A study of private medical services in Jerusalem, recently released by the Myers-JDC-Brookdale Institute, aims to provide information to policy makers who will be deciding whether to expand the program, commonly known by the Hebrew acronym, "Sharap," to government hospitals nationwide. Currently, private medical services are legal and available in four major Jerusalem medical centers - Hadassah Ein Kerem, Hadassah Mount Scopus, Shaare Zedek and Bikur Holim. Patients who take advantage of these services pay a fee to the hospital, which enables them to consult with a senior physician of their choice or designate a specific physician as their surgeon. A portion of the fee is kept by the hospital, while the rest is passed directly to the physician. In Jerusalem, these hospital-based private medical services are available for both in-patient and out-patient care. Currently, these services are offered in hospitals run by nonprofit voluntary organizations, and Israeli law does not permit the establishment of such services in government hospitals or in those operated by the Clalit health services. According to the Brookdale researchers, Bruce Rosen, Gur Ofer, and Miriam Greenstein, the possible establishment of similar, hospital-based private medical services elsewhere in the country raises a number of policy-related concerns. These concerns include the extent to which private services are also accessible to poorer patients and whether the program creates a "two-tiered system of health care" in which poorer patients receive a lower standard of care. Furthermore, with the introduction of the hospital-based medical services, many fear that senior physicians will spend their time "inefficiently," taking on a number of simple cases, that might be more efficiently handled by junior physicians, instead of handling more complex public cases in need of greater expertise. In undertaking this study, the researchers also considered the potential benefits that a hospital-based private medical service could bring. Advocates have argued that a patient has the right to choose his or her physician. Many have also claimed that the institution of these services in government medical centers would increase the number of hours senior physicians spend in those hospitals. Furthermore, supporters also argue, these services would provide government hospitals with additional, much-needed income. According to co-author Rosen, who is also head of health policy research at the Myers-JDC-Brookdale Institute, this is the first report of its kind. "There has been only one other study of these services and it was based on a survey regarding patient satisfaction. Ours is the first to use hospital records, the scope and the source of data are unique, as well as the questions we are examining." While the findings remain largely inconclusive, Rosen argues that the study does "open the door" to a data-based discussion of the issues. The research project analyzed data from all 37,000 surgical procedures performed in 2001 in three of the Jerusalem hospitals (Shaare Zedek, Hadassah Ein Kerem and Hadassah Mount Scopus) offering private services. The researchers found that these services are more financially accessible to the middle class than had previously been thought. In part, this is due to supplementary insurance policies which cover part or all of the additional fee. As of 2001, 70 percent of Israelis were covered under supplementary insurance. Furthermore, according to the study, the fees for private operations and procedures are not as high as the public seems to believe. Very often, fees total less than NIS 10,000, while in 2001, the median price for privately-performed surgical procedures at Shaare Zedek was NIS 5,000. Nonetheless, such sums are out of reach for many of Jerusalem's numerous impoverished residents. Ran Melamed, Deputy Director of Yedid, a leading non-profit social rights organization in Israel, is concerned that while private medical services and supplemental insurance are currently considered optional, in the foreseeable future, these services will become so common that, to receive a reasonable standard of health care, health consumers will have to pay for them. At that point in time, Melamed argues, medical services that are considered standard will be out of reach of poorer populations and, "there will be no way for low income families to obtain the health coverage they need." Indeed, among its other findings, this study did find that patients now frequently employ private services for basic and routine procedures. Rosen explains, "Much of the private service is the 'bread-and-butter' of medicine: less complex, less risky procedures, at least relatively speaking." Jerusalem's poorest populations, who have least access to the hospital-based private medical services, include the haredi and Arab populations. The Brookdale study found that while few in the Arab community are able to afford these private services, many in the haredi community do take advantage of them, despite their low level of income. The authors of the study speculate that this phenomenon is most likely due to the "well-developed mechanisms of mutual aid" in these communities. According to Rosen, the public seems to perceive that private medical services are better, medically speaking, than public health care. Yet the data on this issue remain inconclusive. Rosen explains that the study did not examine the ultimate outcome of procedures performed privately and publicly (due to a limitation of the available data), but researchers did examine the seniority of the physicians involved and the complexity of the procedures. Researchers found that in the cases of the most complex and medically-risky procedures, patients who were not able to use private health care services were "very likely" to receive a senior, tenured physician as part of their surgical team. Thus, opting for private services does not increase the likelihood that a complex operation will be performed with a well-qualified surgeon present, although it does increase the likelihood that the lead surgeon (the one officially in charge of the operation) is seasoned. While the public perceives that the qualifications of the lead surgeon are of paramount importance, medical experts say that health benefit is more strongly correlated to the presence of an experienced, tenured physician on the surgical team. In the case of simpler surgeries, many people who could afford to do so opt for private medical services, thus employing highly qualified physicians for procedures that were neither risky nor difficult and may well have been properly executed by a more junior physician. Results of the study suggest that it is prudent to use private services in cases of "moderately complex surgery" in which public funding might not pay for a senior physician, but the presence of such a physician could dramatically increase the chances for the surgery's success. Does the existence of the private system lead to an inefficient use of physicians' time? The data on this issue, too, remained inconclusive. Rosen notes that many of the senior surgeons who are performing simpler operations are working longer hours to do so, suggesting that they are performing simpler operations in addition to complex surgeries, not in place of them. Advocates of legalization of private medical services in state-owned medical centers also argue that its presence would keep senior physicians physically in government hospitals. Today, many work part-time in government hospitals and then spend afternoons in private clinics. Rosen further emphasizes that, "the health gains from the private medical services are not always as large as people had previously thought. In some cases, the benefits can be very large, but in many cases they probably are not. It is important for patients to have access to information and make informed decisions." But Melamed contends that the data do not tell the entire story, since the study did not examine surgical success rates. "As soon as physicians receive more money, they do more and pay more attention," he cautions.