Health policy researchers pursue objective data to present to decision makers so they can make beneficial changes in healthcare decisions.
But health ministers and administrators in government bodies, health funds, hospitals and other institutions have additional considerations – such as politics, financial limitations and lobbyists. The two groups need each other, but they don’t always consult enough with each other or reach the same conclusions.
“Politics is so messy. There is evidence- based medicine, but there should be evidence-informed policy,” said Dr. Moriah Ellen, a senior lecturer at the Jerusalem College of Technology’s Machon Tal, an assistant professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto and an investigator at McMaster University in Canada.
Ellen, who was interviewed by The Jerusalem Post, has consulted for the Ontario Ministry of Health and Long-term Care, the World Health Organization (WHO) and other local and international institutions and worked at Israel’s Gertner Institute for Epidemiology and Health Policy Research . Other well-known Israeli health policy research centers include the Myers-JDC-Brookdale Institute, National Institute for Health Policy Research and the Taub Center for Social Policy Studies.
With a master’s of business administration degree in health services management and a doctorate from the University of Toronto, Ellen’s main research interests are knowledge translation, health policy and systems, aging and health and coping with waste and the use of unnecessary services within health care. “There have to be policies based on evidence, but there are so many interests. Policy makers should take all this into account,” said Ellen.
SHE AND her Cleveland-raised husband, who has a master’s degree in business administration and works in Internet marketing, came on aliya in 2008 from Toronto.
They have five children aged eight (twins) to 15 and live in Beit Shemesh. Ellen teaches research seminars that focus on health system and policy issues to religious women in Machon Tal’s nursing school and organizational behavior, management and leadership to ultra-Orthodox women in its business school.
“I feel I am really contributing,” she said. “The idea is not just to publish research, but also to make a difference to the country’s health.”
She was living in Israel when the WHO asked her to do a project as a consultant on midwifery and a different project on aging to help policy makers make decisions on these subjects. “I wrote a technical report of 70 or 80 pages for one and a 20-page report for World Health Day as well.”
Although she always wanted to be a physician “in theory, but I didn’t like blood and opening veins. So I did a MBA in health management. I go to a lot of health conferences. I even went to see videos of heart surgery instead of going to lunch. But I would still do research professionally,” said Ellen.
Impressed with the Canadian system, she is complimentary about Israel’s as well.
“We have an incredible health care system, with excellent electronic medical records, infrastructure, community health clinics and more. Israeli doctors are very good at trying new things. We are very advanced and efficient, and when judged by OECD indicators, we are doing well. But we can always improve, as can the Canadian system.”
Concerned about overuse of some medical services in both countries, she was involved in a Canadian project called “Choosing Wisely,” which has aroused much interest among Israeli doctors and medical administrators.
“When I was in Toronto, we had a dialogue with 22 key stakeholders across Canada on overuse, and it was argued again and again that politicians have to have the will to address problems. The Israel Medical Association has already had a second meeting just a few weeks ago about it, and no country has hit the ground on this and run so fast,” said Ellen. “Other countries can learn from Israel on its speediness to adopt new ideas.”
Some medical tests, treatments and procedures provide minimal benefits to patients but, in some cases, they may even be harmful.
The project encourages all patients to ask their doctors or other healthcare providers five questions when consulting with them and aims to promote conversations between clinicians and patients by helping patients choose care that is: supported by evidence; not duplicative of other tests or procedures already received; free from harm to patients and truly necessary. “There are places in Canada where a sign with all the questions is posted behind the doctor’s back so all who come can read them,” Ellen said.
THE MAIN questions and possible additional ones or short answers are:
• Do I really need this test or procedure? Tests may help you and your doctor or other healthcare provider determine the problem. Procedures may help to treat it.
• What are the risks? Will there be side effects? What are the chances of getting results that aren’t accurate? Could that lead to more testing or another procedure?
• Are there simpler, safer options? Sometimes all you need to do is make lifestyle changes, such as eating healthier foods or exercising more.
• What happens if I don’t do anything? Ask if your condition might get worse – or better – if you don’t have the test or procedure right away.
