What health systems can learn from each other

Dr. Dan Merenstein conducts study of how doctors paid, whether approach could reduce superfluous medical testing in US.

By JUDY SIEGEL-ITZKOVICH
DAN MERENSTEIN 311 (photo credit: Judy Siegel-Itzkovich)
DAN MERENSTEIN 311
(photo credit: Judy Siegel-Itzkovich)
Who would have dreamed a decade ago that Israel’s shekel would be one of the world’s most stable currencies – and that the US State Department would send a Fulbright scholar to examine aspects of our health system as a possible model? But both of these are true.
Dr. Dan Merenstein, an associate professor and chief of research at the department of family medicine at Georgetown University in Washington, has just spent some four months in at Hadassah-University Medical School in Jerusalem to study our system for reimbursing doctors and compare it to that in the US.
Making the acquaintance of Dr. Amnon Lahad – head of the department of family medicine at the Hebrew University Medical Faculty and a staff member at the Hadassah Braun School of Public Health and Community Medicine – at a medical conference, he later asked him to be his sponsor, mentor and host during his Fulbright research study here. As Lahad also works in family medicine in the central district for Clalit Health Services, his guidance helped Merenstein immeasurably. The research, whose findings will become available next year, specifically compares the “bundling” system of payment for medical tests compared to the fee-for-service system used in the US.
“Over-testing in the US is believed to be a result of defensive medicine triggered by malpractice lawsuits and physician reimbursement schedules with fee-for-service leading to improper incentives for ordering tests,” Merenstein said in an interview with The Jerusalem Post not long before his scheduled return to Washington. The physician says results from his study could help inform American public policy and lead to changes.
He said that combining overtesting that doesn’t improve health outcomes with a feefor- service health system is an untenable model that should be examined as the American healthcare system undergoes significant changes.
Merenstein speaks basic Hebrew that he learned in elementary school as a child, and practiced during six months he spent at a kibbutz after high school. He attends a Conservative synagogue with his family. He graduated from Brandeis University and Jefferson Medical College, and completed his residency at Fairfax Family Practice in Virginia where he was chief resident. Prior to coming to Georgetown in 2005, he spent three years in private practice followed by two years at Johns Hopkins University as a clinical research scholar.
In addition to seeing patients once a week and teaching medical students and undergraduates in the US, he has much research experience. He conducts evidence-based clinical trials on a variety of subjects including respiratory infections and functional foods such a probiotic yogurt. Recently he was the primary investigator on an US National Institutes of Health planning grant for examining the role of antibiotics and steroids in treating acute sinusitis.
Merenstein, on faculty in the human science department at Georgetown’s school of nursing and health studies, came to Israel with his schoolteacher wife (who studied for a year at Bar-Ilan University) and four sons aged two, five, eight and 11. The boyishlooking doctor and medical researcher charmed the scores of leading Israeli medical professionals he was introduced to, and who he even interviewed, around the country. He met heads of the health funds, senior physicians at the Hadassah University Medical Center and the medical school and visited BIU’s new Galilee Medical Faculty in Safed, among others.
“Dan is wonderful,” said Lahad.
Many doctors he met here already knew of him before being introduced to him: An article he wrote, published in the Journal of the American Medical Association (JAMA) in 2004, about a traumatic experience he went through has been part of fifth-year medical school curriculums since then.
In a JAMA’s “A Piece of My Mind” column entitled “Winners and Losers,” Merenstein recalled a middle-aged, highly educated patient he encountered during the third year of his residency in 1999. He conducted a physical exam and discussed the importance of colon cancer screening, seatbelts, dental care, exercise, improved diet and the use of sunscreen. He also presented the risks and benefits of screening for prostate cancer and documented the discussion.
“I never saw the patient again, and after I graduated, he went to another office. His new doctor ordered prostate-specific antigen [PSA] testing without discussing the risks and benefits of screening with him. Unfortunately for this patient, his PSA level was very high, and he was subsequently diagnosed with incurable advanced prostate cancer.”
Nothing could have been done at this advanced stage, and it is difficult to treat at any stage, wrote Merenstein.
“The literature does not support that early detection would have changed his outcome, although society and many physicians do believe so, thus making the patient live with the false belief that if something had been done differently, he would have survived longer.”
But in June 2002, both his hospital department and Merenstein were served with court papers for alleged negligence for not insisting that the patient be screened for PSA, and the case went to trial a year later.
