Under the National Health Insurance Law, the health funds are obligated to treat their members' medical conditions - but not to prevent them from getting ill or screen them for early signs of disease. Yet insurers have gradually realized that prevention and early detection pay for themselves, as treating a serious chronic disease or complications of acute ones is much more expensive.
Thus the four health funds - Clalit Health Services, Maccabi Health Services, Kupat Holim Meuhedet and Kupat Holim Leumit - did not have to be dragged kicking and screaming when the Health Ministry announced in March 2004 a permanent national project to compare their performances in reducing and preventing disease. Called by then-minister Dan Naveh "the most important reform in the health system in the past decade," it began as a research study by Prof. Avi Porath at Ben-Gurion University of the Negev in Beersheba and was funded by the National Institute for Health Policy Research. Today it is run by Porath and Prof. Gad Rabinowitz in conjunction with BGU's department of industrial engineering and management and coordinated by Anat Raskin Segal.
Have you noticed that since 2004, during periodic visits to your family doctor for the flu or other acute problems, you have had your blood pressure tested and been sent for lab tests to see if you have diabetes or high cholesterol? If you are a woman between 50 and 74, have you received invitations to undergo a mammography every two years? If you are over 50 or suffer from a chronic disease, have you received a reminder to get your annual flu shot? If you haven't been asked, demand it.
The health funds have encouraged primary care physicians to take this proactive approach, as the National Community Medicine Indicators Project compares data from the four insurers, and each wants to look good. The 118-page report is available in both Hebrew and English but not in Arabic, Russian or Amharic on the Health Ministry Web site (www.health.gov.il) and the National Health Policy Research Institute site (www.israelhpr.org.il). Data on all relevant health fund members are submitted by the four health funds to the BGU researchers without identifying the insured individuals, so medical confidentiality is ensured.
The results in the report that has been made public are not categorized according to health fund, but a different version with comparisons has been given to a small cadre of decision-makers. The Health Ministry, Porath and the project's steering committee have not yet acceded to the demands of Maccabi Health Services director-general Prof. Yehoshua Shemer to publicize all the findings on 46 different indicators. Shemer, who published the latest health indicator report for his own health fund on Maccabi's Web site last year and this year, predicted at the last National Health Council 10 days ago that health services will become more equitable if insurers are forced to publish their data and reveal where preventive screening and early diagnostics are the weakest.
SHEMER, A former Health Ministry director-general and former chief medical officer of the Israel Defense Forces, insisted that the public are entitled to transparency and the right to know how well and equitably their insurers provide these vital services. He insisted that "the public are more intelligent than you think" and urged immediate publication of the four health fundsâ€š statistics on screening and other disease prevention activities.
But Prof. Eran Halpern of Clalit Health Services and Uzi Salant of Kupat Holim Meuhedet argued at council meeting that the time was not ripe, as there were no accurate socioeconomic statistics about the memberships of each health fund. Those insurers with larger memberships of poorer and less-educated people have greater difficulty getting them to go for screening, so public comparisons without socioeconomic indices would be unfair and the public would "not understand" the statistics in their available form.
Health Ministry director-general Prof. Avi Yisraeli said that in principle, the ministry would like to release comparative statistics on health fund performance as soon as possible, but that it wouldn't be immediate.
"We have begun meeting on ways of releasing statistics on mortality and morbidity in the hospitals. We have not yet persuaded ourselves that it is correct to do this," said Yisraeli, as the various hospitals treat different socioeconomic groups and publication could induce medical centers to refuse difficult cases so their success rates would not decline. "We hope to go ahead with this process. We haven't given up yet."
Porath said that while the health funds haven't reached the optimal number of members in their screening programs, they have involved a growing number of them. Additional health indicators such as whether members smoke, as well as indicators relating to children's health, will be added.
Although Naveh said in 2004 that he hoped health funds that excelled in their objectively assessed performance would get an extra share of health taxes allocated by the National Insurance Institute according to a formula that does not include quality, but only the ages of members and the number with a handful of expensive conditions.