• What are the costs? Costs can be financial, emotional or a cost of your time. Where there is a cost to the community, is the cost reasonable or is there a cheaper alternative? She pointed the overuse of antibiotics, especially when patients come with a viral cold and demand getting antibiotic pills that are useless against it.
“There are still some physicians who don’t know they should not be giving them. One push has to come from the public, and the media can help with that, as it’s a public problem that has to be more widely known. It’s an international problem, as overuse of antibiotics causes resistance by bacteria, which results in many of the pills becoming ineffective in fighting disease. The drug companies don’t invest in developing new antibiotics because they wouldn’t be profitable enough; they prefer to make new medications for chronic diseases.”
Ellen added that in many south African countries, patients don’t have to get a prescription for antibiotics, but just go to a pharmacy.
“But that affects all of us, even those who live far away. You need antibiotics for specific conditions, and they should be used sparingly.”
AT MACHON Tal, she has two research groups, one group of students examining the perceptions of the public and the other the perceptions of nurses on antibiotics resistance. “Nurses are champions for infection prevention.”
Overtesting for certain conditions such as prostate-specific antigens for prostate cancer and other things is also harmful, she said.
In many cases, there is too much testing, because doctors fear malpractice suits and don’t feel protected from them, she explained.
But there is underuse as well. For example, she strongly encourages people of all ages and health status to get a flu shot every year; this has been clearly proven effective in research. She thinks all physicians and nurses in direct contact with patients, especially in hospitals, should be required to get the shots to protect patients as well as themselves.
Ellen has also researched the benefits of day centers for elderly, especially for dementia, as in Melabev institutions, but not only them.
“Those who don’t or can’t attend centers are more likely to suffer from social isolation. This is a huge problem in old people. They also have to be counseled on how to avoid falls, avoid taking superfluous medications (which is known as polypharmacy) and preventing cognitive decline.”
She bemoaned the fact that while abroad, the health portfolio is fought over, but in Israel, it seems that no one except the current holder, Health Minister Ya’acov Litzman, really wanted it. The ministry deals with life-and-death issues.”
THERE HAS been only one physician among the more than two-dozen health ministers in Israel – Dr. Ephraim Sneh, who was not considered a great success by people in the ministry. In Canada, federal and provincial leaders in health are not always doctors.
The Israel Medical Association made a big fuss nearly two years ago when Litzman appointed, for the first time, a Treasury economist – Moshe Bar Siman Tov – as director- general. Since then, he has been accepted and even highly respected.
“You can be a good physician and not a good hospital administrator, and a good hospital administrator without being a physician,” Ellen stated.
“A person with the best skills to be a leader and a decision maker should head the ministry and hospitals.
If a clinician is very good at administration, then it would be fine. There are some physicians running hospitals who haven’t practiced medicine for decades. A top administrator must have the most applicable skills.”
On the issue of how to expand the basket of health services provided by the health funds – which was static for around a decade at NIS 300 million but just for 2017 was raised to nearly NIS 500 million, Ellen does not insist on an automatic 2% update. “We are good deciding what to add, but I’m not sure we are good at removing outdated medical technologies.”
THE RELATIONSHIPS between health policy researchers and policymakers here is, she believes, very strong. In other countries, the gap is wider,” she insisted. “But other countries have found ways to bridge the gaps. Here, there are not huge gaps, but the problem is that the research being conducted in institutions is not necessarily relevant.”
She pointed out that in Canada, it is required that proposals regarding health policy research be the result of consultation and partnership between the two sides. They always check with them.”
She recalled that she and colleagues in Canada once did a two-week in-depth study of what works in supportive housing for the mentally ill.
“What could be achieved by politicians and state agencies was kept, but what was unrealistic was shelved.”
She concluded: “I am a health policy researcher and here to support decision makers in an unbiased manner. In some issues, they look at scientific evidence, but in some others, they can do better. When they go to medical conferences, some senior decision makers just give a speech and leave. It would be better for them to remain and share information, as decision makers and academics don’t really mix at conferences, and both sides lose out. Linkage and exchange don’t need to happen only at conferences; they can happen in other forums as well and many times. Those other forums are more productive. We need to determine what works best for Israel and build on that.”