The seriousness of the Health Ministry’s shortcomings in half-a-dozen fields
examined by the state comptroller is made clear by the fact that 280
Hebrew-language pages of the whole 800- page semi-annual report have been
devoted to it. The section is thus no compliment to Deputy Health Minister
Ya’acov Litzman (United Torah Judaism), who has been at its head for the last
three years, and indirectly to Prime Minister and formally Health Minister
Binyamin Netanyahu, not to mention some of its senior
Litzman has had three different directors-general in the
same number of years that he has run the ministry.
Never within memory
has a third of a state comptroller’s report been devoted to a single ministry’s
administrative failures. Lives have been endangered or shortened; quality of
life has declined among the bureaucratic victims; huge amounts of money have
been wasted and administrative rules broken, the comptroller clearly declares or
Running as a thread through much of the criticism is the fact
that for decades, the ministry has failed to persuade itself and the Treasury
that it cannot ethically or practically own and run state hospitals that it is
also responsible for supervising as a regulator.
Medical negligence by
professionals in the public and private hospitals and health fund clinics was
the first subject the comptroller handled.
He recommended that the whole
system of risk management, reporting to the authorities and to patients and
their families, insurance coverage in public and private institutions and
supervising needs to be completely reconsidered and reorganized. Failure to do
so could risk the stability of the health system as we know it, he
The cost of pending medical negligence cases against general,
psychiatric and geriatric hospitals, district health offices and ministry
headquarters totals NIS 3.2 billion.
This estimate does not include the
health funds and their hospitals, other hospitals owned by voluntary
organizations and private hospitals.
The public’s growing awareness of
the possibility of suing for what patients and their families believe are
medical errors and outright negligence, as well as eager handling of cases by
lawyers, have led to a seven percent increase in state payments for insurance in
the last five years alone. In the last six years, the comptroller wrote, average
payments to patients and their families due to lawsuits have risen by 260% in
the last six years, and insurance premiums paid by the employers skyrocketed by
30% between 2008 and 2010. The number of lawsuits rose between 2005 to 2011 by
The Health and Finance Ministries don’t even have up-to-date
statistics on the general cost of medical negligence insurance or estimates of
future costs, the comptroller wrote, adding that massive sums of money are spent
on legal expenses, with less going to patients and their families who were
genuinely harmed. The cost to the health system and the government of “defensive
medicine” in which doctors try to protect themselves from lawsuits by ordering
unnecessary tests, is also astronomical.
The fact that the insurance
market in this field is controlled by Harel Insurance and its agent (the Madanes
company) and that few subcontracting insurance companies abroad have been found
to share the risk has also hiked premiums tremendously, the comptroller
Obstetricians in hospitals, clinics and Tipat Halav family health
centers are among the most-sued medical professionals, and “defective children”
whose congenital problems were not detected in the uterus can sue as much as 25
years after their births; this liability period should be shortened, he said.
Other high-risk specialties are orthopedic surgery and neurosurgery and those
who privately perform esthetic plastic surgery.
insurance, the comptroller continued, may encourage doctors to be less careful,
as their hospitals, clinics and other employers pay the premiums.
addition, the comptroller wrote time after time that because doctors at public
institutions who do private work have their malpractice insurance paid for by
the public purse -- which is a heavy burden on public hospitals and heath funds
that employ them for their “day jobs.”
Numerous committees have discussed
these subjects and made recommendations, but the government has never managed to
cope with the complicated issue.
Young physicians and those living in the
periphery of the country who work for public medical institutions and do not
“freelance” (or have the opportunity to do so) in private hospitals “subsidize
part of the cost of insurance policies who do private work,” said the
comptroller. “This is problematic and creates distortions in the health
As some of the riskiest professions are not required to have
insurance to cover malpractice and premiums through the “monopolistic” insurers,
hospitals and health funds have set up independent “self-insurance” funds to
cover lawsuits, but the Health Ministry did not set up guidelines or require
supervision of these to ensure that patients and families are legitimately
compensated for damage to health.