THE LAST report, the third since Porath initiated it, includes figures on health fund members who are exempt - mostly due to low income - from National Health Institute (NII) deductions, which does give some socioeconomic indications. The partial or full exemption covers about one-tenth of the population or approximately 682,000 people, and is granted on the basis of several criteria, including of old-age pensions, disability payments and families with four or more children.
However, the report notes in its introduction: "It is agreed that a fair comparison among the health funds that does not mislead the public will be possible only after considering the socioeconomic gaps. The funds today do not have data on all their members' socioeconomic situation, such as income, education and so on. And there are those who think this is good. Already in 2007, will we take a significant step in this direction by presenting data on the regional-geographical level. There is a connection between geographical region and socioeconomic condition, and we will use it to provide a fair comparative analysis."
Although a more restrictive definition was applied for chronic persistent asthma, it was found in the new report to affect about 1% of the population in the reported age groups. Among young adults, asthma is more prevalent among men. In older adults, it is more prevalent among women. The rate of flu vaccinations was found to have improved over the years, reaching an average of 31% of asthma patients, with older ones more likely to get the shot. Asthma patients who are exempt from NII payments are 12% less likely to get flu vaccination.
Last year, breast cancer screening by mammography included 56% of women aged 50 to 74, but women who have an exemption from NII payments are 8% less likely to get mammograms. The report quotes Shlomit Cohen, 53, from Haifa, whose life was saved by the scan: "In the summer of 2000, I was on vacation in Eilat with my husband. The routine mammogram scheduled for me just happened to be while I was on vacation, so I planned on skipping it. At that time I didn't pay much attention to my health, and took it for granted. However, because of urgent issues at my husband's job, we were forced to come home early, so I went to the exam after all... I fought the disease for two years, and in the end I won. My doctors told me that early detection is what saved my life."
Only 9% of men and women aged 50 to 74 were found in the new report to undergo fecal occult blood tests for colorectal cancer, while another 12% underwent invasive colonoscopies over the past five years and were therefore not included in the target population for fecal occult blood tests. Among people 60 and older, those exempt from NII payments were less likely to have fecal occult blood tests than those who do have NII payments deducted from their salary.
The prevalence of diabetes treated by medication continued to rise during the reporting period, reaching 3.8% of the general population and 5.8% of adults aged 18 and older. The rate of those examined for HbA1c - a key indicator of blood sugar balance - at least once a year continues to rise, reaching an average of 90%. The rate of patients who attained a good control of their blood sugar level (HbA1c below 7%) is 43%, while the rate of uncontrolled patients (HbA1c above 9%) fell to 16% during the reporting period. About 18% of all diabetes patients are treated with insulin, especially those unable to control their blood sugar with diet, exercise and medications. The rate of testing for LDL cholesterol (low-density lipoprotein or "bad cholesterol") in diabetes patients continued to rise, reaching 87% during the reporting period. A striking improvement was also found in the rate of diabetes patients who reached the target LDL level below 100 mg/dl - up to 48% during the reporting period. More diabetics are now being tested annually for microalbumin in their urine (a high level means kidney problems) than before, but it still includes only 56% of them.
About 70% of the adult population underwent testing for blood cholesterol levels, with women more likely to be tested than men, who visit their family doctor less often. However, the rate of women who reached the target cholesterol level is somewhat lower than among men. A 25% drop in LDL cholesterol in 35% of 1,000 patients can save the lives of 40 out of 90 people who would otherwise die of heart attack.
This is a load of statistics, but early screening can saves lives. Fifty-one-year-old Yona Blank, a manager at a well-known hi-tech company, was highlighted in the report as having a family history of coronary disease: Her father had a heart attack at 50 and her brother has high cholesterol. "In a regular blood test, her family physician found her cholesterol level to be a source of concern. He recommended that she maintain her lifestyle and diet, and also treated her with statins. Yona sighed with relief when the next blood test showed a marked improvement. Let us hope that the next report on health indicators will show even more progress.