Alex is spending the month in Tel Aviv as an International Fellow at the Gertner Health Policy Institute. Over his next few columns he will share his adventures in Israel with us.
In addition to caring for Israelis in several diverse clinical settings and traveling throughout the region, during my month long fellowship in Israel I have had the privilege and honor of working with Israeli leaders in medicine and public health.
During my first week, I spent an afternoon meeting with Dr. Tami Shochat, the director of the Israeli Centers for Disease Control. It was an honor to meet the women who leads this prestigious and important agency in Israel. Like her colleague at our CDC, Dr. Thomas Friedman, Dr. Shochat is charged with setting the vision for prevention and disease management in Israel. We discussed a number of her efforts, many of which centered around initiatives to collect population data on Israeli health.
Another leader who I met with was Dr. Ehud Davidson, Deputy Director General & Head of the Hospital Division at Clalit. Clalit is Israel’s biggest health services provider and largest health insurer. For the last century, Clalit has provided care throughout Israel and now runs the largest network of hospitals in Israel.
During my conversations with Drs Shochat, Davidson and countless other clinicians and policy experts in Israel several interesting distinctions and features of the Israeli health system have come to light.
Health Care Delivery in Israel
In Israel health insurance is universal and provided for all by the government. Through an approximately 5% tax on income, every citizen gets health insurance. Since the 1995 National Health insurance Law, all Israeli citizens must then sign up with one of Israeli’s four HMOs (of which Clalit is the largest at 54% of all Israelis). The HMOs pay physicians directly and in the case of Clalit, also own hospitals.
The Israeli government updates yearly its list of uniform benefits that are provided under the HMO. No citizen can be denied these services or membership in any of the HMOs, regardless of race, age, gender, or level of health. Israeli’s can purchase (70% do) supplementary insurance on top of their mandated plan that will allow them to see any doctor they wish and have additional available procedures and treatments beyond the uniform benefits.
One of the benefits of the universal health care system and the national pride in having large families is a generous infertility treatment benefit. This is manifest in payments for in-vitro fertilization (IVF) for all women for up to two offspring. This would be unheard of in the U.S. where each cycle of IVF can cost in the thousands and is rarely covered by insurance.
Challenges in the Israeli System
Several challenges exist in Israel in the coming years.
First, the population is getting older. After the atrocities of the Holocaust in the mid 1940’s Jews fled to Israel seeking freedom and opportunity. Soon afterwards they began having children and this group of ‘baby-boomers’ is now hitting the age of retirement. As the population ages these next few years and this large group retires and becomes sicker there will be a decrease in the proportion of Israelis paying into the program compared to those using services at a higher rate. This will create a financial challenge. Israel uses 8% of its GDP on healthcare (compared to 18% in the US). This rate, while very low, will likely change in the coming years as the population ages
The second issue facing Israel is providing effective care to the Arab and rural population. Due to consanguinity (relations between blood relatives), a high proportion of Israeli Arabs have genetic illnesses. These folks are sicker because of it and thus have a higher usage rate of health services.
A third health care issue in Israel is the capitation fee model. Clalit and the other 3 HMOs in Israel receive a capitation sum for each enrollee. A capitation fee is a fixed sum of money available to pay for health services for an individual. In the US and worldwide, the capitation model has been tried with some success. The model often puts the onus of cost control on the HMO (and thus the physician). For every dollar the HMO spends below the capitation sum, they can save and profit from the surplus. In Israel the capitation is age adjusted to provide larger sums for older patients who will utilize a greater amount of health services, but only recently has the government provided additional sums per year for certain patients who have certain illnesses that require additional health care utilization. The Israeli health ministry will be working hard over the next few years to refine this list and ensure an appropriate model for health care funding.
A fourth issue for the Israeli health system is electronic health records and quality. In the US we have created several quality measures under the ACA (Obamacare), including bonus payments for providers meeting diabetes health indicators. We have developed the Patient Centered Medical Home (PCMH) which allows for increased patient access with web portals to view test results and communicate directly with their doctor, greater drug adherence by allowing physicians to prescribe electronically and monitor prescription fill rates, and improved quality by allowing the creation of groups of patients with the same illness who can be monitored for meeting standard care measures. The U.S. has also moved to the electronic medical record (EMR). New initiatives in Israel encourage EMRs.
A fifth issue in Israel stems directly from the ageing population; a physician shortage. As the population ages more doctors are needed. In response Israel has opened a fifth medical school and is increasing the enrollment of the other four. Despite these efforts, there will be a 10 year gap while the training occurs where Israel will have a great need for physicians. Clalit and the other HMOs are trying innovative strategies to lure doctors to their facilities (Israeli doctors are notoriously underpaid). This will be an emerging issue for Israel over the next decade.
Alex Berger, a new GTJ contributing columnist, is a native of the Washington DC Metropolitan Area. He graduated in 2008 from the University of North Carolina and is currently in his last year of a combined MD/MPH program. He is excited to be back in the DC area and to share tips on nutrition, health, and fitness. He can be reached at Alexander_Berger@med.unc.edu.