As medical staffers do not want to be
labelled as chronically prone to accidents and outright malpractice, they are
reluctant to report cases in which patients were hurt, and many families are not
provided with swift and accurate medical records to prove their cases, the
The medical institutions have not been required to run
effective risk-management and error-prevention departments.
fails to provide “knowledge management” to share information about medical
errors among the various institutions despite a large amount of know-how in the
field, the comptroller wrote.
He recommended that the government adopt a
no-fault system that would encourage medical professionals to report errors and
to consider the possibility of requiring all medical institutions to have
insurance as a condition for being licensed.
As a large amount of time
generally passes between the medical incident and investigations, the ministry
must set time limits and appoint objective experts to make recommendations as
soon as possible. All institutions must quickly report all details to
patients/families that a medical error took place, the comptroller
In addition, he said, legislation or directives are needed
to set down the authority of the Health Ministry’s ombudsman, who deals with
complaints. More must be done to prevent medical errors, he
REHABILITATION OF GERIATRIC PATIENTS
An elderly patient who
suffers a stroke or fractures his hip can usually improve his functioning and
raise his quality of life if he undergoes physiotherapy and other medical
rehabilitation as soon as possible. If there is a delay, or the patient is sent
to an unsuitable facility or does not get any such treatment at all, he or she
is likely to further decline, require geriatric nursing care in an institution,
suffer a serious decline in quality of life and even have a shorter life
expectancy. But there is also a serious shortage in the number of
physiotherapists and others who perform rehabilitation.
All of this means
not only human suffering but – as the population continues to age – major losses
to the economy as well. Ironically, the lack of suitable facilities is due to
the government desire to “save” money.
Yet the comptroller found that the
Health Ministry is sorely lacking in supplying such services at a high level or
at all, even though residents are entitled to them as part of the basket of
The number of general and geriatric rehabilitation beds
and of hospitalization days in such institutions has declined seriously in the
last decade, with average occupancy at over 105%. Some parts of the country have
an adequate number of beds, while others – especially the north (one geriatric
rehab bed per 3,200 elderly) and the Jerusalem area (one bed per 1,268) – have
too few. The national average is one per 486, the comptroller wrote.
result, many patients needing rehabilitation remain too long in general
hospitals‚ internal medicine departments, making them even more crowded. He also
found that they are also hospitalized in departments and institutions that are
not licensed for geriatric rehabilitation.
As the Health Ministry owns
geriatric hospitals, it has a conflict of interest in that there are private
institutions that compete with them; the comptroller found that despite serious
crowding in state-owned institutions, the ministry allowed the the number of
licensed beds in private facilities to decline, he continued.
disabled elderly needing rehabilitation usually need transportation to get
outpatient care, they should be reimbursed for this, but the ministry does
require the health funds to do so; only Maccabi Health Services does it
voluntarily. In addition, the ministry did not set standards and measurements to
determine whether the patient’s condition was improved by therapy he did
receive. Many rehab departments were not required to function in the afternoon,
when family members are free from work to help get them there; there is no care
on Fridays or eves of holidays.
The comptroller noted that the
possibility of using telemedicine to encourage patients in the periphery to do
exercises themselves under professional supervision and assessment from afar has
been totally ignored by the ministry.
As the share of the elderly in the
population is expected to double by 2030, the comptroller urged the
establishment of a professional team to examine ways to expand the number of
rehabilitation beds significantly. The ministry’s conflict of interest between
owning state institutions and regulating and supervising them –and of giving
preference to their own facilities at the expense of private ones – must be
resolved, he continued. The comptroller recommended that in view of the “serious
shortcomings” in the ministry’s handling of this key field, the establishment of
a separate and independent new unit or branch that would deal exclusively with
rehabilitation policy and implementation around the country.
DIALYSIS AND ORGAN TRANSPLANTS
Among 21 Western countries, Israel has the
highest mortality rate for kidney-failure patients who are undergoing dialysis.
Between 1990 and 2011, the number of patients requiring the mechanical filtering
of their blood by dialysis has risen from 1,590 to 5,500. But the comptroller
found that the ministry has failed to promote prevention of the condition
(partially by heading off diabetes), early diagnosis of kidney problems and the
proper supply of the treatment.