“As the trial progressed, we presented national experts who discussed the controversy surrounding prostate cancer screening and explained some of the potential dangers of PSA... such as false positives, indolent vs aggressive cancers, sensitivity and specificity.
Our experts explained that because of the questionable benefits vs associated risks of PSA screening, a shared decision by the physician and the patient was recommended by all of the national health associations.
The science was clearly in our favor.”
During the closing arguments of the trial, the plaintiff’s lawyer “put evidence-based medicine on trial. He threw EBM around like a dirty word... He defined EBM as a cost-saving method. He urged the jury to return a verdict to teach residencies not to send any more residents [out] on the street believing in EBS.”
On June 30, 2003, seven days after the trial began, Merenstein was exonerated, but his hospital department was found liable for $1 million and fined.
“Dan acted correctly,” said Lahad. “But the court ruled that according to common practice, PSA screening should have been carried out. In Israel, such a court case would not have occurred, but in Virginia – before a jury of ordinary citizens – it did.”
Meanwhile, researchers at Johns Hopkins this month reported that routine MRI imaging “does nothing to improve the treatment of patients who need injections of steroids into their spinal columns to relieve pain.”
Moreover, they found that the imaging devices play only a small role in a doctor’s decision to give these epidural steroid injections, the most common procedure performed at pain clinics in the US.
The findings, which just appeared online in the Archives of Internal Medicine, highlight the indiscriminate use of an expensive imaging tool that shows little clinical benefit.
“Our results suggest that MRI is unlikely to avert a procedure, diminish complications or improve outcomes,” says study leader Dr.
Steven Cohen. “Considering how frequently these epidural injections are performed, not routinely ordering an MRI before giving one may save significant time and resources.”
A single MRI costs about $1,500 in American hospitals.
“Overtesting in the US is believed to be a result of defensive medicine triggered by malpractice lawsuits and physician reimbursement schedules,” Merenstein said in Jerusalem, “with fee-for-service leading to improper incentives for ordering tests.”
The US healthcare system is in big trouble and facing bankruptcy, he said in the interview.
“Americans don’t want any government to be involved, but it will have to get involved eventually because the country just can’t afford it,” said the Georgetown researcher, one of nearly a dozen annual Fulbright scholars in Israel, some students and a smaller number faculty.
“We had to write in our applications what we wanted to do for our research and why.
There is no question that doctors in America order too many medical tests, both to protect themselves from lawsuits but also because they are paid fees for every service they give. But in Israel, there is the bundling system, in which health fund doctors are paid the same amount per patient no matter what they do for the patient. They have no incentive to order unnecessary tests,” Merenstein said.
Doctors working for the health funds earn more if more patients come to them for care.
“Clalit general practitioners and family physicians generally get paid the same per patient; at Maccabi Health Services, there is a small element of fee for service. Israelis usually undergo simple urine and blood tests, while in the US, there are complete physicals,” said the US physician. “I want to understand the system better, but in Israel, patients usually come to say they feel ill and want medications. Even here, there are more tests than necessary, but in the US, it is much worse. Testing there is part of the culture.”
But he thinks it would be more economically beneficial if more Israeli physicians had X-ray equipment and electrocardiogram equipment in their offices rather than requiring patients to go to a health fund installation or elsewhere for these. He thought it was a mistake that Israeli women have to go to gynecologists to get a Pap smear done for early detection of cervical cancer.
“And I recommend more evidence-based testing,” he added. “The Republicans despise Obamacare, the reforms presented by President Barack Obama that he has had great difficulty implementing; they say they will abandon it completely if a GOP president is elected. But that’s easier [said] than done.
Something serious must be done to reform the US system, because the country can’t afford to go on like this.
“Israel has a great health system, with its national health insurance and accessible care; In the US, there are almost 40 million people without health insurance, and they seek treatment when they are sick and desperate.”
Merenstein was also very impressed by the massive computerization of medical files here.
The relative share of the GDP that healthcare gets in the US nevertheless is almost twice that in Israel even though is population is not healthier, concludes Lahad.
“And our computerized records are outstanding.
This is because it’s a much smaller country, but mostly because our computer experts are excellent. Dan certainly couldn’t see such a huge amount of digital medical data anywhere in the US, such accessible medical records, which reduce overtesting and waste.”