Although the four public health funds are called “kupot holim” (“ill funds”) in
Hebrew, too many of the insurers are still convinced that their most important
responsibility is to treat rather than prevent illness. But Kupat Holim
Meuhedet, the third largest health fund, and its director- general Prof. Asher
Elhayany are now taking health promotion so seriously that its new approach
promises to be a revolution in Israeli healthcare.
Meuhedet was formally
founded in 1974 as a health fund that merged the Amamit health fund established
in 1931 by (the then) Hadassah Hospital physicians and a smaller health fund to
provide medical services for the collective agricultural labor settlements. It
merged with Merkazit, founded in 1936 for the General Zionists’ workers’
organization to provide medical services for the self-employed and salaried
workers in the towns, and later to professionals. It offered an alternative to
residents who did not want to join the Histadrut – or were not accepted by it –
which was required in order to be covered by the labor federation’s Kupat Holim
Clalit (now Clalit Health Services).
Elhayany, until 19 months ago
director-general of Clalit Health Services’ Meir Medical Center in Kfar Saba,
took over the Meuhedet at the most difficult period in its history.
of Meuhedet’s senior management had to resign or be replaced following the State
Comptroller’s report alleging that the administration was rife with corruption,
nepotism, waste, mismanagement, bribery, conflict of interest, nonexistent
accountability and concealment of documents.
Ironically, at the same
time, Meuhedet’s 8,500 doctors, nurses and other staffers, who are generally
known to be skilled and competent, continued to work without its members
suspecting anything was wrong.
The then-comptroller, Micha Lindenstrauss,
called for the establishment of a state committee to investigate the health fund
that insures over a million Israelis, and his aides said it was one of the most
serious reports released by the office in decades. Meuhedet was still an
“Ottoman society” based on laws going back to Turkish rule in 1903 and was not
required to have independent boards of directors to supervise it.
comptroller suggested that Meuhedet had developed a “culture of thievery and
deception” over the past decade. The allegedly corrupt management hired
freelance contractors to bring in large numbers of haredi families and yeshiva
students in exchange for benefits, including cash payments. The allegedly
illegal dealings are believed by the State Comptroller’s Office and others to
have involved hundreds of millions – or even billions – of shekels, and dozens
Meuhedet regards haredi families, who constitute 40
percent of its Jerusalem members (and to a much lesser extent, Arab families) as
a source of significant profits. The National Insurance Institute – not the
health funds – covers all delivery costs in hospitals, and these families are
younger and healthier on average than non-haredim. Thus more haredi members
means higher profits for the health funds. As the predecessors of Meuhedet were
founded in Jerusalem, the health fund is very strong in the capital, thus giving
Meuhedet much incentive to seek out more ultra-Orthodox members.
interview with The Jerusalem Post
, Elhayany said that since he joined Meuhedet,
about 40 new managers had been hired and that they are supervised by independent
public and professional bodies.
Thus the health fund’s executive has been
transformed, and he has determined a new path for it – with much more emphasis
on keeping healthy people healthy.
Born in 1952 in Meknes, Morocco and
brought to Israel at the age of one, Elhayany is married with four children.
Elhayany received his medical degree from Ben-Gurion University’s Health
Sciences Faculty in 1980. He also studied public and medical administration at
Harvard University’s Kennedy School, has a master of public health degree from
the Hebrew University and worked as a family physician in Clalit Health
Services. He was a deputy director of Soroka University Medical Center in
Beersheba and a member of the board of the National Center for Health Policy
“I started almost from zero when I became director general,”
Elhayany said. Although none of the previous executives went to prison, most of
then left, went on pension or resigned. The new managers came from other health
funds including Maccabi Health Services and Kupat Holim Leumit.
less than the other health funds, but they came for the challenge and the
ideals,” he continued.
Former deputy health minister Ya’acov Litzman’s
program to provide basic dental care for children – which was taken advantage of
largely by haredi families – cost Meuhedet NIS 27 million a year as compensation
per treatment did not cover the costs to the health fund, he said.
government’s capitation rules mean that health funds are paid more for treating
the elderly, not for children, so this scheme, which was a failure, cost us a
lot of money.” Another problem with the capitation is that more money is given
to the geographic periphery, as opposed to the social periphery.
are poor people in the center of the country and rich people in the north or
south, in places like Kfar Vradim or Omer. There are many residents of Jerusalem
and Tel Aviv, for example, who are economically disadvantaged, but we don’t get
compensation for treating their more serious medical conditions,” he said.
