There will never be enough in the state-subsidized "health basket" to satisfy all patients - but the public committee that recommends how to expand it within budgetary limits is doing a very good job, says Prof. Yehoshua Shemer, who designed the selection technique that has been used for over 11 years. Shemer, a former Health Ministry director-general who is now chairman of Assuta Hospital, told The Jerusalem Post this week that Israel still offers one of the most generous health baskets among countries with national health insurance. He was commenting on the recommendations by the public basket committee on Friday of drugs (and additional indications for drugs) worth a total of NIS 415 million, that would be offered to patients. These medical technologies will be provided to relevant patients from 2009 by their health funds at nominal cost; those that remain outside the basket have to be purchased by patients on their own. The National Health Council will meet on Wednesday to decide whether to approve the recommendations and send them to be signed by the health and finance ministers. A couple of years after the National Health Insurance Law went into effect in 1995, Shemer proposed a way of expanding the basket as new drugs and techniques became available - despite strong opposition from the Treasury, which wanted to keep the basket as static as possible. Shemer's procedure - having a committee of doctors, public representatives, Treasury and Health Ministry officials meet for months to discuss the pros and cons of each candidate for the basket - has been in effect since. However, the Treasury still decides each year by how much to expand the basket, and the committee must work within those limits. Most public health experts believe that this power should be taken away from the Treasury and that the basket be automatically increased by two percent annually. A private member's bill to set an automatic 2% increase each year has been submitted to the Knesset, and Shemer hopes it will pass. "We provide more medications than almost any country with national health insurance," said Shemer. But there are some improvements that can be made in the basket committee system, he said. He would use a ratio of cost and quality-adjusted life years (QALYs) as an objective way to set criteria for including proposed medical technologies in the basket. QALYs are a measure combining the time by which life is extended and the quality of life of an intervention. It assumes one year of perfect health-life expectancy to be worth 1 and calculates a year of less-than-perfect life expectancy as less than 1. Thus medical interventions can be compared and weighed according to benefits gained in terms of the patient's quality of life and survival. Shemer noted that there are already 240 medical technologies whose QALYs have been turned objectively into numbers. "The basket committee should calculate the cost per QALY for each of the drugs and medical conditions [possible new indications] for existing drugs," he said. "This is now used around the world to compare cost-effectiveness of medical interventions." In addition, he would like the committee to explain objectively why a certain candidate was added to the basket and why another was not, to neutralize any vested interests, public pressure or lobbying from outside the committee. In addition, he said, a law should be passed making the health basket committee a statutory body. Because this was never done, numerous petitions to the High Court of Justice have claimed the committee has no legal right to decide how to expand the basket. Shemer said it is a shame that the Israel Medical Association has not been represented in the basket committee for two years, ever since IMA chairman Dr. Yoram Blachar resigned, claiming that the committee had too many Finance Ministry representatives and no one representing patients. IMA representation is needed as part of a system of checks and balances, Shemer said. The public representatives, including ethicists, are needed to "ensure that processes are clean and on the right track." It is a "mission impossible to satisfy everyone, but the basket does include two or three times more expensive cancer drugs than the British National Health System, and the Israeli committee has taken into account new research that proves a certain drug extends life that was not available in previous years." He praised the Health Ministry's unit for medical technology assessment, headed by Dr. Osnat Luxenberg, for preparing the committee's material on candidate drugs. "They have done excellent work," said Shemer, who was previously her boss at the ministry.