Healing Health Care

A nationwide physicians’ strike points to the malaise in Israel’s health care system.

By ZIV HELLMAN
IT IS A BALMY AND WARM DAY on the grounds of the Hadassah Hospital on Mt Scopus in Jerusalem, in early June. According to the morning radio news program, the doctors at the hospital are supposed to be on strike today, part of a rolling series of work sanctions instituted by the Israel Medical Association (IMA) at various public hospitals throughout the country.
But the entrance to the hospital does not reveal any hint of the strike – no picket lines, no loud demonstrators waving signs.
Personnel at the main information desk answer questions as usual. The ER is functioning normally, because the strike is limited to non-urgent treatment. Ambulance crews are sunning themselves between emergency runs, sipping coffee and smoking.
The ambiance is relaxed and quiet.
In fact, it is too relaxed and too quiet. The outpatient clinic ward, which should be a hub of crowded activity, has very few patients and only a doctor here and there accepting a patient into an examination room. A receptionist initially refuses to speak to the press, but when promised she will only be identified by her first initial, M., she agrees to discuss the patients’ reactions to the strike – at first haltingly and then in a rush. “Of course we are hearing endless complaints,” says M. “There are people who have waited a long time for an appointment, and when they have to reschedule, they get angry. At first people came even when they heard there was a strike day, on the radio. Now they know better, and many don’t even bother to show up. I can understand their frustration. I would feel the same.” She does not turn everyone away.
“Children get treated, strike or no strike,” she says, in Russian-accented Hebrew. “We have a list of exceptions. Someone who recently suffered a stroke and whose treatment cannot be delayed, for example, will get a regularly scheduled appointment.” As for non-exceptions, she says with a sigh, “We try to find another time for them. In between other appointments next week, or at another clinic. It is not easy.”
There are plenty of patients and doctors in the hallways of the surgery ward. Given the heated passions that the strike has stirred, many of the physicians are wary of being quoted in the press, and ask not to be identified by name. “There is a strike today?” asks Dr. Ronit Gur (a pseudonym, at her request), in what sounds like a sarcastic tone. A young intern with short dark hair and piercing blue eyes behind round-rimmed spectacles, Gur is dressed in scrubs and looks harried. “Plenty of people turned away from the outpatient wards came here, and we’ve treated them,” she tells The Report. “I am on call at the hospital every single day, even on strike days, even though I do not get paid on those days.” The physicians are striking, Gur says, “for two things. Increased staffing, so that we have less of an absurd work burden and better salaries.” The demands, she says, are “super-justified. At the end of a marathon shift I am so exhausted I can barely think.”
Dr. Shimon Blum (also a pseudonym), a senior surgeon who is at least 35 years older than Gur, walks by and nods his head in agreement. “We haven’t had staffing needs updated in 30 years,” he claims. “In the meanwhile, the population has doubled, the oldest patients we see are 20 years older, and the demands on us have quadrupled. This cannot go on. I’ve seen three strikes in my career. In every strike, we make only minimal demands and then we need to wait for the next strike to get what we should have achieved in the previous round.”
ISRAEL’S HEALTH CARE SYSTEM has garnered much praise in recent years. Israel’s per capita health costs are half those of the United States, for example, and the country expends a much smaller proportion of its GDP on health care, yet it provides universal health coverage and topnotch, technologically up-to-date care.
Compared to the US, Israel has more physicians per capita, a lower infant mortality rate and higher life expectancy, and lower rates of cardiovascular disease. Surveys indicate remarkable general satisfaction with the health care system.
But the IMA has for some time been warning that the system has increasingly been incentivizing private care at the expense of public care. In other words, doctors have little incentive to give anything but the most minimal amount of hours to the public system, then rush off for more lucrative work in the private health sector.
Focusing its complaints on extremely long working hours at low pay imposed on public hospital physicians, with the work burden only expected to get heavier with a shortage of doctors looming on the nearterm horizon, the IMA has taken its complaints to the next level, instituting rolling doctors’ strikes at public hospitals throughout the country since March, while conducting negotiations with the Finance Ministry on a new collective agreement for doctors.
Interns at Israeli hospitals can sometimes put in 28-hour shifts. In contrast, the Institute of Medicine in the United States, which is chartered by the National Academy of Sciences to provide advice on issues related to health, has issued recommendations that duty hours not exceed 16 consecutive hours, after the “New England Journal of Medicine” published an alarming study documenting the extent to which serious medical errors by interns in intensive care units increase when they are sleep deprived.
