Introduction
In recent years, in Italy collaborative models between commercial enterprises and healthcare providers based on customer loyalty programs have attracted increasing attention in Italy.
These include initiatives that grant consumers credits, points, or forms of cashback that can be used to obtain reductions on the cost of medical services provided by affiliated healthcare facilities.
From the operators’ perspective, such instruments aim to combine marketing objectives (customer retention, increased sales volumes) with goals related to prevention and facilitating access to healthcare services.
However, their implementation raises delicate legal issues, particularly in relation to the regulation of healthcare advertising.

The operation of cashback in the Italian healthcare sector
The typical structure of these programs can be described as follows:
• a commercial enterprise (the partner) grants its customers, upon the occurrence of certain conditions (typically the purchase of goods or services), a percentage of the expenditure in the form of cashback;
• such credit may be used by the customer to obtain a reduction in the price of healthcare services provided by one or more medical facilities affiliated with the partner;
• the economic value of the credit used is borne by the commercial partner, which pays the healthcare provider the corresponding amount as consideration for marketing and promotional services rendered by the provider within the framework of the program.
From an economic standpoint, the program constitutes a form of reciprocal marketing: on the one hand, the partner strengthens customer loyalty by offering a benefit perceived as an “extra” compared to a mere discount on its own products; on the other hand, the healthcare provider benefits from increased visibility and a potential rise in patient inflow, without directly bearing the cost of the price reduction.

Healthcare advertising in Italy: the regulatory framework
The main critical issue concerns the compatibility of such initiatives with the rules governing healthcare advertising, which in Italy are particularly restrictive.
In particular, Article 1, paragraph 525, of the Italian Law No. 145 of 30 December 2018 (Budget Law 2019), as subsequently amended, provides that communications relating to healthcare activities must be limited to objective and verifiable information, such as professional qualifications and credentials, specializations and characteristics of the activity performed, the type and standards of services offered, and the costs of services, provided that these are presented in accordance with criteria of transparency and truthfulness.
Conversely, purely persuasive or suggestive elements are excluded, including special offers, discounts, promotions, and similar arrangements that may influence the patient’s free and informed decision-making.
The rationale of this framework is to prevent healthcare choices from being transformed into acts of consumption driven by economic advantage rather than by clinical needs and adequate medical information.

Price reductions and communication: what is actually prohibited
A point often misunderstood in practice concerns the possibility of applying favourable economic conditions to healthcare services. Sector-specific legislation does not, in fact, absolutely prohibit healthcare providers from setting differentiated tariffs or more favourable economic conditions for certain services or specific categories of users.
What is relevant, for the purposes of assessing compliance with the regulatory framework, is not so much the existence of a price reduction per se, but rather the use of such reductions for customer-attraction purposes, as well as their aggressive communication to the public.
From this perspective, where such economic conditions form part of partnerships or collaborations between healthcare providers and commercial operators, attention is primarily focused on the manner of communication towards users. Communications addressed to the public, whether by the commercial partner or the healthcare provider, must not emphasize in a suggestive manner the economic advantages associated with healthcare services, but must be limited to informing the public of the existence of the agreement between the two operators.
In particular, formulations such as: “Specialist consultations at 50% off if you purchase from X”, “Exclusive offer: full check-up at half price”, or “Health promotion: medical services at never-before-seen prices” are problematic.
Accordingly, communication relating to such forms of collaboration must maintain a predominantly informational character, focused on the nature and characteristics of the services, as well as on the transparency of the related economic conditions. Conversely, the use of aggressive promotional messages or language typical of retail marketing (countdowns, “today only”, “limited availability”, etc.) remains prohibited.

The role of the different actors in communication
A further aspect to consider is the allocation of communicative roles between:
• the commercial partner, which intends to promote the agreement to its customers;
• the affiliated healthcare provider.
As a general rule, partners may limit themselves to communicating their participation in the initiative or in the territorial network (for example, by indicating that they are partners of the project), without directly promoting the healthcare services of the provider or using messages that may constitute, even indirectly, a form of healthcare advertising.
The healthcare provider, for its part, must strictly adhere to the criteria of objective information set out by sector-specific legislation, avoiding presenting healthcare services as subject to promotions, special offers, or discounts.
In this context, it is advisable that agreements between the commercial partner and the healthcare provider expressly regulate the content and limits of their respective communications. Particular attention should also be paid to the preparation of any informational materials relating to the initiative, which should adopt a descriptive and institutional tone, avoiding promotional wording.

Conclusions
Healthcare cashback programs in Italy represent a tool which, at least in theory, may appear attractive in fostering forms of collaboration between commercial enterprises and healthcare providers, with the aim of combining customer loyalty strategies with objectives of prevention and facilitating access to healthcare services.
However, their implementation encounters particularly stringent constraints within the framework of Italian healthcare advertising regulation, which seeks to prevent healthcare choices from being influenced by consumer marketing logic or by economic advantages presented in an attractive manner.
While it is true that the Italian legal system does not absolutely prohibit healthcare providers from applying differentiated or more favourable economic conditions to certain services, it is equally true that such conditions cannot be used as a promotional lever nor communicated in a manner typical of retail marketing. Healthcare services cannot, in fact, be presented as products subject to offers or promotional campaigns.
It follows that the most critical element of such initiatives lies not so much in the price reduction itself, but in the transformation of healthcare services into objects of commercial promotion. In this context, proper regulation of the relationships between the commercial partner and the healthcare provider, as well as control over the content of communications addressed to the public, becomes particularly significant.
Only a carefully designed program, which keeps communication strictly within informational (and non-promotional) boundaries, can reduce the risk of conflicts with healthcare advertising regulations and with the principles protecting health and the patient’s free self-determination.