Who would have dreamed a decade ago that Israel’s shekel would be one of the
world’s most stable currencies – and that the US State Department would send a
Fulbright scholar to examine aspects of our health system as a possible model?
But both of these are true.
Dr. Dan Merenstein, an associate professor
and chief of research at the department of family medicine at Georgetown
University in Washington, has just spent some four months in at
Hadassah-University Medical School in Jerusalem to study our system for
reimbursing doctors and compare it to that in the US.
acquaintance of Dr. Amnon Lahad – head of the department of family medicine at
the Hebrew University Medical Faculty and a staff member at the Hadassah Braun
School of Public Health and Community Medicine – at a medical conference, he
later asked him to be his sponsor, mentor and host during his Fulbright research
study here. As Lahad also works in family medicine in the central district for
Clalit Health Services, his guidance helped Merenstein immeasurably. The
research, whose findings will become available next year, specifically compares
the “bundling” system of payment for medical tests compared to the
fee-for-service system used in the US.
“Over-testing in the US is believed
to be a result of defensive medicine triggered by malpractice lawsuits and
physician reimbursement schedules with fee-for-service leading to improper
incentives for ordering tests,” Merenstein said in an interview with The
Jerusalem Post not long before his scheduled return to Washington. The physician
says results from his study could help inform American public policy and lead to
He said that combining overtesting that doesn’t improve health
outcomes with a feefor- service health system is an untenable model that should
be examined as the American healthcare system undergoes significant
Merenstein speaks basic Hebrew that he learned in elementary
school as a child, and practiced during six months he spent at a kibbutz after
high school. He attends a Conservative synagogue with his family. He graduated
from Brandeis University and Jefferson Medical College, and completed his
residency at Fairfax Family Practice in Virginia where he was chief resident.
Prior to coming to Georgetown in 2005, he spent three years in private practice
followed by two years at Johns Hopkins University as a clinical research
In addition to seeing patients once a week and teaching medical
students and undergraduates in the US, he has much research experience. He
conducts evidence-based clinical trials on a variety of subjects including
respiratory infections and functional foods such a probiotic yogurt. Recently he
was the primary investigator on an US National Institutes of Health planning
grant for examining the role of antibiotics and steroids in treating acute
Merenstein, on faculty in the human science department at
Georgetown’s school of nursing and health studies, came to Israel with his
schoolteacher wife (who studied for a year at Bar-Ilan University) and four sons
aged two, five, eight and 11. The boyishlooking doctor and medical researcher
charmed the scores of leading Israeli medical professionals he was introduced
to, and who he even interviewed, around the country. He met heads of the health
funds, senior physicians at the Hadassah University Medical Center and the
medical school and visited BIU’s new Galilee Medical Faculty in Safed, among
“Dan is wonderful,” said Lahad.
Many doctors he met here
already knew of him before being introduced to him: An article he wrote,
published in the Journal of the American Medical Association (JAMA) in 2004,
about a traumatic experience he went through has been part of fifth-year medical
school curriculums since then.
In a JAMA’s “A Piece of My Mind” column
entitled “Winners and Losers,” Merenstein recalled a middle-aged, highly
educated patient he encountered during the third year of his residency in 1999.
He conducted a physical exam and discussed the importance of colon cancer
screening, seatbelts, dental care, exercise, improved diet and the use of
sunscreen. He also presented the risks and benefits of screening for prostate
cancer and documented the discussion.
“I never saw the patient again, and
after I graduated, he went to another office. His new doctor ordered
prostate-specific antigen [PSA] testing without discussing the risks and
benefits of screening with him. Unfortunately for this patient, his PSA level
was very high, and he was subsequently diagnosed with incurable advanced
Nothing could have been done at this advanced stage,
and it is difficult to treat at any stage, wrote Merenstein.
literature does not support that early detection would have changed his outcome,
although society and many physicians do believe so, thus making the patient live
with the false belief that if something had been done differently, he would have
But in June 2002, both his hospital department and
Merenstein were served with court papers for alleged negligence for not
insisting that the patient be screened for PSA, and the case went to trial a
“As the trial progressed, we presented national experts who
discussed the controversy surrounding prostate cancer screening and explained
some of the potential dangers of PSA... such as false positives, indolent vs
aggressive cancers, sensitivity and specificity.