OVER 17,000 DOCTORS HAVE been participating in the IMA work sanctions. The last time a physicians strike was held, in 2000, it lasted nearly five months. The IMA has threatened that it will launch a strike July 1 that will virtually shut down the country’s hospitals.
The work sanctions are usually single-day strikes conducted at specific hospitals on a rotating basis, with other hospitals working at regular capacity. By staggering the strike days among different hospitals, the IMA can claim in labor court that it is not fully striking, only implementing sanctions, which limits the authority the court has to issue backto- work injunctions. Rotating the strike also reduces the harm to the public, always a concern in medical strikes.
When a hospital goes on strike, it operates with a skeleton staff under weekend procedures, usually treating only urgent cases and ongoing treatments that cannot be delayed without significantly harming patient health. No non-emergency operations are performed and clinics are closed, with only some exceptions permitted, such as patients requiring emergency cancer treatment, dialysis and in-vitro fertilization treatment. Health clinics associated with the Clalit and Leumit Health Maintenance Organizations (HMOs) have also joined in the strike.
The IMA is presenting its negotiating demands as less a standard union effort to increase the income of its members, and more of an effort to “save the health system.”
According to Ronit Schwartz Ben-David, IMA spokeswoman, underinvestment in the health system over the past 20 years has led to “severe doctor shortages, an overburdened workload on physicians and neglect of the country’s periphery.”
To rectify this situation, Ben-David tells The Report, the IMA is demanding the immediate creation of 1,000 new positions for doctors in hospitals throughout the country; 25 percent increased pay for physicians working in peripheral areas, along with housing assistance; 25 percent increased pay for doctors in specialties in which there are severe shortages; a reduction in the on-duty hours imposed on interns (without any wage reduction), and flexible retirement opportunities for doctors in the 62 to 70 age range. In addition to all of the above, the IMA is also calling for an across-the-board 50 percent pay increase for all doctors.
The Finance Ministry has so far agreed to meeting only some of the IMA’s demands. “We do not feel that giving across-the-board wage increases that will mainly benefit the most senior doctors is the right approach,” says Hadar Horn, a spokeswoman for the Treasury, in an e-mail response to The Report. “Our position is that improvements to the conditions of residents are justified, along with instituting time-clocks registering the hours doctors put in at public hospitals, and adding doctors in peripheral areas and in specialties in which there are shortages.”
Dr. Yitzhak Ziv-Ner, head of orthopedic rehabilitation at Sheba Hospital and deputy chairman of the IMA, tells The Report that the interns are one of the striking doctors’ top concerns. “We are fighting for reducing the burdens and hours imposed on interns,” he says emphatically. “It is not in the interest of patients to be treated by doctors who are exhausted by 24 grueling hours of intense work.”
The Report catches Ziv-Ner on the way to a labor court hearing on the strike, and he is in the middle of a hubbub of activity, yet is still able to clearly articulate the main items that are on the IMA’s agenda. “In addition to the interns, we need, in general, to add more staff positions for all doctors.We understand that this will not happen overnight and we are willing to be flexible and temporarily reduce the burden on junior doctors by putting senior doctors on rounds. But that has to be only a temporary fix.”
MANY PHYSICIANS PARTICIpating in the work sanctions identify with the claim that unless changes are instituted, the main price will be paid in damage to public health.
“The Health Ministry is saving money by not staffing hospitals properly,” complains Dr. Charles Milgrom, professor of orthopedics at Hadassah Hospital in Ein Kerem, Jerusalem. “If there is a war, or a similar emergency situation, we might have enough surgeons to deal with the situation but… there are not enough anesthesiologists in the country, and we will be in big trouble,” he tells The Report.
“Incentives are important,” says Kobi Glazer, a professor at the Tel Aviv University School of Management, specializing in Health Economics, who served as an economic consultant for the IMA several years ago. “If doctors do not get decent salaries, they will leave the public health system, moving to other options, such as private health care, the bio-tech industry, and positions abroad.”
But not all doctors fully agree with the IMA’s approach or its tactics.
“The reasoning behind the strike is unclear to me,” says Dr. Michael Bayme, a surgeon at Soroka Hospital in Beersheba.
