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Until recently, the directors of the four health funds - Clalit Health Services, Maccabi Health Services, Kupat Holim Meuhedet and Kupat Holim Leumit - were judged by the Health Ministry only according to how much money they saved the public. They even received bonuses if they minimized their "red ink." This longstanding policy won the warm approval of Treasury officials, who try to keep a lid on health expenditures at all costs.
But health experts, both in academic institutions and the government, have finally realized that giving incentives for cutting costs is not necessarily the way to promote better health. If obese patients who smoke and get no exercise are not encouraged by their doctors to undergo tests, change their lifestyles and take medications; if middle-aged women are not sent for biennial mammograms; if the elderly and the chronically ill are not given flu shots every winter, they could eventually cost insurers much more.
PROF. AVI PORATH, a physician and epidemiologist who heads an internal medicine department at Beersheba's Soroka University Medical Center and a senior Ben-Gurion University Health Sciences Faculty researcher, became aware of the problem years ago. He voluntarily decided to research various national health indicators - such as how well diabetics control their blood sugar, whether the elderly get their eyes checked, how many patients are tested for hypertension, blood lipid and sugar levels - and presented his data to the Health Ministry.
Interested in cultivating a healthier populace despite budgetary pressures, the ministry adopted Porath's Health Indicators Project as a national program two years ago. A small amount of funding was obtained from the National Institute for Health Policy Research at Tel Hashomer, and the health funds allocated money and manpower. Porath was commissioned, with two other part-time researchers, not only to study national health indicators but also to produce an objective comparison of the health funds' performances.
Outgoing health minister Dan Naveh then called it "the most important health system reform" in the past decade. Although the work is being done mostly outside the government, the ministry established a steering committee of senior officials including director-general Prof. Avi Yisraeli, associate director-general Dr. Boaz Lev and deputy directors-general Dr. Yitzhak Berlovich and economist Gabi Bin-Nun, while an outside auditor was hired to ensure that the data were accurate and could fairly be compared.
Unveiling the project before health reporters in March 2004, Porath said health fund directors had been reluctant to share data. But they promised Porath to "do the maximum and ensure that their members get the tests and counseling they need." The project was expected to give a boost to disease prevention in the community, which has been given short shrift for many years. The efficient collection and comparison of data based on uniform standards and evidence-based medicine was made possible by digitalization of many health-fund procedures and records and the growing medical consensus on disease prevention and treatment, said Porath, who suggested that the hospitals' performance could eventually be assessed as well.
Naveh expressed his hope that eventually the health funds that excel 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 today include quality, but only the ages of members and the number with a handful of conditions that are expensive to treat) - but this has not yet been implemented.
Porath made good on his promises, and a week ago published his second data report, part of which can be downloaded in English from the ministry's Web site at www.health.gov.il/Download/pages/public-report-English-2002-2004.pdf (a somewhat longer Hebrew version has also been posted, but a much longer one meant for health system decision makers has not been made public). Each health fund received a report comparing its performance with its competitors, but these too haven't been released to the public because of several problems that will be explained below.
This year, the areas chosen for evaluation are among the most important in community medicine for many different segments of the public - diabetes and cardiovascular disease as major diseases in the adult population, juvenile asthma, mammography, and flu shots for high-risk populations.
The BGU team write in the new report, which covers 2002 to 2004, that the level of Israeli medical practice in the five key areas is relatively high compared to that in other Western countries, and national quality indicators show the health funds are providing most health care on an egalitarian basis.
Although the funds were found not to discriminate against the poor, residents of the periphery, women or the elderly, the researchers did find "discrepancies in favor of insured who are not qualified for a discount or exemption for health services." In addition, the report said that "a small portion of the indicators are beginning to show a trend toward improvement from year to year."
In an interview with The Jerusalem Post last week, Porath said the national program is quite unique even though the report includes only about 30 health indicators so far, and not the targeted 50.
"We know of no other country that supplies national data on its health indicators. In Britain, for example, there is only sampling, but not data on all residents. In other countries, reporting by the health maintenance organizations is only voluntary, and the insurers can report whichever statistics they want so they can look good."