There is a severe shortage of
nephrologists (kidney specialists) – of the 171 in the specialty, 30 are
retired, 44 are 60 years old or more and only 18 younger than 40. Who will treat
the patients of the future without incentives for doctors to go into the
specialty? A number of public hospital nephrologists were also allowed to work
at up to three nephrology clinics in the community – some located at some
distance from one another – without receiving ministry approval for
This means a nephrology specialist is absent from the hospital
facility while patients undergo dialysis even though regulations require one to
In addition, although a significant number of kidney patients
could undergo peritoneal dialysis (through the abdomen) at home – reducing the
burden on public and private clinics and minimizing costs – the number of such
patients has dropped significantly, reducing their quality of life. The ministry
did not even investigate why this has happened, he wrote.
also has not required the health funds to assess the quality of their work
according to patient outcomes.
As for organ transplantation, even though
the ministry’s Israel Transplant coordinating center has increased the number of
potential organ donors by various innovative ideas and programs, the comptroller
said that not enough is being done to save lives. In January 2011, some 1,150
Israelis were waiting for organs, and by the end of the year, 105 of them died
without getting one.
There were dozens of cases in which nephrology units
and dialysis clinics failed to send blood samples, as required, from their
patients to determine whether they are suitable for a transplant if a donor
kidney was received.
Instead, dialysis patients themselves had to arrange
for the blood test. As a result, at least some of the patients did not undergo a
transplant even though an organ was available. Abroad, there are advanced tests
to suit donor kidneys to patients who have high levels of antibodies so their
bodies do not reject the organs, but these sophisticated tests are not available
here, the comptroller wrote.
While there still are countries willing to
accept foreigners for organ transplants that do not deal with the illegal
removal of organs, the ministry has not looked into the possibility of taking
advantage of such supplies and services, even though more Israeli lives could be
saved by legal transplants abroad paid for by Israeli health funds.
comptroller also protested against the fact that the ministry has not issued
regulations that would as an incentive exempt live kidney donors from paying
health taxes, even though it was decided back in January 2010.
Transplant’s ADI database contains a list of 400,000 Israelis willing to become
organ donors after they die. That should be enough for a hospital to remove the
organ when needed to save a life. But the comptroller noted that Israel
Transplant usually allows close relatives to veto the taking of an organ even in
the case of a ADI member. He suggests that this policy be reassessed so that any
card-holder’s commitment actually be carried out.
disapproved of the initiative by a number of modern Orthodox rabbis (the
majority of haredi rabbis are opposed to recognize lower-brain death for taking
organs) who set up an “alternative” organization (called Bilvavi) of Jewish
They were assembled to ensure for member families that the
potential donor indeed suffered lower-brain death. The comptroller opined the
this organization was unnecessary, as families can already – by checking a
square on the ADI card – stipulate that the clergyman of their choice can do
MISMANAGEMENT AND LACK OF SUPERVISION AT MAGEN DAVID ADOM
nationwide ambulance, first-aid and blood supply organization Magen David Adom
was established here in 1930. More recently, it lost much of its independence:
It is supervised by the Health Ministry and required to observe regulations,
some of which prevent it from giving services without collecting fees from those
it serves. A whole list of positions and official bodies was set down, from the
president appointed by the president of Israel for three years to the national
convention to the council and the actions committee and its various
The government is supposed to have representatives on
these bodies to help supervise them.
The last two were charged with
supervising the daily activities of MDA, whose director-general since 2005 is
Eli Bin and whose chairman of the actions committee, Dr.
Noam Yifrah, was
appointed in 2004. A control committee met only once in 2008/2009; at other
times, only a small number of members were present. Too often, MDA institutions
supervised themselves, the comptroller reported.
