Beyond teaching and research: the hidden economic value of university-affiliated physicians in Italian public hospitals.

University-hospital conventions within the Italian Servizio Sanitario Nazionale, regulated by D.Lgs. 517/1999, allow academic clinicians to serve as clinical directors in public hospitals. While the educational and scientific benefits are well described, systematic economic evaluation of these arrangements is lacking. A 12-month Budget Impact Analysis was conducted comparing two staffing models: (i) a hospital-employed clinical director fully remunerated by the regional health service, and (ii) a university-affiliated professor whose base salary is funded by the university under national conventions. Direct personnel costs were calculated using CCNL Dirigenza Medica salary tables, statutory allowances, employer contributions, and institutional payroll data. Analyses were performed from both the hospital perspective and the system-wide public-sector perspective, with deterministic sensitivity analyses assessing robustness. Academic integration reduced hospital personnel expenditures by 66.6%, with average annual savings of €145,100 (95% CI: €141,900-€148,600) per department. Savings remained above 50% across all sensitivity analyses. When university-funded salary components were included, total public-sector expenditure for the academic-integrated model approximated that of the conventional model, indicating cost redistribution rather than system-wide savings. University-affiliated clinical directors provide substantial and reliable hospital-level cost savings for Italian public hospitals through redistribution of salary obligations across the public sector. However, this economic advantage does not imply demonstrated improvements in clinical productivity, research output, or educational value, which were not evaluated in this study and require dedicated empirical investigation. Clear distinction between economic and non-economic dimensions is essential when interpreting the role of university-hospital conventions.