A checkup for the health funds

New Maccabi Health Services head speaks about improving public satisfaction with Israel's healthcare.

dr ehud kokia 224.88 (photo credit: Maccabi Health Services)
dr ehud kokia 224.88
(photo credit: Maccabi Health Services)
Four men - directors-general of the public health funds - are largely responsible for the wellness of all Israelis. But among Eli Depes of Clalit Health Services, Ehud Kokia of Maccabi Health Services, Shmuel Mualem of Kupat Holim Meuhedet and Nissim Alon of Kupat Holim Leumit, only Kokia is a physician. "The head of a health fund must be a good administator," he says in an interview with The Jerusalem Post. If he can also be a doctor, it's preferable, as the doctor-patient relationship is the most important thing in healthcare, and people choose their insurer according to the doctors in it. I understand that. But being a physician is not enough if one isn't a good manager." The second largest of the four health funds, Maccabi now boasts almost 1.8 million members, or 24 percent of the Israeli population - including half of all new immigrants, who hear about it by word of mouth. It also has 6,000 employees, a NIS 6.4 billion annual budget and 150 community clinics. Although Kokia - a gynecologist and fertility expert by training - has been at Maccabi for 12 years after spending two decades in the IDF, he says he "never dreamed" of being the fund's director-general. But Prof. Yehoshua (Shuki) Shemer, Maccabi's high-profile and charismatic director-general for six years, suddenly announced he was leaving to join the private sector (and become the health fund's unpaid associate chairman and chairman of its Assuta private hospital). Kokia competed against six or seven candidates from within and outside Maccabi, and in May, two months after Shemer's resignation, was chosen for the post. HE WAS told it might be hard to replace Shemer - a former IDF chief medical officer and director-general of the Health Ministry who initiated the process for expanding the basket of health services, as well as a longtime Tel Aviv University professor and researcher "I was told I was going to have to fill his 'big shoes,' but I bring other shoes," says Kokia. "Shuki set very high standards that I have to meet. I worked with him very closely. He gave Maccabi a balanced budget for years and developed it greatly. He set a high standard. Every one has a different type of management, and though he is still involved as a member of the directorate, he gives me a free hand. It is a very good institution, and much of the credit should go to Shuki for setting the goalposts of high quality and economic stability." Maccabi was established in 1941 by a group of German and Austrian Jewish physicians who had fled the Nazis "They wanted to offer health services without politics or bureaucracy." The existing health funds were then owned by political movements. Kokia was born to well-known Jerusalem family named Kukiashvili which arrived here in the 19th century from Georgia (formerly a Soviet republic). They bought tracts of land in what is today the center of town on and around Jaffa Road. But his part of the family, he says, didn't inherit a lot of money. Born in the old Shaare Zedek Hospital and raised in the Mahaneh Yehuda market area, Kokia joined the academic service (Atuda) in the IDF, studying medicine at TAU's Sackler Medical Faculty. Later, he completed a two-year fellowship in fertility at the University of Maryland and graduated from the US Navy/Air Force's rigorous aeronautical medicine course in Pensacola, Florida. "I took the advanced flight surgeon and survival course in 1990. For a Jerusalemite who didn't know how to swim at 40, I had to swim a mile with my boots on. That I passed is one of the things in my life of which I am most proud." During his military service, he served as commander of the Israel Air Force's aeronautical medicine center. In 1995, after returning to civilian life, he joined Sheba Medical Center at Tel Hashomer, where his wife Ira was studying to be a pediatrician. They have two children, a biologist named Hila and Uri, a professional basketball player. Then Kokia joined Maccabi and served in a variety of positions, including head of the Negev district, director of the medical branch and, most recently, as head of the health division, which is the highest position below the director-general. IF YOU randomly ask Maccabi members if they're satisfied with their health fund (as I have), you'll get very few complaints. Thus Kokia and the heads of the other insurers were startled by recent Ben-Gurion University of the Negev and University of Haifa research showing that trust of the insured in their managements and directors is very low - especially after other ongoing surveys by polling organizations showing 85% to 95% satisfaction, especially among the elderly, new immigrants and Arab Israelis. In addition, residents can switch to another health fund twice a year merely by filling in a form at a post office, but only 1% actually do. If it is any consolation to the health funds, trust in the Health Ministry was much lower in the new study - at 2.7 out of five. DR. SHLOMO MIZRAHI and Nissim Cohen of BGU and Prof. Eran Vigoda-Gadot of the university in Haifa queried a sample of 650 adults from all the health funds. Clalit Health Services, the largest insurer, received a score of 3.19 for trust in the fund; 3.15 on its performance; 3.67 for trust in its doctors; 2.79 for trust in its central management; 3.1 for trust in its directors; 2.51 for cooperating with the public in making decisions; and 2.81 for accessibility. The corresponding ratings for Maccabi were 3.06; 3.28; 3.54; 2.77; 2.9; 2.49 and 2.61. The ratings for Kupat Holim Meuhedet were 3.09; 3.17; 3.8; 2.62; 2.87; 2.41 and 2.64, while those for Kupat Holim Leumit were 3.15; 3.2; 3.65; 2.78; 3.05; 2.5 and 2.75. While there weren't major differences in most categories, Maccabi Health Services received higher marks than the others in efficiency, use of advanced technology and high-quality facilities. The researchers said the fact that managements received lower marks than services showed the need for immediate improvement in administration and to run themselves according to the standards required by the National Health