facilities (+2.5%) in the 2002-2022 period, with the exception of the emergency period, marked by numerous emergency measures strengthening of NHS: between 2019 and 2022, spending by public structures rose by 5.2%, compared to +1.8% for accredited ones.
Including solvency services, which went from 31.5 billion euros in 2012 to 40.6 billion in 2023 with an average annual growth of 2.3%, and the intermediated component, which recorded an average annual increase of 5 .5%, the overall health expenditure reached i 176.2 billion In the 2023. In 2022, however, health spending had totaled 175.7 billion.
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