The comptroller stated
that actual supervision of these MDA officials and institutions is highly
inadequate due to the lack of professional appointments and followup.
noted that the tenure of senior officials has not been limited.
liable to bring about the accumulation of too much power in their hands and
prevention of monitoring and renewal in the organization,” he wrote. MDA
president Yehuda Skornik “could be faulted for not succeeding in getting the
council to discuss changes in the rules that the committee
There are a number of first-aid and rescue organizations
that are purely voluntary and do not charge for the services, the comptroller
said. But while ongoing disputes among them over “territory” have caused
disruptions, the ministry has not managed to resolve the the disagreement and
set down who does what.
MOONLIGHTING BY HOSPITAL DIRECTORS
directors-general of state-owned medical centers make excellent salaries, some
of them “moonlight” as advisers, members of boards of directors and even board
chairmen in private companies to earn more. The comptroller focuses on two
veteran administrators – Sheba Medical Center at Tel Hashomer’s Prof. Zev
Rotstein and Tel Aviv Sourasky Medical Center’s Prof. Gabi Barbash.
follow-up to a previous report, the comptroller wrote that Rotstein worked in
five other positions at “eight hours a week for a total additional salary of NIS
20,000 a month. Rotstein had written in a ministry form that he was giving
“medical advice” to four companies without detailed, as required, exactly what
was the nature of his work, the amount of hours and what he earned at each of
In 2009, the ministry and the Civil Service Commission approved his
request for a five-year arrangement.
Since he put all four companies on a
single form, there was not enough detail to know exactly what Rotstein was doing
and whether his moonlighting work constituted a conflict of interest between
this and his “day job” at Sheba -- the largest public hospital in the country,
according to the comptroller.
Sourasky is a large and prestigious
state-municipal hospital in Tel Aviv. Barbash, who was at one time
director-general of the Health Ministry, performed work at six other jobs, four
of them as a board member in three private companies that develop medical
equipment and drugs and a fifth doing academic teaching (but he resigned from
this last November). Besides that, he was an adviser to a private company that
produces soft drinks. The comptroller said Barbash did not receive authorization
to work at one of the biotech companies.
In one form, Barbash wrote that
the three biotech companies that paid him had business and research connections
with Sourasky but stated he did not make decisions there on the hospital’s
purchase of goods from the three companies. But Barbash noted that in the
future, there could be a connection between his work as a company director and
his position at Sourasky. The ministry/Civil Service Commission committee should
not have been depending only on Barbash’s written statement but instead should
have studied in detail his outside work and whether they conflicted with his
hospital work, said the comptroller.
In 2007, the Tel Aviv Municipality
allowed Barbash to be chairman of the board – a much more influential position –
of a subsidiary of one of the biotech companies, even though he was permitted to
be only a board member and had promised to update the authorities if his work
The comptroller said the ministry had not set down
uniform criteria for senior government health officials to do private work. The
comptroller said that public hospital directors should be allowed to teach
part-time in medical and nursing schools, but the authorities should consider
barring them from moonlighting for private companies so that they could devote
most of their time to the hospital, their main job.
could be signed to raise their salaries so they could give up external and
perhaps conflicting employment, he added.
Asked to comment to The
Jerusalem Post, Barbash said: “The problem is not with the salary, which is OK,
but with the pension. We did negotiate with the Treasury wage chief to change
our employment agreement to increase the retirement salary and give up all
external work. but he did not want to change it.”
Barbash maintained that
even though other state hospital directors moonlight, the report focused on him
and Rotstein. “We are more interesting.”
As for his advice to the
soft drink company, Barbash explained that he was “advising them on employees‚
health issues, not on manufacturing, and by the way, they do a lot to change
toward healthier drinks.
There is a need to set reasonable suitable
salaries to hospital CEOs with [fair] retirement payments so that they can be
asked to devote all their time to running their medical centers.”
To defend itself from criticism, the ministry sent health
reporters a 1,420-word Hebrew document giving a list of dry, technical
responses, such as “We have set up a committee,” to only some of the
shortcomings raised in the report, and numerous important issues were ignored.
Numerous important issues were glossed over; for example, the MDA section of 54
pages rated only three sentences from the ministry.
On other issues, the
ministry passed the buck to other authorities.
The ministry refused to
orally provide the Post with a detailed overview on why it had earned such a
huge chunk of criticism in the report and hinted that it is run better than had