Does the fact that State Comptroller Micha Lindenstrauss devoted an unprecedented 200 pages of his 1,000-page biannual report on government activities to the Health Ministry mean that the scandals are worse or that investigators who supervised the ministry's activities were especially energetic or productive this year?
The answer is probably both. Shortcomings involving health services are often related to life-and-death matters. The fact that - according to this hard-hitting chapter - lives are being endangered, or even lost because of poor ministry management and supervision makes the reader sad and angry.
Radiotherapy is considered one of the most effective weapons against malignant tumors, causing the number of cancer patients seeking such treatment to grow. But although this trend has been clear for a decade and committees of experts have recommended and warned, the Health Ministry has done nothing to expand radiotherapy facilities and increase and upgrade manpower to cope with increasing demand.
The comptroller slams the ministry for this negligence, which has resulted in long waiting lists, equipment breakdowns, a shortage of nuclear accelerators, erroneous doses of radioactivity, too-short radiotherapy sessions and too-few physicists, radiotherapy physicians and technicians. All these shortcomings, he concludes, pose "significant concern for serious harm to the quality of treatment given to patients."
His staff chose at random the radiotherapy facilities in one government hospital (Rambam in Haifa) and one owned by Clalit Health Services (Rabin Medical Center in Petah Tikva). Only when the investigation ended in September 2005 did the ministry suddenly ask professionals to recommend a program to ensure the quality of radiotherapy equipment.
While demanding a major reorganization to suit radiotherapy to future needs, the comptroller also called on the ministry and hospitals it owns and supervises to ensure that current cancer patients get the best possible radiotherapy.
Much of the chapter's criticism was devoted to the ministry's supervision of the four health funds. This is the job of a deputy director-general. The comptroller does not name names but only positions; he also left out the fact that the deputy director-general in charge of health fund supervision - Michal Abadi-Boyanjo - resigned from her position at the beginning of this year to become chief accountant of the First International Bank. The comptroller also neglects to mention that she was allowed to serve as a member of at least one board of directors of an outside organization while she held her ministry job.
Moving to the bank post, she left numerous and serious failures at the ministry that are detailed by the comptroller. (Abadi-Boyajo's seat has been filled only temporarily by a ministry lawyer with expertise in drug and medical equipment licensing; no permanent appointee has been named.)
Three of the four health funds - not Maccabi Health Services - used illegal incentives to try to attract new members, especially from the haredi and Arab communities (whose large, younger families make them more profitable). Offering better ambulances, home delivery of drugs, night opening hours and free transport to and from specific clinics, the comptroller said that they thereby discriminated against other members and violated the principle of egalitarianism.
The ministry's health fund supervisor did nothing to stop this, the comptroller said. She also failed to ensure that people have reliable and accurate information about their rights and the ability to get what they deserve from their insurer.
In addition, health fund managements were not consistent in their rejection of members' requests for subsidized medications.
The insurers send letters to doctors recommending they prescribe cheaper drugs (often generics or earlier-generation ones) to save money; this puts pressure on physicians not to prescribe more expensive medications that could benefit their patients more.
Although members of a health fund are entitled to switch to a different one twice a year, only 1.1 percent of them actually change to another insurer, and among the elderly, the rate is less than a third of that.
The ministry did not take action to facilitate switching from a health fund that provides unsatisfactory care for the elderly or sick to another one. This is largely because supplementary health insurance policies purchased by 70% of the population are available only to members of the same health fund and not others, and anyone who switches faces restrictions and must go through a waiting period. The comptroller said the "fine print" in these policies prevented policyholders from knowing their rights and comparing the various plans.
The ministry was also strongly criticized for poor supervision of the health funds' administration of supplementary health insurance plans, which enable policyholders to choose their surgeon, for example, instead of receive the one who is on duty. But instead of the operation being covered by the publicly funded basket of health services and the surgeon's fee by supplementary health insurance, the comptroller said that Abadi-Boyanjo allowed the insurer to pay for the surgeon and the operation with money from its supplementary health insurance.
This saves money for the insurers, while causing "underuse" of basket funds and encouraging the Treasury to allocate less for basic health services. It also puts pressure on patients to join supplementary health insurance plans and thus leads to increased "privatization" of health services at a time when government participation in health costs continues to shrink.