Analysis: A good, but not revolutionary, deal

Agreement signed between IMA and doctors’ employers will not resolve all the serious problems of the public health system.

Rambam doctors strike march 311 (photo credit: Piotr Fliter)
Rambam doctors strike march 311
(photo credit: Piotr Fliter)
The long-sought agreement signed on Thursday between the Israel Medical Association and the doctors’ employers will not resolve all the serious problems of the public health system. But it will make a significant contribution over the next eight years to increasing the number of physicians, encouraging them to live and work in the periphery and specialize in “unattractive” medical fields, and minimizing their regret that they did not become a computer whiz, lawyer or accountant instead.
So believe leading physician and outgoing Hadassah Medical Organization director-general Prof. Shlomo Mor-Yosef, and senior Ben- Gurion University health economist Prof. Dov Chernichovsky, who were interviewed by The Jerusalem Post.
Mor-Yosef, a gynecologist by profession who will conclude 10 years as Hadassah’s chief administrator later this year, has been closely involved in the negotiations as representative of an employer of the largest group of physicians in the capital.
“The agreement has an ideology; it is not an across-the-board wage increase,” said Mor- Yosef. It deals with the years of fewer doctors and a lower level of medicine in the periphery, the public hospitals’ shortage of medical manpower, the lack of equity and the many night and weekend shifts whose burden is carried largely by young medical residents, he continued.
“The accord focuses more on a doctor in intensive care in Safed’s Ziv Medical Center than an ophthalmologist in Tel Aviv,” he continued.
Unlike the agreement that ended the previous IMA sanctions in 2000, “in which wage rises were uniform, it will not be the same benefits for all this time. And that is good. The Treasury agreed to allocate more public money because it was the way to promote improved medicine in the periphery and in those specialties that few doctors want to study because they offer lower incomes.”
One section in the agreement involves what the Treasury has long aspired to – that physicians will punch a time clock or use some mechanism such as a cellphone application so that employers will know where hospital doctors are when they are supposed to be on duty.
Mor-Yosef noted that neither the two Hadassah University Medical Centers, Shaare Zedek Medical Center nor Bikur Holim Hospital – all Jerusalem institutions owned by voluntary organizations, will use time clocks for doctors. They have had Sharap (private medical services) as options for those patients who can afford or have insurance to cover it. So managements know that their more senior doctors are in the hospital beyond mid-afternoon because they perform private consultations and perform surgery late in the day and into the evening because of the arrangement.
According to the new accord, per-hour basic wages will be paid according to a five-day, rather than six-day week, and those who work more will get overtime. Medical specialists will not have to work late-night and weekend shifts six times a month like the residents, but they will do a number of shifts, usually until 11 p.m., each month so that they can respond on site rather than be consulted only by phone or called in if necessary.
The Hadassah director-general gave much credit to Prof. Yitzhak Peterburg, a former director-general of Clalit Health Services (still the largest public health fund), who is now a deputy CEO of Teva Pharmaceuticals and previously was head of Cellcom. Peterburg’s name as a non-binding mediator was raised by a senior Health Ministry official, and he agreed some 10 days ago, even though he was about to fly abroad to conclude a deal for Teva.
He worked almost round the clock, even 50 hours at one go – to bring the two sides together.
“Yitzhak has a great deal of know-how and experience as a doctor and management abilities as an administrator,” Mor-Yosef said. “He learned the issues very fast. He understood what was important and what was not. Without his work, the agreement would not have been reached.”
Weeks of intensive involvement by National Labor Court President Nili Arad failed to forge an agreement. Mor-Yosef said that no major changes were made in the draft agreement reached a month ago when IMA chairman Dr. Leonid Eidelman halted his 12-day hunger strike in Jerusalem. That seeming “breakthrough” collapsed under pressure from medical residents who claimed it was unfair to them.
“The new agreement clearly benefits medical residents, doctors in the periphery and in short-handed specialties. The result is very impressive. It was because of ideology that some doctors oppose it, because social justice was boosted. Those in the center of the country will not get as much an increase as they wanted,” said Mor-Yosef.
The 1,000 doctor slots that will be added to the system under the agreement will not come immediately. It will take a few years, concluded Mor-Yosef, as they have to finish medical school, get their medical licenses and learn their specialties. In the meantime, idealistic physicians could return to public hospitals and others could return from abroad, he said. “But I hope that the atmosphere in clinics and hospitals will be improved due to the agreement.”
Chernichovsky, who along with his position at BGU is also a senior economist at the Taub Center for Social Policy Studies, told the Post that “on the face of it, there is a significant wage increase. It won’t be the same for all doctors, and some of it could be reduced by inflation. I am for differential pay as incentives for where improvements are needed. But I don’t believe that the Finance Ministry brought about real structural change in the system – and that was due to a weak point at the Treasury.”
The large amount of copayments by ordinary people for medications and various services will remain high, and the public share of healthcare expenditures will remain too low, Chernichovsky said.
The health economist declared that if he had been able to orchestrate the agreement by himself, he would have the Treasury adding another billion shekels, with money from the four health funds’ supplementary health insurance going to increase the number of full-time physicians in the hospitals and much less money leaking out into private medical institutions.
“If this extra money were injected, we would get different health care; it would literally save the public health system,” he said.
“If I headed a major network of private hospitals, I would not lose sleep over the new agreement, as people with means will continue to spend their money on private care. I am worried in the context of Israel in general that now that the agreement has been concluded, the government will say: ‘We have solved the health system’s problems.’ But there is more to do. Doctors will continue to leave the public system for the private one, as the demand for them is still there. I don’t yet see the doctors who will fill the 1,000 job slots that are urgently needed in the hospitals. These fundamentals are not being resolved.”
Chernichovsky noted that if the Treasury is not ready for new wage demands from the nurses and other medical professionals in the system, the doctors’ agreement will not end the trouble. Nurses are also needed in the periphery, he said.
But he did not want to end on a sour note. “I see some good tidings in this agreement. We see cracks in the doctors’ wage structure in the public health system, which is new. This could lead to more individualized contracts – not private contracts but for the first time wages dependent on where you are and what you do. This is a blessing, even though it could weaken the solidarity in the IMA, as there would be tension among groups. But nevertheless, this is the right direction.”
Asked about the large number of community doctors who work in the various health funds and as independent physicians for them, Chernichovsky said: “They are getting a wage that is good compared to that in the hospital. They don’t have to do shifts. They can finish their job every day and do work at a second or third job,” he said.
As for Prime Minister and formally health minister Binyamin Netanyahu and Deputy Health Minister Ya’acov Litzman, Chernichovsky said: “Despite their formal titles, they were not in the game in an explicit way. They were not a partner in the negotiations. The Health Ministry has almost no say on the economic side of the system. The minimal involvement of the ministry in the whole process is a symptom of the office’s relative weakness in the system.”