The passage of 20 years is a good time to take a look at how the medical system has changed since the National Health Insurance Law went into effect in 1995 and guaranteed universal health coverage under the guiding principles of equity, mutual aid and social justice.
So much has occurred since 1995 in Israeli demography, medical and information technology, epidemiology and standards of living, and some would argue that the government intentionally eroded the principles and the level of public funding for the health system. Others may contend that the health funds or citizens themselves should be given more responsibility for healthcare and preventing the onset of disease.
Specifically, one could ask whether these changing conditions require the need to reevaluate the distribution of responsibilities among medical institutions and stakeholders in the health system.
Thus an all-day conference on “Health and Healthcare – Who’s Responsible? The Role of Individuals, Providers and the State” was an appropriate venue for an assessment.
Held early this month at Jerusalem’s Menachem Begin Heritage Center, the conference was organized by the capital’s Taub Center for Social Policy Studies and attended by 120 experts.
The Taub Center
, a social-policy think tank originally funded by the American Jewish Joint Distribution Committee, now depends on private donations, and calls itself “completely independent and unbiased,” said its new director, Prof. Avi Weiss.
Up until the last few decades of the 20th century, contagious diseases were the main concern of the world’s health systems, he noted, but “today we are worried about chronic medical conditions, lifestyles, fitness, smoking and so on. The way markets are organized has changed, and the roles of the different partners in healthcare have too. People are expected to take care of themselves more than ever before. Twenty years ago, 68 percent of medical expenses were paid for by government, but today, the figure has dropped below 60%. In other Western countries, however, the state is taking a larger share.”
Today, governments are increasingly proactive, teaching people how not to get sick. When citizens are healthier, their care costs less. “In the Bloomberg rating of healthy countries, Singapore rated first, Australia third and Israel sixth.
According to Taub Center veteran health economics researcher Prof. Dov Chernichovsky, his first involvement in the subject was when Eliezer Shostak – the health minister from 1977 to 1984 – asked him for his ideas on health reform. “At the center, we study elderly health care, infrastructure, medical manpower, mental health reform, the health funds and the periphery versus the center. It is all forward thinking, said the Ben-Gurion University emeritus professor.
SHAARE ZEDEK Medical Center director-general (since 1988) Prof. Jonathan Halevy noted the significant changes in the healthcare system since he was chosen to head the Jerusalem hospital. “Universal coverage is something to be proud of, and the health basket provided to all residents is very important, despite its shortcomings. Israeli life expectancy is fourth in the world for men and 12th for women. The patients are empowered. When medical students ask me to recommend what specialty to study, I recommend geriatrics and oncology. The last two decades saw a lot of media exposure to medicine and a plethora of information, not all accurate, in the area of social medicine. People have much higher expectations that they can be successfully treated, and there are much better diagnostics. When I received my MD degree 42 years ago, the techniques for diagnosing gallstones produced 50% false positives and 50% false negatives. Soon, patients will be able to monitor conditions and even diagnose them with their smartphones,” said Halevy, who three times was voluntary chairman of the public committee recommending additions to he health basket and for six the chairman of Israel Transplant.
But electronic gadgets, he continued, are not enough. Doctors need to have compassion for their patients.
Hi-tech medicine must be complemented by compassionate care and empathy. “Sadly, I think that the patient-physician relationship [here and abroad] has not improved in the last 20 years. There are long waiting times for consultation and treatment. There is over-insurance; not only the basic basket but also health fund supplementary health insurance (held by 78% of the population) and private health insurance (held by 40%).”
Before all this medical technology was introduced, many x-rays were performed on parts of the body, said Halevy. Today, computerized tomography (CT) scans replace many of the x-rays. There used to be bleeding ulcers and lots of surgery to repair them, but today, with medications, it is very rare to see this kind of treatment.
In addition, he said, there are excellent, very advanced digital records in the community. And knowing how to type on their keyboards without looking, doctors are more able to look at their patients.
“Personalized medicine based on genetics is just starting, but it is the future of medicine. All drugs are not suited to everyone; not everyone reacts to them. There is fine-tuning of medicine, and it will take years to be perfected.”
The Shaare Zedek director said he was pleased when the four public health funds changed their names to “Health Services” and stopped calling themselves “sickness funds.”
Patients are going to community health fund clinics for most tests and many treatments instead of to hospitals, where pediatric departments are emptying out, said Halevy. “If things can be done without hospitalization, it is much better. If I were asked how to change things for 2025, I would add more intensive-care beds and make cardiology departments smaller, because many heart attacks can be prevented completely with lifestyle changes, medications, technology and quick treatment,” Halevy said.
