Seeking an optimal mix of high quality health care without going bust.
By JONATHAN MARCUS
The cost of health care is spiraling over the whole of the Western world, a result of growing life expectancy and a continuing flow of expensive and innovative medical equipment and medications coming onto the market.
Thus health care is becoming increasingly expensive, and the standards of treatment and service are declining or, at best, standing in place. Many people want to immunize themselves from these woes by taking out some kind of health insurance.
All Israelis receive basic health coverage - from general practitioners and specialists in clinics, hospital outpatient and inpatient hospitalization - from one of four public health funds. They can also opt for supplementary health insurance through their health fund and health insurance schemes offered by the private insurance companies.
Under the 1995 National Health Insurance Law, every Israeli resident must choose a health fund, and no one can be turned down because of age or state of health. These basic services are financed through the health tax (mas briut) deducted by employers from salaries (or sent in by the self employed) via the National Insurance Institute, which distributes the money among the health funds according to a formula based on the size and ages of their patient populations.
The basic idea is that nobody should be left without medical care, and the system does indeed manage to achieve this objective, at least on a basic level. Certainly, the non-elective and emergency procedures are dealt with reasonably adequately. But there are still long queues for some procedures and no coverage for very expensive, life-saving medications not included in the basket of health services, as well as too few nurses in hospital wards.
To avoid these problems, private health care is seen by some as a supplementary solution.
Private medicine is provided in a growing number of for-profit hospitals and medical centers. In addition, private care (called Sharap), in which you can choose the doctor you want for consultation or to perform surgery, is available in a limited number of voluntary hospitals (mostly in Jerusalem). It is illegal in government and Clalit Health Service-owned hospitals (which doesn't mean that it doesn't actually occur "under the table"). Senior doctors in medical centers with Sharap are permitted to use hospital facilities to treat their private patients, in exchange for sharing fees with them. Sharap treatment a entitles you to select the doctor who will operate on you and enables you to get consultations arranged faster, but legally is is not supposed to speed up scheduling of operations. It also does not buy you any different level of nursing care from that provided in any case by the hospital.
The second level of health insurance brings you somewhat closer to getting private health care, within the limitations previously described. The health funds provide supplemental health services (Shaban) insurance. These plans offer partial cover for some private consultations and treatment, plus other benefits, including reduced charges for some mediations not included in the basket of health services.
The problem with these plans is that the rules can be changed almost unilaterally by the health funds, and supervision by the Treasury's insurance department is not very rigid. On the other hand, the plans do cover a lot of items not included in the health funds' basic basket of services. A client of mine has a child who suffered from serious acne. The medication prescribed would have cost NIS 600 a month for half a year, but supplemental insurance covered half. In terms of long-term geriatric care insurance, the level of cover is rather low and again is hedged around with a number of conditions. Each health fund plan treats the subject differently. (I hope to go into the whole issue of long-term care insurance in a later article.)
Insurance plans provided by private insurance companies are sought by some because of the "holes" in the other two layers. Customers sign up individually or through their workplace agreements or other organizations. Private medical insurance plans are designed to cover "catastrophic" cases and do not in general provide cover for the more routine, simple medical problems supplied by the public health funds.
The coverage offered under private insurance plans is for all surgery, transplants and medication not included in the basic basket. Surgery includes any invasive procedure. Transplants are covered normally with no limitation on the amount of cover or at the very least a very high ceiling, which is more than enough to cover the cost of transplants. The cover for transplants gives freedom to go abroad for the procedure without requiring the Health Ministry's prior approval (a condition for activating the transplant coverage under supplemental health services schemes offered by the health funds). But in any case, even many patients with private insurance have difficulty finding organs abroad because of the severe worldwide shortage.
A growing number of new medications are not included in the health funds' basket, whose additions are approved by the Health Ministry upon recommendation of a public committee that meets at the end of each year. How much the basket is expanded annually is decided by the Finance Ministry and approved by the cabinet after much begging by and bickering with the Health Ministry. The amount by which the basket is expanded has not kept up with the needs of patients and the rapid development of new medical technologies.
Private insurance plans offer customers fixed, transparent coverage that cannot be changed by the insurance company except to the advantage of the policyholder. There is a large variety of plans on the market, varying in price and content. Additional coverage is often available as optional extras.
As with any insurance plan, the question of which to choose and the level of coverage required depends on personal preferences and how much the customer is willing to pay in premiums. Consult with a professional before deciding on medical insurance. The Israeli system is somewhat complicated, and familiarity with the overall picture is vital for getting an optimal mix.
The writer is an insurance broker.
jonathan@bh-ofs-israel.co.il