Wednesday, September 10, 2008

Israel's Healthcare System

Navigating the Healthcare System in Israel

Israel has one of the most advanced public healthcare systems in the world. Israeli citizens are provided with a very wide basket of health services in first-rate clinics and hospitals, and administered by highly-trained physicians, nurses, and technical staff. The health care system in Israel is still characterized by being public, in both the financing and the delivery of health services. The distribution of the health services around the country is relatively equal, and there are very short queues for various procedures. Life expectancy is high, infant mortality is low, and the people’s satisfaction from the health system is high— all of that achieved with a relatively low rate of expenditure (7.8% of the GDP compared to 16% in US).

As of 1995, Israel has had a National Health Insurance Law (NHIL) that provides health coverage to all citizens of Israel (there are no uninsured people in the country). The healthcare system in Israel is based on four health plans called “sick funds” which are not-for-profit entities. These are comparable to the Health Maintenance Organizations (HMOs) found in the USA. As of 1995, contributions to the health plan of choice are compulsory, and are collected through the equivalent of a health tax. People are free to move from one health plan to another. All Israeli citizens, irrespective of their age, income, or existing medical conditions, are entitled to full medical insurance with an identical package of health benefits offered by all four health plans. This package is determined by the government through the Ministry of Health (MOH) and offers a uniform basket of services. In addition to the compulsory health insurance, individuals can purchase additional voluntary health coverage known as “complimentary insurance” offered through their health plan. About 70% of the population has this type of additional coverage. People may also purchase private health insurance from a variety of private insurance companies. Tourists and other non-citizens must arrange health insurance for their stay in Israel as they are not covered under the NHIL. However, nobody will be denied needed medical care by hospitals.

The four health plans are Klalit Health Services which covers about 55% of the population, Maccabi Health Services (24%), Meuhedet Sick Fund (11%) and Leumit Sick Fund (10%).

The MOH provides some services not offered by the health plans. They include preventive care such as immunizations, maternal and baby care, psychiatric care, long-term hospitalization and control of communicable diseases. The MOH plays a very unique and sometimes controversial role when providing healthcare. On the one hand it regulates, plans, supervises, and licenses various activities, and on the other hand it owns and operates several government-funded hospitals, so in a sense it regulates and monitors itself. It owns about half the acute-care beds in Israel. The remaining acute beds are in other hospitals— many owned by Klalit Health Services— including public and private hospitals.

The provision of primary-care varies by health plan. Klalit has a network of primary-care clinics to which members can come at will, or by making an appointment, to see a primary-care of pediatric physician. No co-payment is required for such visits. Other plans provide lists of physicians who are associated with the plan and patients see them in their private offices. Secondary-care (i.e. specialists) is provided either through specialty outpatient clinics, either in a hospital if owned by the health plan, or health plan-designated clinics. A small co-payment is required for most specialists and it covers visits through 3-month quarters. Prescription drugs also involve a nominal co-payment. Such drugs can be obtained either in health plan pharmacies or private pharmacies that have special arrangements with the health plan.

The Israeli NHIL stipulates a National List of Health Services (NLHS) which all residents are entitled to receive from their health plans (HMOs). Every year, as part of the annual budgeting process, the government determines the additional budget that will be available to fund new technologies. Since the budget allocated is far from being sufficient to keep up with the pressures of the growing healthcare market, using a priority-setting process is inevitable. This list has been updated annually for almost a decade using a structured review and decision-making process. The Israeli-explicit priority-setting experience is unique and may be considered groundbreaking.

Israel is also the leading country in the world in the scope of computerization. Clinical information systems have been widely implemented in Israel since 1990. Electronic Patient Records (EPRs) have been installed and actually running among all primary-care physicians in Israel, as well as in many secondary care clinics and in hospitals. Almost all primary care records in Israel and the vast majority of secondary care records are fully computerized. This facilitates electronic real-time documentation of all physician-patient encounters during a visit, selective context-based data retrieval during treatment monitoring, order entry for drugs, laboratory referrals, expert consultation and imaging, as well as a bi-directional interface with administrative computerized systems.

Unfortunately, in the last few years there has been a decrease in the government’s share of financing health services and a shift to more private use, raising problems of equity. Many people do go to private physicians as they want to make sure they have consulted the “best”. People do feel that if they see a physician privately, they will receive preferential treatment once they encounter this physician in the hospital. Unfortunately, this is sometimes true. °

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