Guest Blog Post
Let me introduce myself. I am the Chuck who Ada Beth has mentioned in her posts. In addition to being the official blog photographer, I am a doctor, grandfather, rower, and Ada Beth’s husband and life partner. I practiced medicine for almost 20 years and during that time became interested in how the healthcare system affects the health of populations in addition to providing care for individual people. That led me to a number of medical leadership positions trying to manage the cost and quality of care, and participation in national groups that measure and improve quality of care in the US; so it was natural for me to explore how the Israeli health care system works during our stay in Israel. I am fortunate that our good friend Cindy has contacts with a number of leaders in healthcare in Israel and arranged for me to meet them. I want to thank her and all of those people who so graciously shared their time and opinions with me.
How much should healthcare cost?
Should everyone have the same access to healthcare?
What health care benefits and services should be considered basic?
How much should we invest in healthcare technology?
How do we provide support and incentives for individuals to take care of themselves to prevent illness and manage their chronic conditions?
How do we best measure quality and value in health care?
Sound familiar? These are questions that were on the minds of the leaders of Israel’s largest Kupat Holim (literally, sick funds in Hebrew). They call themselves HMOs – I guess they haven’t heard that the term “HMO” has been replaced with other terms, PPO, EPO, consumer directed plans, etc., after HMOs were bashed in the 1990s for trying to manage the quality and cost of healthcare (more on this later).
The Macro Overview
In Israel today, everyone has access to healthcare. It’s considered a basic right and is funded by a progressive tax paid by all Israelis that starts at 3.1% and increases to 4.8% for higher earners. Even though 95% had access to health care prior to 1995, in that year Israel passed the National Health Law that assures that all citizens have access to health care and determines the basic basket of services that must be provided. The basket of services offered through the plans sounds very similar to that in the US – all basic preventive and acute care, transplants, cancer therapy, and specialized care. This national system covers about 60% of all health care costs and supplemental insurance (which most people purchase) and out of pocket expense (co-payments and services that are not covered such as dental care) make up the rest. The government owns about half the hospital beds in the country and currently provides all of the mental health care services.
While the funding comes from the government, everyone has the ability to choose which of 4 HMOs to join (this has some similarities to the exchanges proposed in Obamacare). The HMOs were founded between 1920 and 1940, well before the growth of health insurance in the US. The largest HMO is Clalit that covers about 53% of the population, employs physicians directly and owns a number of hospitals. The other HMOs contract with physicians in a variety of ways and include hospitals that are owned by Clalit or by the government. Everyone is able to choose their doctors (mostly GPs) from the network of their HMO and get most of their care from GPs.
There is a special fund and program for children originally started by Hadassah in 1913 called Tipat Halav (a drop of milk). Tipat Halav is separate from the health plans and there is no copayment for basic child health care. There is a fixed budget for hospital care, so hospitals have to be relatively efficient. The hospitals are all paid by the HMOs for their services at prices the government sets – similar to Medicare DRGs. The hospitals can give discounts to HMOs, but cannot charge more.
So far so good – everyone has access to essential health care services at an affordable price and a relatively efficient administrative process.
Now for the downsides –
While the basic health plan covers all basic services there are co-payments and additional services, such as dental care (this is true in the US as well), are not covered.
While there is good access to GPs and primary care, there can be long waits (months) for specialty care (although this is increasingly common in the US as well).
Most people buy supplemental insurance, an additional cost that allows them more benefits and covers some of the co-payments.
As in the US, the clinics in the poorer areas are more challenged – they get the same capitation rate for their members, but the members require more time and are sicker than those in the higher socio-economic areas.
If you use the basic insurance, you will get access to good specialty care, but you won’t be able to choose which doctor (remember the Patient Bill of Rights issues?). For example, if you need a hip replacement, you will be referred to an orthopedist and will see whichever one is available. If you want to see a specific one, you can do so, but you will have to pay out of pocket to see them at their private office. The “top” specialists all have two practices – the HMO practice and the private practice. If you choose to pay for the private practice, you will see the doctor of your choice and you can be seen sooner.
There are some private hospitals that cater to those who can pay out of pocket. These hospitals still can receive payment for the hospital admission from the HMOs, but they can charge patients more for nicer rooms, better food, and, of course the easier access (see the website for Hertzeliya Medical Center http://www.hmc-ims.com/default.aspx which is in English and that says something too – appeals to a higher socioeconomic group). The private hospitals boast that they only give hospital privileges to the “top” doctors, and in fact do restrict privileges to doctors with more experience and who are chiefs of departments in their HMO practices.