“There never will be enough money for health systems, but we can run the health
Now it is run differently compared to before the big
shakeup. “There had been no service division, or strategy or planning. It has
been restructured. Now the management works well together and is divided up into
regions. We have about 700 branches, and we have been completely
THE HEALTH fund’s new concept, led by Elhayany, it to
provide all members (or “customers”) with active personal medical care,
initiated by Meuhedet and suited to each individual.
“We are not going to
wait until the customer gets ill; we will help him to follow a healthful
lifestyle every day of the year. I always thought that we should do all we can
to prevent people from having to go to hospitals. It can take years to be
profitable, but the long run it will save.”
“In Canada, there are two
provinces, Ontario and British Columbia, from which Israel can learn. Residents
on average live 9.8 years longer with a high quality of life and only one year
of dependency on others before they die. In Israel, residents live longer than
in many other countries, but the average number of years of dependency is 10!
The Canadian provinces put a lot of effort into health promotion.”
are many factors that affect quality of life. Coping with grown children leaving
home, going on pension, losing a spouse and other factors can cause more
disease, said Elhayany.
“We need to determine each member’s health
identity and then carry out interventions.
Everyone who asks for one [by
calling Meuhedet] can ask for a case manager or trainer. They will fill in a
questionnaire and get help either by phone from a health coach or via the
Internet – at no cost to them – and even face to face,” he continued. After the
program runs successfully for a considerable period, there may be a charge for
the coach, he added.
The coaches will make contact with members every few
weeks to see how they are progressing.
Even though Meuhedet is a veteran
health fund, most of its members are youngish. There are only 70,000 of pension
age. In Rehovot alone, however, there are 4,200 older members.
screened all of them who regularly visit the clinics. We found that some are
hospitalized again and again for health failure, for example. We found most
didn’t follow the doctors’ orders on taking medications. We sought out
volunteers from Yad Sarah who assisted them and made sure they take their
medication and follow other advice. The recidivism was halted.”
organization also provided volunteers to alleviate the loneliness of elderly
When The Jerusalem Post suggested several promotion and
prevention ideas previously ignored by senior Health Ministry officials –
including health-related annual gifts to encourage whole families to get flu
shots, stickers on the inside of drivers’ doors to remind them not to leave
small children in vehicles, establishing a pilot program to turn ritual baths
into health-education centers for religious and secular women at night using
specially trained women – he said immediately: “I have accepted all of them!”
“According to the outdated way of thinking, if people fell off a cliff, we sent
an ambulance at the bottom to save them. But you can also go upstream and
prevent them from falling in the first place,” Elhayany said with a
This is not a one-time project but a change in philosophy, for
interactive, continuing involvement, said the director-general, who is a family
medicine specialist, and thus has a more holistic view.
“So far, only a
short time after the program began, thousands of Meuhedet members have joined,”
Overweight and obesity costs the country abut NIS 10 billion a
year in medical costs and disability. A recent State Comptroller report found
that 44% of adults aged 18 to 64 and 69% of Israelis over 65 suffer from
overweight. Encouraging exercise and teaching proper diet can reduce that
figure. The health fund has also managed to get more members to get flu
vaccinations in both the center of the country and the periphery. This
immediately reduces the costs of treating patients who develop complications of
the flu and have to be hospitalized.
Elhayany chose TV star Zvika Hadar –
who twice suffered a heart attack within a short time but was resuscitated by
his personal physician in his Meuhedet clinic – to represent the personal coach
Instead of smoking a cigar, he holds an unpeeled cucumber between
his fingers, and has significantly slimmed down. Hadar proved to Meuhedet
members that it is possible to change one’s lifestyle if one really wants
“I won’t preach to anyone, but I have pledged to myself and my family
that I will live differently, continue living, be healthy and remain healthy,”
Elhayany notes that all four public health funds are
shrouded in deficits.
“Next year, the 20th anniversary of the National
Health Insurance Law will be marked. It will be time to conduct a reassessment.
The government made changes that hurt implementation of the law. Out-ofpocket
payments by residents have grown, and state subsidization of healthcare has
declined. We must think about what residents need.”
He noted that the
more people agree to pay privately to get the healthcare they need, the more the
Finance Ministry believes that it doesn’t have to increase public funding for
“But this can’t go on, and the basket of health services has to
invest more in health promotion and disease prevention.”
A FEW days after
the interview with Elhayany, the Meuhedet board of directors attempted to
dismiss him because of allegations that he appointed senior people without the
board’s approval and other complaints.
Elhayany has denied any
wrongdoing; the Health Ministry will consider the issue after
Even if Elhayany does not remain director-general, his
unprecedented programs for health promotion and disease prevention seem to have
become so accepted that they are likely to survive him.