Where your health taxes go

By JUDY SIEGEL-ITZKOVICH
If you think you're paying health taxes to ensure quality medical care for yourself and your immediate family, you are partly mistaken. Tens of millions of shekels a year in health taxes - collected by the National Insurance Institute and allocated among the insurers - are used to provide free or discounted medical care, supplementary health policies and medications to staffers and pensioners of three of the four public health funds and and even let them jump queues for diagnosis and treatment ahead of you. But that is not all: Their first-degree relatives (parents, children and siblings) are also considered "personnel" who enjoy these same benefits. The only insurer that does not grant these inequitable benefits is the saintly Maccabi Health Services. In his 115-page chapter on the Health Ministry, the State Comptroller castigates administrators for numerous shortcomings, not only for preventing the health funds from providing staffers with these costly benefits. Others were inadequate rehabilitation of mental patients in the community, deficient testing of semen in hospital sperm banks, allowing some health funds to inequitably distribute big-ticket medications; and granting expensive medical care to people from the former Soviet Union who pretended they were immigrants and then went back home. The National Health Insurance Law that set the national health system in motion in 1995 was aimed at prohibiting discrimination against some and granting extra benefits to the privileged. Before it began, the Clalit, Meuhedet and Leumit health funds offered special benefits to their staffers and personnel's first-degree relatives. But the ministry not only failed to reduce these unfair extras; even those benefits that were not part of wage agreements were allowed to grow, the comptroller noted. Health Ministry negotiations over economic recovery programs with two health funds that ran a deficit would have been a natural occasion to demand cancellation of such benefits, the comptroller suggested, but this was not done. The comptroller also said he had received reports over the years of preference in treatment and free care given by government-owned hospitals to senior staffers and their relatives. These cases raise issues of conflict of interest and of clear ethical problems, he said, but nothing was done to halt the practice. All these should be "rooted out" of the health system, the comptroller demanded, especially since they are so widespread that they discriminate against ordinary patients. The possibility of requiring hospital staffers to report to hospital manages when a relative is treated free and to require hospitals to inform the Health Ministry when senior staffers get preferential treatment should be considered, he said. After hearing the criticism, the ministry thanked the comptroller for bringing the subject to its attention and said it would halt these benefits "in accordance with its legal authority." In 1995, responsibility for psychiatric care was supposed to be transferred gradually from the Health Ministry to the health funds. We are still waiting. Although the Health Ministry finally announced its plans for the transfer last year, it was bogged down by protests from mental health workers and from health funds that said they were not ready because they were not going to be compensated adequately by the Treasury. The ministry has still not announced an official date for the transfer. Mental health services fall between the chairs as responsibility is divided between the two. The ministry is supposed to give hospitalization, clinic care and rehabilitation, while the health funds are to provide psychiatric and psychological treatment. This means that patients move from one institution to another, without continuity of care and therapists. In the meantime, the ministry has been implementing programs for significantly reducing the number of inpatient beds in psychiatric hospitals and moving patient services to community facilities, either public or run by profit-making entrepreneurs. But this process, says the comptroller, has not been going too well. Last year, only 12,000 psychiatric patients - or 14 percent to 22% of those eligible for rehabilitation - via studies, preparation for employment and leisure activities - in the community, were actually received in community facilities. In 2004, Kupat Holim Leumit unilaterally announced that it would no longer provide mental health clinic services to its 4,000 members entitled to it. The Health Ministry reacted by saying patients could go to state-owned clinics, but because there are too few of these, the queues for treatment became much longer for everybody. The ministry nevertheless transferred NIS 200 million to Leumit as part of its economic recovery program and did not insist that the health fund renew its psychiatric services as part of the deal. Although a law to provide psychiatric rehabilitation has been on the books for five years, the comptroller found that the ministry has "not prepared itself adequately for implementing it or established the necessary mechanisms for it to function." The number of rehabilitation coordinators who are supposed to refer patients to community facilities is inadequate, as is the appeals process for those who are dissatisfied. The ministry did not authorize psychiatrists to set disability percentages for mental patients, so those who don't want to apply to the National Insurance Institute cannot join a rehabilitation program. The comptroller also found that the National Council for Rehabilitation of Psychiatric Patients - established in 2001 to advice the health minister on rehabilitation policy - has been kept out of the loop of ministry discussions for years. Perhaps this is why the chairman of the council, Dr. Naomi Hadas-Lidor, has just announced her sudden resignation while protesting against the ministry's attitude towards rehabilitation. The ministry has admitted that adult psychiatric patients wait months to get an appointment in clinics, while children may wait even for a year for an appointment. Such delays can be critical, especially when patients are suicidal. The delays lead those who have economic