Health system ombudsman asks insurers for more flexibility

Health system ombudsman

Decision makers in the four public health funds should consult more with their physicians and be more flexible when determining what services and medications to allow patients rather than taking rigid decisions based on the letter of the law, advises the National Health Insurance system ombudsman, Etti Semama. She states this in her 198-page biennial report for 2007/8, which was issued for publication on Thursday morning. It was the first report she produced alone after replacing the first and previous ombudsman, Dr. Karny Rubin. The report was presented to Knesset Speaker Reuven Rivlin this week. Health insurer administrators' decisions should be suited to medical dynamics, and their internal debates about economic costs to the insurer versus treatment benefits to the patient must be held while considering both the physicians and the patients, Semama wrote. In recent years, as the health funds have been pressed by the Health Ministry and the Treasury not to operate at a loss, their managers sometimes take a more stingy approach. According to the Hebrew-language report, which will be put up soon on the Health Ministry's Web site (, a total of 7,920 official complaints about health insurance coverage were filed against the health funds or the government in 2007. Twenty-three percent of them were judged by Semama as being justified. The figure for 2008 was a whopping 9,544; last year, 24 percent were declared justified. The health fund against which the largest number of complaints (per 10,000 members) were filed was the smallest insurer - Kupat Holim Leumit. In addition, Leumit was the target of the highest rate of justified complaints against the health funds. Regarding complaints about refusal to supply patients with certain medications, the highest number of complaints (per 10,000 members) was filed against Kupat Holim Meuhedet, the third largest health fund; in addition, the highest rate of justified complaints on this matter was also against Meuhedet. As for complaints about being denied certain medical tests and treatments (especially for CT, PET and MRI), Leumit was the target of the most complaints. Maccabi Health Services was the target of the most complaints about paramedical treatments and Clalit about choice of service providers. However, in general, Maccabi - the second-largest health fund - was the target of the fewest complaints filed with the ombudsman. Maccabi director-general Dr. Ehud Kokia commented that he was pleased by this - for which his health fund was cited in previous ombudsman's reports - and would continue to work to minimize those justified complaints filed by Maccabi members. Yet Semama pointed out that the rise in the number of complaints that reached her office did not necessarily mean that Israelis are less satisfied with the health services they receive. Instead, it may represent the fact that accessibility of residents to the ombudsman was greater. It was important, she added, for the health system to identify and acknowledge its faults and repair them. She said that more residents are becoming aware of the option of complaining to her office about their treatment because a law that went into effect only last year requires all health fund facilities to post signs about the ombudsman and how to reach her. Semama noted that she believed the complaints she does receive are only "the tip of the iceberg" and that many health fund members are dissatisfied but don't bother or know of their right to complain. Since 2007, the health system ombudsman has had the power to order a recalcitrant health fund to reverse wrong decisions. Most did so, but Semama said that nevertheless, in a few cases, the insurer - mostly Clalit - refused to carry out such orders. Dissatisfied health fund members can go to any post office to fill out a form and switch to another provider if they have been a member of the first for at least six months. But this shortened tenure requirement was created only temporarily, and there is now a requirement of a year's tenure. Semama called for a law that would shorten it to half a year. The ombudsman noted that two years ago, the Finance Ministry prohibited the health funds from including in their supplementary insurance policies the granting of lifesaving drugs not included in the basket of health services. This was officially meant to promote equity in health services, but many suspected that it was changed to promote the business of private insurance companies. Semama wrote that as the wealthy have the option of private insurance to get additional medications, the Finance Ministry and the whole government must help the rest by allowing an annual automatic increase in funds for expanding the basket of health service to include more lifesaving and life-improving medications. She also called on health system policymakers and health fund directors to develop a mechanism that would allocate a set sum of money to treat "orphan diseases" (those that affect only a small number of patients) for which there are no effective medications in the basket of health services.