Our doctors’ recurring condition

Yet another extended strike by public-sector physicians looms after a 127-day crisis ended in 2000.

By
April 17, 2011 02:41
Doctor

doctor cartoon 311. (photo credit: Chris Ware/Lexington Herald-Leader/MCT)

 
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Recollections of the last official doctors’ strike that hit the public health system – 127 days of it, until the middle of July, 2000 – seem all too familiar to those following the present anguish in the hospitals, health fund clinics and families with members needing care.

Even many of the names of the protagonists and antagonists are familiar.

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Ehud Barak, now defense minister, was then Labor Party prime minister; Binyamin Netanyahu, now prime minister and health minister, was head of the Likud opposition. The chairman of the Israel Medical Association, now Dr. Leonid Eidelman, was then Dr. Yoram Blachar, who aroused the fury of the man in charge of the Health Ministry.

Today, Netanyahu doesn’t intervene; Agudat Yisrael MK Ya’acov Litzman runs the ministry as a deputy minister. During Litzman’s first year in the hot seat and Blachar’s last, the two battled over health matters on a regular basis. In 2000, the active health minister was Shlomo Benizri of Shas, now serving a four-year sentence after being convicted for accepting bribes.

While there’s a vivid feeling of déja vu, much has changed in the past 11 years. There is a severe shortage of physicians, with Israel shifting from the prestige of having the highest number of doctors per 10,000 citizens to the shame of having one of the lowest. Many Russian immigrant doctors who arrived en masse in about 1990 and blessed the health system are becoming pensioners.

The Finance Ministry’s budget and wage chiefs have become hugely powerful, replacing Health Ministry officials in making decisions about doctors and nurses, public-health spending, pricing and hospital development.

Nearly all agree that the eclipsed ministry has no say and has become impotent and irrelevant on these issues.



Thanks to the Treasury’s first Arrangements Bill in the late 1990s, the state share of health spending has been reduced to little more than half, and individuals needing services have to dig deeper into their own pockets.

WITH THE European Union uniting the continent, Israeli medical students abroad who earn a European license can practice anywhere they like. More and more senior physicians and researchers are lured to “greener pastures” in the US and elsewhere by high salaries at a time of worldwide physician shortages; Israeli medical professionals are regarded as among the best minds and best trained, and are eagerly sought abroad. Take a law degree and sue doctors for alleged malpractice instead of being accused of it yourself, or get hired by a pharmaceutical or information technology company.

Respect for medicine seems to have eroded, as half of medical students and residents are women, and it appears to be more a low-paid “woman’s profession” like social work, school teaching, nursing, physiotherapy and cleaning.

Private medical centers such as Tel Aviv’s Assuta Medical Centers or the Herzliya Medical Center thrive and expand to 500 beds in the center of the country, as the gap between medical care there and in the periphery expands. As public hospital doctors’ salaries dwindle, an increasing number of senior physicians work either partially (during and after their publicsector jobs) or wholly in these luxury facilities to provide private care. Women, not always willing to devote all their time to medicine and research while raising a family, constitute at least half of all medical students and residents, while shortages grow.

It’s a different world for medicine, and the need for systemic reform becomes much more vivid and urgent than it was during the 1999-2000 strike; all sides, including the Treasury, agree that hiking doctors’ wages is just a partial step to a solution, because the system has become so “deformed” and imbalanced.

ALTHOUGH THE tightlipped Treasury has done little more with its public relations staffthan issue bulletins on “how much the average Israeli physician earns (NIS 26,000 a month),” there is no “average” doctor.

There are interns and residents who spend half the month on duty in teeming emergency rooms, internal medicine departments and other wards doing dayand- night shifts that last 24 hours because few senior specialists are still willing to do it.

There are well-known department heads whose Jerusalem medical centers allow consultations and the performance of operations in the afternoons and evenings through Sharap (private medical services); fees are shared by the institution with the doctor.

There are health fund physicians who work 9 to 5 in the community, earn middling amounts per patient seen and treated, and veteran doctors who never advanced due to lack of opportunity or desire and are stuck at the same pay scales they earned when young.

As many of the additional financial benefits of hospital physicians are included in take-home salaries only for exhausting, family-disrupting overtime work, those who don’t do it get low returns. And even specialists who retire after decades find that their pensions go no farther than that of the average gross national wage.

Prof. Yoel Donchin, for example, a senior intensive care specialist, anesthesiologist and surgical safety and first-aid expert who just retired from Hadassah University Medical Center after 35 years, receives NIS 8,000 a month. People don’t pay anesthesiologists or intensive care specialists Sharap, he notes, just as they do not pay privately for neonatologists, pathologists, radiologists and those in other altruistic specialties like internal medicine. As a result, hospital residents are reluctant to study for years to become certified in these fields.

“Conditions in the hospitals are very bad,” he says in an interview. “Doctors work like those who built the pyramids in Egypt – without being provided the straw.” Although his views are “socialist,” meaning he feels that every patient deserves the best possible medicine without paying extra for it, and he has always strongly opposed doctors’ strikes, Donchin has reluctantly concluded that they must act now to shake up the government, especially the Treasury.

Doctors don’t strike like Bezeq or Electric Company workers; they do not walk away from their posts and refuse to make repairs. They take care of patients who would be endangered, said Donchin. Each hospital has an “exception committee” that allows doctors to take care of such cases.

“The Treasury boys [the all-powerful young decisionmakers in the Finance Ministry’s budgets and wage divisions] have never needed to go on strike. They work on personal contracts, get money for every second they work, and when they leave the Treasury, they go to work for banks and other companies for elite salaries and benefits. Doctors don’t, so don’t let these functionaries tell us what to do. If physicians were compensated for what they really do, the Treasury would collapse.”