means to turn to private psychiatrists and psychologists, but those who cannot afford them have to wait and are discriminated against, the comptroller says. The ministry was also criticized for rehabilitation services from entrepreneurs without them being chosen by public tender. The ministry even paid twice - wasting NIS 40,000 of public money - for supposedly housing the same 18 mentally ill patients in two paid hostels at the same time. The comptroller insisted that the ministry prevent such wasteful occurrences in the future. Since 1993, fresh semen may not be used for artificial insemination and in-vitro fertilization due to fears that the woman and/or the resulting embryo could be infected or affected by a variety of diseases. Instead, the semen must be frozen in hospital sperm banks, of which there are 13 (12 of them in public hospitals and one in a private one). The comptroller looked into the functioning of eight sperm banks around the country. In some, male donors did not have to supply health declarations (including that they are not hard-drug takers) and files lacked information such as whether they were carriers of hepatitis B or C, as required by law. In some, donors were not tested to see if they were carriers of Tay-Sachs disease, which, if given to women who are carriers could result in the birth of a baby doomed to die of the horrendous genetic disorder. A comprehensive medical history of the donor was not always taken, leading to the possibility of the birth of defective babies. Genetic data on donors was not always saved, even though this would be needed if a baby with a genetic disease were born, the comptroller said. Rules state that donors cannot produce "too many" babies with their semen, but no official limit was set. If there are too many, the greater the risk that siblings grew up and married each other. Some hospitals set the limit at 20 babies and others at 15; others had no idea how many pregnancies resulted. Not all the sperm banks performed tests for HIV and other conditions in would-be donors at all or as often as required. In one hospital, a woman who was found to be a carrier of familial dysautonomia - a serious genetic disease - was given two sperm donations from a man whose carrier status for the disease was not determined. Only later was as different donor's sperm used. In some hospitals, women received lower-standard semen whose sperm showed inadequate motility and thus were much less likely to result in conception. The comptroller also reported that sperm was given even after it had been frozen for more than the maximum period. Some frozen semen was obtained from sperm banks abroad, but the ministry neglected to demand that the foreign banks report on every medical problem, including miscarriages and diseases, in recipients of sperm they collected from problematic donors. Inventories were not well accounted for in some hospitals, which could not report how many vials they had and where they came from. In general, technologies and guidelines used in sperm banks are behind the times, concluded the comptroller, who called for the appointment of a professional interdisciplinary team to make recommendations on improving the function of sperm banks. There is an official basket of health services set by the government that all health funds are supposed to supply at nominal or subsidized cost to members with relevant conditions. But the comptroller found that Kupat Holim Clalit often refused to give Plavix - an effective, vital drug for preventing reclogging of coronary arteries - to certain members. Plavix is given to patients at nominal cost for a limited time after the patient became sick. It was found that Leumit targeted 100 expensive drugs in the basket (including Plavix) that would not automatically be given to patients. Instead, patients had to get special approval from the district office of their health fund in order to receive the prescribed drug. After examining files, the comptroller found that some patients received Plavix, while others with the exact same condition did not. A relative of "a prominent public figure" received a refund for expensive non-generic medications he bought in a private pharmacy even though he did not provide medical authorization justifying the purchase of this drug instead of the much-cheaper generic brand. The same thing happened with a relative of a Leumit physician. "Ordinary" patients who requested the same drug were told by the health fund's pharmacy that they had none and did not suggest they go to a private pharmacy and get a refund. The comptroller concluded that Leumit must reconsider its entire process of drug authorization to prevent members from receiving expensive drugs at nominal cost even though there is no justification for doing so. Although Absorption Minister Ze'ev Boim told The Jerusalem Post recently that he had looked into allegations that "immigrants" from the former Soviet Union had come to Israel to receive expensive medical treatment at no cost and then left the country and found no such phenomenon. The comptroller devotes a section to such instances - involving people to "pretended" they were going to settle in Israel, when in fact they just wanted to get medical care and left without any intention of settling in Israel. Many of these were not even entitled to be immigrants under the Law of Return, the comptroller found. In 2003 to 2005, 360 immigrants received treatment ranging from NIS 100,000 to NIS 865,000 apiece soon after their arrival. Of these, 39 were found not to be eligible for immigrant status and thus was ineligible for medical care at Israel's expense; their care alone cost about NIS 1 million. Eleven of the 39 did not fill in health declarations as reqired before they came here. The comptroller also focused on immigrants who received medical care worth more than NIS 25,000 each within 60 days of their aliya. There were 1,074 of these. Ninety of them left the country after receiving treatment. While all deserving immigrants must be given the medical care they require, he said, more effort should be taken to close loopholes and prevent the allocation of money for medical treatment by people ineligible for it and with intentions of emigrating.