“The message of the doctors’ union is difficult to follow and I do not like the battle taking place at the expense of the people who depend on public hospitals. Private care patients have not been hurt. I’ve seen doctors using the strike in public hospitals to work more hours in the private health system. We cannot say we need the support of the public and then harm the public system.”
Ziv-Ner says he is sensitive to claims that the strike is harming the public. “We want to find a solution without hurting people,” he asserts. “We are doctors. No one who needs urgent care is or will ever be turned away.
The public should not be a hostage.”
At the same time, Ziv-Ner insists that the IMA will not back down. “Maybe we are too concerned about the public,” he says suddenly, with a touch of anger. “Maybe that is why the government is not hearing our concerns.”
In an effort to put a stop to the rolling strikes, the Finance and Health Ministries petitioned the Tel Aviv Regional Labor Court to issue back-to-work orders to the doctors.
The court, however, declined to issue backto- work orders. It also ordered the parties to include the issue of increasing the number of doctors on hospital staff in their negotiations.
As of this writing, negotiations between the two sides are continuing but revealing very little progress.
DESPITE WIDESPREAD MISCONceptions, the country’s health care system is not a socialized, singlepayer system. The system is closer to what could be termed “regulated competition”: universal state-financed insurance coverage is provided through four competing HMOs.
Adding private insurance payments to these figures, it turns out that public sources account for only 56 percent of Israel’s national health, according to OECD accounting estimates, and that share has been declining over the years. This makes for an interesting comparison with the US, where public sources account for approximately 48 percent of health care expenses, paid through Medicare, Medicaid and the Department of Veterans’ Affairs.
“There isn’t one system here, and private and public health care gets mixed together,” says Bayme, who studied medicine at NYU and worked as a physician for nearly ten years in the US before immigrating to Israel. “Patients will have surgery at a private hospital and then go to follow-ups at public clinics, or the other way around. All the possibilities are available, and people choose whichever works for them.”
The combination of low pay at public hospitals with an expanding private health sector has been leading doctors to seek to shift their work to the private sector.
“Doctors look for ways to work elsewhere [outside public hospitals] as much as possible, in private medicine or other places,” says Milgrom. “That leads to a shortage of doctors in the public hospitals.”
The situation is exacerbated by a more general phenomenon of an expected shortfall in doctors in the country in the near future. Given the density of physicians in Israel – 3.6 per thousand, compared with only 2.4 per thousand in the US – this might seem a surprising concern. But Israel has relied heavily on immigration as a source of new physicians, especially the large immigration from the Former Soviet Union in the 1990s; it is estimated that fewer than 40 percent of all licensed physicians in the country up to age 65 have studied in local medical schools. The sources of immigration are drying up, however, and greater reliance on homegrown physicians will be inevitable.
The country currently has four medical schools and is planning to open a fifth.
“There was no shortage of doctors for a long time because the country enjoyed a nice free supply of immigrant doctors,” agrees Milgrom, who was an immigrant doctor himself, arriving in Israel in 1982 from Chicago, after undergraduate and graduate studies at the University of Chicago, and medical studies at the State University of New York (SUNY). “At one point, I think most of the doctors I worked with were immigrants from Russia. In the 1930s, we got doctors coming from Germany as a present from Hitler. But those days are over. We cannot bring in Thai doctors, because doctors need to understand their patients, and for that they need to have the same culture. There is already a shortage, and in some specialties there is a big shortage.”
Glazer agrees. “This is a global phenomenon, but that means there will be competition between countries in attracting physicians,” he warns. “We need to prepare for this now, whether that means increasing the number of medical students, or improving the conditions of doctors in order to attract more talented young people to the field, and keeping them here.”
Milgrom does not hide his anger at both the Finance and Health ministries. With regard to the Finance ministry, he says, “We had our first strike in 1983. That was a 14-week strike that included a hunger strike. We got very little then. The Finance Ministry is playing a trick repeatedly on doctors. The base salary for a doctor [working at a public hospital] is very low, at 7,000 to 9,000 shekels per month. The take-home salary is higher than that, because of all sorts of additional payments, but the pension is based on the base salary alone. So retiring doctors end up in big financial trouble. They retire with lower pensions than civil servants.”
Bayme agrees that the way physicians’ salaries are calculated is detrimental. “Most of the salary is based on fictitious elements, and not paid as a straightforward salary,” he says. “That is wrong. Pay a salary for the work done. Give people a decent salary without paying games, and you will have no problem attracting residents.”