In Scandinavia, he continued, it's voluntary and covers less than a third of the population. In the US, where there are tens of millions people without insurance, figures do not reflect reality.
Porath stressed that because his report covers health fund members on a national basis, even a small change in any of the indicators has far-reaching significance. This comprehensive view, he added, will make it possible for managers and decision-makers to make wiser, better-educated decisions.
The report shows that 48% of those over 65 were vaccinated against the flu. The figure for 2005 is expected to be significantly higher, Porath said, because the media's hysterical attention to potentially fatal avian flu - against which there is no effective vaccine - caused conventional-flu vaccine supplies to run out. The 48% figure marks an improvement over previous years, but the health funds still have a long way to go; they need to vaccinate not only the elderly but also young children who are now packing the hospital emergency rooms with respiratory disorders and other influenza complications. No sex-related differentiation was found in the rates of vaccination, the report said, but those with exemption from National Insurance Institute-collected health taxes (because of large families, chronic diseases or other factors) were vaccinated in significantly fewer numbers (42%, compared to 52% for the rest of the population).
As for mammography for women over 50, the health funds showed "no improvement" over the first indicators report, and the rate remained steady at 52%. About one percent of the population have been diagnosed with asthma, and the rate of those getting medication to prevent attacks was found to be higher and continued to rise during the monitoring period, especially among younger people (to 89%); among older people the percentage remained unchanged at 85%. But older women received less preventive medication for their asthma than older men. The rate of asthma is double among those with exemption from paying health tax than among paying Israelis, while those with exemptions were actually 11% more likely to be given flu shots. As for diabetes, 87% of such patients undergo blood tests for HbAc1, which is a marker for how well blood sugar is controlled, but the increase in the rate of patients attaining good control in their sugar levels was halted at the 40% level. Nevertheless, the rate of uncontrolled patients dropped to about 18%, with the rest attaining intermediate control. The vast majority of diabetics are being tested by their health fund for "bad" cholesterol levels, and 43% of them were found to reach target levels, but there was no improvement in the rate of testing diabetics for urine microalbumin (a sign of kidney damage) or annual eye examinations. About two-thirds of the higher-risk population of different ages has been tested for cholesterol. But patients who do not pay health taxes are significantly less likely to purchase statins, the drug that effectively lowers "bad cholesterol" levels, and women were less likely than men to keep their cholesterol under control.
Although the health funds have provided Porath's team with all the data he requested, he says comparative data can not be made public because these statistics have to be reprocessed according to socio-economic and geographic variables of Israeli neighborhoods in cities, towns and rural areas that are kept by the Central Bureau of Statistics. Thus Porath's team will be able to know whether a Clalit, Maccabi, Meuhedet or Leumit member in a poor section of Dimona is offered the same disease prevention and treatment as people living in wealthy Ramat Hasharon.
Porath maintained that most of the health funds are reluctant for such data to be published. Instead, he said, the insurers want to raise their prestige and polish their reputations by displaying high national averages, rather than problem areas, neglect or intentional discrimination.
"We hope that in 2006, we will manage to persuade all health funds to agree to releasing socio-economc and geographic data so the public will know more and be able to compare their real performances," Porath stressed, noting that exemption from paying health taxes does not accurately reflect socio-economic factors. "When this full disclosure is accomplished, the ministry could allocate incentive payments to reward health funds for monitoring and improving the health of all socio-economic groups.
Bin-Nun, the ministry economist who is enthusiastic about the national indicators program, commented that he preferred voluntary health fund cooperation, but that if they refuse to go along with the ministry's policy, mandatory regulations or laws could be enacted. "And if we find that in the Negev, for example, the health indicators are much lower than in Tel Aviv, it would require government intervention.
"The project is still in its infancy. We want a regular Treasury budget allocation for it and to expand the number of indictors studied. Eventually we may bring it inside the ministry as part of its supervisory and regulatory responsibilities. The Finance Ministry has not balked, because so far it has not paid for it," said the ministry economist. Encouraging the health funds to prevent diseases and treat them early is clearly cost effective, so he hoped the Treasury would abandon its long-held view that health fund directors who only cut costs are champions.
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