Our experts explained
that because of the questionable benefits vs associated risks of PSA screening,
a shared decision by the physician and the patient was recommended by all of the
national health associations.
The science was clearly in our
During the closing arguments of the trial, the plaintiff’s lawyer
“put evidence-based medicine on trial. He threw EBM around like a dirty word...
He defined EBM as a cost-saving method. He urged the jury to return a verdict to
teach residencies not to send any more residents [out] on the street believing
On June 30, 2003, seven days after the trial began, Merenstein
was exonerated, but his hospital department was found liable for $1 million and
“Dan acted correctly,” said Lahad. “But the court ruled that
according to common practice, PSA screening should have been carried out. In
Israel, such a court case would not have occurred, but in Virginia – before a
jury of ordinary citizens – it did.”
Meanwhile, researchers at Johns
Hopkins this month reported that routine MRI imaging “does nothing to improve
the treatment of patients who need injections of steroids into their spinal
columns to relieve pain.”
Moreover, they found that the imaging devices
play only a small role in a doctor’s decision to give these epidural steroid
injections, the most common procedure performed at pain clinics in the
The findings, which just appeared online in the Archives of Internal
Medicine, highlight the indiscriminate use of an expensive imaging tool that
shows little clinical benefit.
“Our results suggest that MRI is unlikely
to avert a procedure, diminish complications or improve outcomes,” says study
Steven Cohen. “Considering how frequently these epidural
injections are performed, not routinely ordering an MRI before giving one may
save significant time and resources.”
A single MRI costs about $1,500 in
“Overtesting in the US is believed to be a result of
defensive medicine triggered by malpractice lawsuits and physician reimbursement
schedules,” Merenstein said in Jerusalem, “with fee-for-service leading to
improper incentives for ordering tests.”
The US healthcare system is in
big trouble and facing bankruptcy, he said in the interview.
don’t want any government to be involved, but it will have to get involved
eventually because the country just can’t afford it,” said the Georgetown
researcher, one of nearly a dozen annual Fulbright scholars in Israel, some
students and a smaller number faculty.
“We had to write in our
applications what we wanted to do for our research and why.
There is no
question that doctors in America order too many medical tests, both to protect
themselves from lawsuits but also because they are paid fees for every service
they give. But in Israel, there is the bundling system, in which health fund
doctors are paid the same amount per patient no matter what they do for the
patient. They have no incentive to order unnecessary tests,” Merenstein
Doctors working for the health funds earn more if more patients
come to them for care.
“Clalit general practitioners and family
physicians generally get paid the same per patient; at Maccabi Health Services,
there is a small element of fee for service. Israelis usually undergo simple
urine and blood tests, while in the US, there are complete physicals,” said the
US physician. “I want to understand the system better, but in Israel, patients
usually come to say they feel ill and want medications. Even here, there are
more tests than necessary, but in the US, it is much worse. Testing there is
part of the culture.”
But he thinks it would be more economically
beneficial if more Israeli physicians had X-ray equipment and electrocardiogram
equipment in their offices rather than requiring patients to go to a health fund
installation or elsewhere for these. He thought it was a mistake that Israeli
women have to go to gynecologists to get a Pap smear done for early detection of
“And I recommend more evidence-based testing,” he added.
“The Republicans despise Obamacare, the reforms presented by President Barack
Obama that he has had great difficulty implementing; they say they will abandon
it completely if a GOP president is elected. But that’s easier [said] than
Something serious must be done to reform the US system, because the
country can’t afford to go on like this.
“Israel has a great health
system, with its national health insurance and accessible care; In the US, there
are almost 40 million people without health insurance, and they seek treatment
when they are sick and desperate.”
Merenstein was also very impressed by
the massive computerization of medical files here.
The relative share of
the GDP that healthcare gets in the US nevertheless is almost twice that in
Israel even though is population is not healthier, concludes Lahad.
our computerized records are outstanding.
This is because it’s a much
smaller country, but mostly because our computer experts are excellent. Dan
certainly couldn’t see such a huge amount of digital medical data anywhere in
the US, such accessible medical records, which reduce overtesting and waste.”