DONCHIN ADDED that in intensive care units (he continues to be responsible for accident prevention at Hadassah), “the most difficult decisions we have to make are not what drug to give or procedure to use to save lives, but who attached to a respirator gets a bed in advanced intensive care and who has to try to survive in an internal medicine ward. A doctors’ strike at this time is like performing an amputation to save the patient.”

The retired anesthesiologist calls on the IMA to require Health Ministry doctors who are administrators and don’t treat patients to apply sanctions and strike with their colleagues if push goes to shove.

The solution to the healthcare crisis is for the government to finally decide to spend money on it, rather than to constantly reduce public funding, Donchin concludes. “We have strategic problems; the government must change its priorities. If it spends millions on the Iron Dome missile to save a single person in the south, it can decide to spend money to save the lives of intensive-care patients.”

The IMA’s Eidelman is upset by the fact that some of the media, especially pro-privatization Ha’aretz, have depicted the crisis as revolving mostly around the possibility of allowing Sharap in public hospitals beyond Jerusalem.

“We never made it an issue. Litzman has said it is a solution – keeping doctors in hospitals day and night, instead of them going to earn more privately. I don’t understand why people refuse to go into depth on the issues. We said private medical services in public hospitals might help in peripheral hospitals, but only if residents were allowed to pay for them with their supplementary health insurance (Shaban) policies and not out of their own pockets. In fact, Tel Aviv Sourasky Medical Center and Sheba Medical Center were permitted to offer Sharap for six years, even though they are public institutions, but it was stricken down by the courts.”

Senior doctors should be encouraged financially to work shifts, said Eidelman, and residents should get 150 percent compensation beyond the seventh shift duty in a month. While younger doctors should get differential payments, retirees whose pensions are unfairly low should be paid more, he added. “Every problem needs a different solution.”

Ben-Gurion University health economist Prof. Dov Chernichovsky, who also proposes health reforms as a consultant for the World Bank to developing countries like Colombia and Mexico, advocates the use here of Shaban to choose one’s physician. About a fifth of the public can’t afford to pay their health fund the extra fees; the government should pay for them, while Shaban must become a mandatory payment for the rest of us, he insists. “Governments don’t like to raise taxes, so they wouldn’t call this an additional tax, but it could be required as car owners pay car insurance. Shaban payments now averaging NIS 120 per person per month would rise to about NIS 150.”

With universal Shaban, he continued, doctors would opt for working long hours in their public hospitals rather than outside. Those who continue to do private medicine would not be allowed to work also in public hospitals, he said. Senior doctors would also reduce the shift burdens of residents.

To increase public funding of public hospital services, says Chernichovsky, “the Treasury must swallow the pill and agree that in seven years, the amount of public funding must increase to the OECD level of 70% instead of today’s 53%. This would restore the situation we had before the first Arrangements Law was in place and things started to fall apart.”

But his BGU health economist colleague, Prof. Gabi Bin-Nun – who worked in that field at the Health Ministry for over 25 years – is a fierce opponent of Sharap and the option of Shaban covering the patient’s choice of doctors. “Voluntary insurance can’t become mandatory. It should be put into the basket of health services for which people pay health taxes. Shaban premiums under the Shaban proposal would push premiums way up, and the elderly won’t be able to pay.

The public healthcare system would be damaged. And Sharap will only damage the public system, not strengthen it, by creating two levels of medicine, one for the poor and one for the rich,” declares Bin-Nun.

There is only one way out, he continues. “The Treasury must strengthen the public system with public money. There must be more fully manned hospital beds. It can’t argue that the doctors got a wage increase only recently as a result of the 2000 agreement; that has not been updated from a decade ago. There is no free lunch.”

Sourasky director-general Prof. Gabi Barbash, who in the late 1990s was a Health Ministry director-general but returned to his prestigious state-municipal medical center, is very concerned about the decline in the health system. “There aren’t enough doctors, nurses and beds.”

He advocates the Shaban system, investing supplemental insurance in the public hospitals to improve wage and medical facility conditions there. “It is so hard to recruit the best doctors. I wrote a letter to the State Comptroller last week stating that at Sourasky, we spend NIS 20 million annually in extra payments for doctors and nurses so we can keep them.”

He believes Treasury officials don’t understand the real problems. “I invited their health liaisons to visit my hospital to see the problems, but after two times, they begged off and said they understood everything.

But they didn’t understand.”

It’s nearly impossible to get any of the sides to agree; consider the past eight months of start-and-stop negotiations between the Finance Ministry and the IMA.

Treasury officials say all that is needed is some differential pay changes as incentives to young doctors in the periphery and getting hospital doctors to punch time clocks (which they have never done) to make sure they are on the job rather than “moonlighting” during the work day.

Some observers even insist, when all is put into perspective, the situation in our health system is “not so bad after all.” Dr. Bruce Rosen and colleagues of the Smokler Center for Health Policy Research at Jerusalem’s Myers-JDC-Brookdale Institute has just published an article in Health Affairs on “What the US Could Learn from Israel About Improving the Quality of Health Care.” Our National Quality Measurement Program, in which all four health funds voluntarily participate, is among the best of the world, he stated optimistically. This system monitors what medical services the weaker socioeconomic sectors get, and this level is constantly improving, wrote Rosen. The US, where tens of millions have no health insurance at all, pales by comparison.

Raise a toast to the optimists and say a prayer for the realists.

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