Conversations in Israel
How to manage with limited income – creative, but challenging ideas
After Ada Beth and I got married, I started our honeymoon with a clinical clerkship at one of the major teaching hospitals, Belinson Hospital in Petach Tikva. In 1972, Petach Tikva was a separate little town outside Tel Aviv. We stayed in a “dormitory,” that was more like a youth hostel or summer camp staff quarters. The hospital itself had good basic services, but was a far cry from the NYU medical center. Now Petach Tikva is essentially part of greater Tel Aviv and Belinson is a huge hospital complex with the Schneider Children’s hospital, cancer center, gynecologic center, etc.
Forty years after my clerkship, I visited with one of the leaders at Schneider Children’s Hospital (http://www.schneider.org.il/Eng ) on the Belinson campus. The hospital is the only comprehensive children’s hospital in the Middle East and serves children from Israel, the Palestinian Authority, Jordan, Gaza, and Africa. As it attempts to balance its budget, it has explored using medical tourism to increase its revenue. It can provide expert care to people from countries where care is not available, such as the former Soviet Union. Because of the large influx of people from those countries in the 70s and 80s, there are a lot of physicians and other healthcare professionals who speak Russian and other languages that makes the care delivery more attractive and efficient.
The people from these countries pay the “rack rate,” of whatever the hospital wants to charge, so they fund additional staff and services that the Israeli budget does not, but here is the rub. While the hospitals currently run at 100% capacity of their budgeted beds, they have some space and can add a few beds for the “medical tourism” patients. This increased income also allows them to hire additional nurses who will serve the foreign patients as well as the Israeli patients. When they do so, the press and Israeli public complain that the hospitals are providing care to make money while the Israeli patients are waiting. Even though these foreign patients are not taking beds from Israelis and are paying for additional services that go to Israelis, the public relations challenges have caused a reconsideration of the program.
Anecdote of management in Israel: Quality is in the eye of the beholder
I have spent much of my career trying to evaluate and improve health care quality, so it was natural for me ask about quality of care in Israel. How do you know if your doctor is good? The usual aphorism in the US is that people choose their doctors according to the 3 “As” – Accessibility, Affability, and Ability in that order. It’s very hard for a patient or even professional peers to evaluate a doctor’s quality. It requires clear measures, adjustment for patient risk factors, and a large enough population to be able to draw some conclusions. Hospitals can meet some of these criteria and publicize their quality (see the ads by the various hospitals such as Special Surgery and Cleveland Clinic in the NY Times).
When I met the head of one of the best known private hospitals in Israel I asked why people come there and pay out of pocket rather than get their care in one of the government or HMO hospitals. He answered that there are two reasons – the doctors are better quality and the care and surroundings are better. I saw on my tour that the care and surroundings are quite nice. They are more similar to those in the newer hospitals in the US, like the renovated rooms at Morristown Memorial where Ada Beth had her hip surgery, than the routine rooms at Mt. Sinai in NY, and the nursing ratios are higher than in the other hospitals. As to the quality of the physicians, I was not surprised to learn that there is no data about the doctors’ performance. The doctors at this hospital are those who are the chiefs of department in their public hospital, have years of experience or have some unique skills, but, as in the US so far, no one has measured success rates, complication rates, or whether the patients fare any better than in public hospitals. By the way, this story is no different from that in US where specialists have gotten together to open specialty hospitals, again without any data that the outcomes are better. On the other hand, there is something to be said about the value of experience and respect of one’s peers.
The employed GPs are expected to see patients every 7-10 minutes or so. This high volume is not that different from the US, but many doctors (and patients) do not find this satisfying. I visited one practice that has developed an innovative approach that works well in part because of the nature of the HMO payment system.
The practice has 4 doctors and 2 sites. One is in an apartment building in a very nice neighborhood in North Tel Aviv. It reminded me of the doctors’ offices in Manhattan brownstones. There is a very small staff with the doctors having one exam room/office. The doctor, Galit, calls in her patients, talks with them at her desk where she has access to all of their electronic medical records. Galit alternately looks at the record and the patient with both being able to see the computer monitor. She highlights areas for the patient to see and points out changes in weight, cholesterol or other findings. She uses this approach both to confirm her recollection and to provide feedback and educational messages to the patient.
One patient came in with a contact dermatitis (skin irritation) from jewelry, a common problem anywhere in the world. The doctor had already treated the patient with steroids, but the rash was no better. With the patient looking on, Galit opened “Up to Date,” a reference tool used commonly in the US, to search for alternate treatments. She found stronger treatment options, then checked to see what was on the member formulary and sent the patient on her way with a recommendation to come back in a few days if it did not get better. Galit said she understood that doctors didn’t do this kind of real time research in the US. I explained that they do, but just not in the exam room with the patient. We still like the mystique of the expert professional.