Insurance Law of 1994. This effort, they said, could improve the health funds' public image, especially if the public is integrated into this effort. Asked to comment when the study was released, Maccabi spokesman Ido Hadari said all such surveys "are important and help us analyze our functioning better. I have no doubt that if our members were more familiar with our activities, the marks would be higher, so we must invest more in exposing the public to them." Kokia comments that at conferences abroad, it is clear that the level of medical care in Israel is among the highest in the world, especially among those health systems that are publicly funded. And in community health services, there is nothing in the world like ours." The academic study, he continues, did not clearly explain the researchers' methodology. "It was a small sample, and it was not clear how they reached some of conclusions. Only if it is published in a peer-reviewed journal can it be taken seriously." Nevertheless, Kokia is taking measures to create stronger and more frequent contacts between Maccabi and its members. "We are going to establish a virtual forum, with thousands of members who will be our sensors on quality of care. It will be via e-mail, but it's not only for the wealthier or older members. We will define a sample of members representing all social and ethnic groups to serve as a permanent sounding board, similar to the Neilson rating samples of TV programs. It will include members who are around 35 years old who don't often go to the doctor. It will also include health promotion and disease prevention." The Maccabi director says the health fund will increase the amount of information provided, as "some of our members don't know what they are entitled to. We are a non-profit organization and believe in transparency." Maccabi also respects Arabs, Russian immigrants and haredim who have special sensitivies, and provides its Maccabiton newsletter in different languages and styles to suit them. The trend of health funds' performing diagnostics and treatment in the community whenever possible instead of referring patients to hospitals is the result of economics, he continues, but also better for the patient in many cases. People are still sent to hospital outpatient clinics and institutes if they have a center of excellence in the relevant field or equipment Maccabi lacks. "If we had enough money, we'd send members to hospital outpatient services. But we can't spend more than the funds we receive from health taxes. We have no choice, so have to work more efficiently. If a cheaper generic drug is as good as, and the same exact molecule as the patented version, we prescribe it; if it is not, we give the original commercial brand. And if a health fund has a balanced budget, it can afford to give additional drugs that are not in the basket of health services." Kokia has set up a small team that is working to minimize communications problems with some members, including elderly, new immigrants and the disadvantaged. "We have many members with serious diseases who get lost in the health system. Every Maccabi branch will locate such patients and assign at least one staff member to be their advocate and help them get through the system." The great power and influence of young Treasury budgets' division personnel is frustrating to all health fund directors. "It's all numbers, not individuals, for them. They are not bad people, but they are theoreticians. After a few intensive years at the Finance Ministry, they leave to make large salaries working for banks. Most of them have never been managers," Kokia says, "and if they were older people with management experience, it would be better." IT'S VERY frustrating when one sees how health policy is made, he adds. "I can sit in the Knesset with MKs, and they agree with us that this Treasury edict is wrong and harmful. But they say there is coalition discipline, and they have to vote for it. We employ a lobbyist for the Knesset as well, as all the health funds do; it is the name of the game and one of the rules of democracy. But we have very little ability to influence the establishment." The 2008 national budget's Arrangements Bill also gives the Treasury control over the salary of all senior health fund employees. The Maccabi director-general will be able to earn no more than NIS 55,000 a month, which sounds like a lot to the average Israeli but not to senior managers in business. Subordinates will be able to earn only a set percentage of the top salary. "In the short term, we will not be affected, as existing staffers' salaries will not go down, but in the long term, it will be difficult to attract excellent people, who will go elsewhere. As a gynecologist and fertility expert, in the private market I could earn a lot more. Fifteen years ago, if I knew there would be a salary cap at the top, I'm not sure what I would have done." The Arrangements Bill also includes a prohibition of health funds' supplementary health insurance policies from offering members medications not included in the basket of health services. Although Health Minister Ya'acov Ben-Yizri originally approved such inclusion earlier this year, he then cancelled it, reportedly under the influence of the Treasury and private health-insurance lobbyists. "I am disappointed that the ministry, which supervises health funds, hasn't protected us against the Arrangements Bill. The ministry should be a regulator and not own its own hospitals, he insists. Asked to comment on Ben-Yizri, Kokia pointedly says: "I prefer not to speak about the minister." The long-term solution to the inadequate updating of the health basket is for the Knesset to approval an annual 2% increase without the annual begging ritual of health officials at the Treasury. In a few years, all the vital drugs would be in the basket. "If I were Prime Minister Ehud Olmert, who was health minister himself, I would accept the automatic update with both hands. There would be no more demonstrations by patients, and he would have quiet." Kokia, a soft-spoken but determined administrator, concludes that he gets the most satisfaction from solving the problem of individuals. "It makes my day. And it is a challenge to finish the year with a balanced budget while offering the best possible service."