Glazer points out that salaries and work conditions need to be considered together. “It is true that if you look at the sum total that doctors earn on average in this country, it comes to a sum that is not a small amount,” Glazer tells The Report. “But that is because they put in a tremendous amount of extra hours beyond their basic work hours in public hospitals. We won’t attract young residents if we tell them they need to work 60 to 70 hours a week their entire careers to earn a salary. Many doctors today are women who are raising families.”
Milgrom also says that he finds attitudes expressed by the Health Ministry during the strike to be misguided. “The Deputy Minister of Health has suggested that to deal with the doctor shortage, senior doctors do the [marathon] shifts that the interns do,” Milgrom points out. “That is impossible. It is physically impossible for the older doctors, and the senior doctors have too much responsibility to work all night and then make critical decisions.”
“The Health Ministry doesn’t have a logical plan,” continues Milgrom. “They approve new MRI machines, for example, but then don’t come up with the financing for them, so they don’t arrive. Other places that did not plan well regretted it. In Sweden, at one point, they were begging retired doctors to return to work to cover shortages. We cannot run the system every day as if we are at war and cannot plan ahead a few years.”
In response, Einav Shimron-Greenbaum, a spokeswoman for the Health Ministry, tells The Report that “it was the Health Ministry that first raised the issue of the need for increased physician staffing and a doctor shortage in some specialties, before anyone else. The ministry has managed to add 160 new positions for doctors in public hospitals, an unprecedented achievement.”
Shimron-Greenbaum, sensitive to claims that the fact that the Health Ministry is headed by a deputy minister, Yaakov Litzman (United Torah Judaism) without a full-time minister (Prime Minister Benjamin Netanyahu nominally holds the health portfolio in the government) also adds that “the ministry is moving forward under the current deputy minister with much greater determination than in the past.”
“IF IT WERE UP TO ME, I WOULD increase the number of medical students, in line with the growing demographics of the country,” recommends Milgrom. “I would also bring Israelis with MDs from abroad. We can give clinical experience training programs for those coming from abroad who need extra training.”
Bayme also points to a mismatch between demographics and the geographic allocation of doctors. “The way physicians are allocated in the country is not well done,” he says. “Demographics have changed since the last time the Health Ministry decided on the allocation of doctors.” Further, Milgrom says there’s a need for more general investment in the health system. “We need to invest in facilities and staff. We already have a backlog of operations because of a lack of nurses, and the lack of space in recovery rooms. Physical therapy sessions are being held in stairwells.
Raise salaries to keep doctors from running off to do private medicine instead of staying in the public hospitals. Give hospital staff the support they need. We need to keep the best doctors in the teaching and research hospitals, otherwise we will have a disaster.”
For Bayme, the main point is balancing the public system with the growing private system. “If you want to strengthen the public system, then yes, offer better terms to the doctors,” he tells The Report. “And I know many doctors who would be very happy to work in public hospitals if they had the opportunity and terms were a bit better. The private system in this country is booming. Let’s get things right with the public system. But we cannot claim to promote the public system and at the same time harm it.”
Glazer recommends strengthening the public health system in a surprising way – by further integrating the private and public systems. He criticizes strict policies forbidding the provision of private health treatment in most public hospitals, a policy that was adopted to prevent a situation in which private care slowly crowds out public care. “No doctors would remain in the public system if they were forbidden from also working in private care,” says Glazer. “But this has led doctors working in public hospitals to leave en masse in the early afternoon, to rush to their other jobs at private hospitals and clinics. This is a redundancy in the system that leads to unnecessary costs and waste, not to mention causing the doctors stress and exhaustion. There is no reason not to allow public hospitals to permit doctors to treat patients on their grounds under private arrangements, at agreed upon hours, as long as it is regulated, and does not come at the expense of public health provision.”
That, claims Glazer, would benefit all involved: doctors would feel less stressed, patients coming to hospitals would have more choice, and the hospitals would have a larger revenue stream that they could invest in shoring up the public health system. “That,” he concludes, “could make a significant difference.”
Ziv-Ner expresses only frustration. “We want to find a solution, to wind down the strike,” he says. “So far, it feels like we are conducting negotiation meetings only for the sake of going back to the court to report that we are doing something.”