This visit took 15 minutes so I asked how the practice manages to provide more time for each patient. Galit explained the doctors agreed that since the quality of their work was the most important factor to them, they decided to have 15 minute visits. They are able to do this since the HMO pays them a quarterly capitation (a monthly retainer) for every member they see that quarter. Rather than have patients come back for follow up that could be done in a more efficient way, the practice developed a website with educational materials about diet and common medical problems as well as the ability to communicate by email. Instead of follow up appointments to generate more revenue as would happen in the US where doctors are paid per visit, this practice uses email to communicate efficiently and open up more time for patients in the office. The practice is different in other socially conscious ways as well. They have a special clinic for children with persistent developmental disorders, provides care for patients with HIV, and volunteer at a free clinic for refugees.
The more things change, the more they stay the same
The Maccabi HMO recently started a new call center to help people with complex illnesses and with chronic illnesses. The doctors refer patients for evaluation and if they are accepted into the program, the health plan assigns a nurse who educates the member and family about their condition, coordinates with the treating physician, and helps the family get the services they need. They are focused on the frail elderly, people with asthma, diabetes, chronic obstructive lung disease (COPD – which, by the way in Hebrew is COPD), and heart failure. The program is only 4 months old and they have only a few thousand people so far, but they are very enthusiastic about the anecdotes they have so far. The challenges have been similar to those in the US, such as how to engage the physician and collaboratively plan care.
Programs like this have been used in the US for years. They are called disease management programs and there is a lot of good data about their performance. The data shows that while some programs, heart failure and care of the frail elderly, produce better outcomes at lower cost, the rest of the programs appear to do neither. I guess we are all destined to make our own mistakes.
Physician evaluation – challenges like the US and issues similar to education
Ada Beth and I have often talked about the challenges of evaluating professional performance. Both doctors and teachers practice alone, deal with widely varying groups of clients (students or patients) with cultural and socioeconomic challenges, language challenges, social supports, etc. What data should we use to evaluate doctor or teachers?
The Maccabi HMO (the second largest with about a quarter of the population) uses the medical record system to provide doctors with reports about their practice and compares them to their peers. Doctors can see how well their patients with diabetes are doing for example. So far, other than sharing the data there is no incentive to use the data but, anecdotally, the doctors who use the data are the higher performing doctors, the ones who need it the least. There has been talk about pay for performance – paying more to doctors who score better – but so far the issues of equity and measurement challenges have not been resolved. The debates are very similar to those regarding both teachers and doctors in the US.
The policy perspective
- The Israel health care system provides good access to care for everyone.
- Care in Israel is economical. In the US, the cost of care is currently at over 17% of GDP and over $8,500 per person per year according to the World Health Organization. Israel spends about 7.6% of GDP or $2100 per person.
- The quality of care judged by public health measures appears to be very good.
- There are concerns about rising cost, the evaluation of health care quality, and how to afford health care as the technology and capabilities continue to advance.
- There are variations in access and quality in ways that are similar to those in the US – the higher socioeconomic groups have better access. There may be a two tier system, but at least the lower tier has guaranteed affordable care, unlike in the US.
A personal perspective
I received the following in an email from one of the physician leaders I met. She sent it during the recent military hostilities with Hamas in Gaza, including rockets fired at Tel Aviv.
This morning, I am in my hospital “wearing two hats”. I am the senior ICU physician for the weekend, and am also the Chief medical officer.
Draw this picture in your mind: in our ICU there are twelve beds. 3 are occupied by orthodox Jews from Bnei Brak. 2 are occupied by Bedouins from the Negev, one is occupied by a patient from Ashkelon, one is occupied by a Palestinian from Gaza, 2 are occupied by Israeli Arabs from the area around us and one is occupied from someone from Tel Aviv…all together… in one ICU ward, in Israel.
I walked in to all the wards of the hospital this morning to make sure that all the staff and parents know exactly what they should do in case of a rocket alarm… Everyone is just the same as everyday… with sarcastic remarks, but still…knowing exactly that this is possible… even more than just possible… right now, right here… and it really does not matter who you are or where you come from…
Then I received a sad call from our Bone marrow transplant unit. They called to say that one of their patients, a 7 years old boy from Gaza, who has been hospitalized in our hospital for a long period of time and has undergone transplantation a while ago, is dying. They called me because the father, who is with him, is afraid that once the child will die, he will not be able to go back. And he wants to go back because he is really worried about his family and his children. So they wanted to see if there is any way to help him return to Gaza. I have some very good connections with the civil administration of the IDF as you know. So I am trying with them to find a way to do that.
Just as I am writing these words, I was told that he died and that we have arranged for the Erez crossing to be opened so the family can return to Gaza with their child for his funeral.
While the story is sad because of the death of a young child, it illustrates in so many ways the values of Israel’s healthcare system and the best of Israel. In Israel, everyone, really everyone, is entitled to decent and humane healthcare.