Although the Health Ministry has for years had a rather “dusty” image, Halevy praised it for “carrying out improved regulation in the last decade. There is still a shortage of doctors, but by opening a new medical school (in Safed) and expanding the others, the problem is “progressing towards a swift and elegant solution.” Yet, he continued, there is “stagnation of financial resources to health services and no regulation of health insurance or of malpractice claims.”
PROF. HAIM Bitterman, the former chief physician of Clalit Health Services who has just been named director- general of the Ashdod Medical Center (a public hospital being built and to be run by the private Assuta Medical Centers) said that a quarter of Israelis aged 45 to 65 suffer from more than two chronic diseases.
Their care constitutes 60% of health costs in this age group; 20% of people over 65 suffer from five or more chronic diseases, and half of the costs in this age group is spent on them.
But horrendously expensive, chronic illness can be prevented, delayed or minimized, continued Bitterman. The responsibility is also on the individual.
Some argue that health insurers should lower their premiums for those who improve their lifestyles and lower their risk for chronic illness, while others argue that those who are sick should not be punished.
Either they were not educated in how to prevent chronic disease, or they were born or live in conditions that make it impossible. “People don’t have much influence and don’t control their lives because of the socioeconomic, cultural and environmental conditions. And genetics, what they inherited from their ancestors, partly determine what diseases they will suffer from.”
The state gets involved in the health of individuals. As it partially funds health services, it feels it has justification in intervening in vaccination, abortion practices, educational campaigns, food labeling, consumption of trans fats and other issues, said Bitterman.
The Internet has provided the public with much more access to health information, with forums and advocacy groups; it grows exponentially before our eyes. It is not only the rich and the young who use it for this purpose, but increasingly also the elderly, he continued. “Health organizations will be able to store information, and they must provide personalized services in health and illness.”
DR. NACHMAN Ash, the former chief medical officer (surgeon-general) of the IDF and now director of Maccabi Health Services’ health division, said that while the insurers try to educate members to promote diseases, it doesn’t always work.
“We have to invest more money on health promotion. Twenty percent of the public still smokes, and half of the population is overweight. Many don’t exercise or check stools for occult blood to detect colorectal cancer. Many don’t even take all of the medications they are prescribed and don’t go for flu shots. Too many who make appointments with physicians are no-shows.” Ash opposes the policy adopted in some countries abroad that those who abuse their bodies should not be given an organ transplant and refusing to treat children whose parents refuse to vaccinate against diseases.
National Insurance Institute director- general Prof. Shlomo Mor-Yosef agrees that patients with chronic illnesses should not be penalized or suffer sanctions, because many conditions that cause disease are not under their control. He urges larger government spending for the basket of health service and not putting the right to lifesaving drugs under supplementary health insurance policies.
HEALTHCARE SPENDING was not a big problem until the mid-1970s, said Prof. Larry Brown, an expert in health policy and management at Columbia University in New York.
“But costs became very salient. Providers are increasingly on the defensive against claims that they are throwing money away on things that are unjustified. Then there is generational change, a rise of consumerism, a distaste for bureaucracy, an aversion to control by the state, and regulation.
“Hospitals in Israel and the US are safer today than they have ever been, but we have so much more data on errors. And doctors don’t always wash their hands between patients. In large hospitals in New York, there is still talk about how to get medical staffers to wash their hands. It’s harder than it sounds.”
DR. BISHARA Bisharat, director of the English hospital in Nazareth, notes that in the Arab population, there is a great deal more to be done to prevent disease. Obesity and diabetes among Arab women are on the rise. Some 55% of them have a bodymass index of over 30 [and are thus obese]. In my hospital, there is more demand than ever for kidney dialysis resulting from renal failure that develops as a result of diabetes and obesity.”
But he has, through incentives, gotten most of his medical staff to get vaccinated against the flu. “Just changing their diets to whole-grain bread would change things by reducing weight gain and glucose levels,” said Bisharat. “The impact of doing this dietary change would be higher than getting three more funded beds in my hospital. Arab men get heart attacks a decade before Jews,” he added, conceding the fact that the smoking rate among the former is nearly 50%.
THE HEALTH Ministry’s new director- general – for the first time ever an economist rather than a physician – is Moshe Bar Siman Tov. His office is re-setting priorities. “We have to strengthen the base of the health system, which is very good, but the financial resources have been eroded.
Doctors’ and nurses’ salaries went up a lot, so the system is short NIS 1 million. We want to change the way the system is budgeted and introduce more transparency. We must also better integrate the digital revolution and put the patient in the center, recognized as a human being with family and feelings.”