Since 1995, Israel has had a health care system with universal insurance coverage. All Israelis belong to one of the four national health plans, which provide a standard basket of health care services set by the government.
On top of the publicly available health care coverage, a majority of the population purchases some form of supplementary private insurance, which offers more flexibility in choosing a physician and covers additional services outside the standard benefits package.
Universal insurance coverage is not a guarantee for the quality of health services. Quality is dependent on the level of financing in the system, the quality of health care providers, and their incentives to provide appropriate and quality care.
Moreover, universal insurance coverage is not a guarantee for equality in the access to quality, appropriate care. There are many reasons for this, including co-payments, cultural barriers, attitudes of health care providers, and geographic differences in access to services.
At MJB’s Smokler Center for Health Policy Research, the dual quest for equality and quality in Israel’s health care system is a central theme that runs throughout the research program.
Promoting Equality in Access and Care
MJB has pioneered the effort to examine the extent of inequality of health care in Israel, bringing this issue to the attention of the health system itself and society as a whole. A seminal Institute report from 2006 highlighted efforts in other countries to develop strategic multi-year approaches to reducing inequalities.
Today, promoting equality is one of the top priorities of the health system, and the Smokler Center is actively engaged in helping to develop and implement effective solutions.
One example is our current work with the Ministry of Health on a major initiative to reduce gaps in health and health care, with a special emphasis on gaps in services between the center of the country and the periphery.
The Smokler Center’s research found that the ratio of doctors working in the community or in hospitals is much higher in the central areas than in Israel’s northern or southern regions.
There are many reasons for this disparity, such as more varied work opportunities for spouses and greater educational opportunities for children. But there is also a significant financial factor.
Although most physicians in Israel are salaried employees of the government, the national health plans, or not-for-profit hospitals, many supplement their income by engaging in private practice. The potential for this additional private income is largely found in the center of the country, where people spend much more per capita on additional private medical care than do people in the peripheral regions, as documented by a recent Smokler Center study.
In an attempt to offset the draw of private money in the center of the country, in 2011 the Israel Medical Association and the three major employers (the government, Clalit Health Services, and Hadassah Medical Organization) came to an historic collective bargaining agreement that, for the first time in Israel’s history, introduced new financial incentives to encourage doctors to work in the public system in peripheral areas. The contract provides for higher monthly salaries for physicians working in the periphery, as well as large one-time grants to physicians who move to the periphery and commit to remaining there for several years. The incentives to boost the periphery were part of last year’s larger collective bargaining agreement to improve the overall financial and work arrangements of doctors across the country.
In addition to the direct incentives to physicians, the government is providing two kinds of financial incentives to the health plans to improve services in the periphery. First, the government is adjusting the formula by which it reimburses the plans, to give added weight to plan members in the periphery. Second, special grants are being given to health plans that meet Ministry of Health criteria for expanding and improving services in the periphery.
Finally, the government is taking other steps to boost health care in the periphery. These include launching a new medical school in the Galilee as a lever for improving health care services in the region, in part by drawing additional leading physicians to the Galilee. Also, the Ministry of Health is expanding the acute care bed supply in peripheral hospitals and is investing in upgrading the technological infrastructure in the periphery.
But will these changes be enough to significantly influence the map of health care services in Israel? This is where the Smokler Center is stepping in, with projects to monitor the regional distribution of health care. Included in this is a project with the Ministry of Health and the Israel Medical Association to carefully track the changing distribution of doctors over the next several years, and to measure whether people living in the periphery have greater access to health care.
Quality of Care
Of course, increasing access to health care is far more valuable if that health care is of high quality. Among the Smokler Center’s projects is its participation in Israel’s national effort to improve the quality of its health care, through a multi-year study of the National Quality Monitoring Project (NQMP), a voluntary collaboration between the Ministry of Health and Israel’s health plans.
This pioneering and highly successful program seeks to use quality indicators to monitor primary care. The indicators range from prevention—have female patients received a mammogram within the previous two years—to the care of chronic disease—is the blood sugar of patients with diabetes being kept under control.
Members of the medical team input information about patient care into a centralized database. The quality report card is then reviewed by management of each of the health plans and by the medical teams, which receive valuable feedback on each patient and their overall caseload. All of this is made possible by the fact that Israel is a leader in the development of computerized clinical records.
These efforts will make very little difference unless the data is actually used to improve quality. Thus, a key component of the Smokler Center’s work has been to examine what the health providers do to translate the information on quality into improvements in quality. The Center interviewed more than fifty health plan managers (physicians, nurses, and lay administrators) about their usage of the indicators. The interviews revealed that the health plans are extensively using the data in a variety of ways, such as monitoring the providers, focusing training efforts, and developing new initiatives to improve quality for specific services or for specific groups. For example, the Maccabi and Clalit health plans have implemented mobile mammography units to reach out to populations who might not otherwise have come on their own for check-ups. As well, all of the plans have introduced innovative computer-based reminders for primary care physicians to direct patients to necessary check-ups and screenings.
Through this research, the Smokler Center has widely disseminated knowledge about some of the most innovative and successful managerial practices, enabling the health plans to learn from one another and to further improve their own efforts.
Ultimately, however, the usefulness of the information depends on the cooperation of the medical teams to supply accurate data and to apply it in their interactions with their patients. There have been primary care physicians who vociferously criticized the program as overly intrusive into their practice and as introducing much additional paperwork that diverted them from their clinical practice.
Thus, in the next phase of the research, the Smokler Center conducted extensive interviews with over 600 primary care physicians to get the broader perspective on their views of the program. In contrast to the voices of the critics, the study found that most physicians viewed the program as significantly contributing to their ability to provide quality care. High percentages did express concerns about the workload and managerial involvement, but overall, they highly supported the program’s continuation and indicated an interest in its expansion into more areas of care.
By documenting the broad base of support for the program, the study contributed to the decision to continue and even expand the program. At the same time, by giving a voice to the physicians’ legitimate concerns, the study spurred the program developers and the health plans to rethink some of the indicators and to use them in ways that would reduce the stress on physicians.
The Smokler Center is actively sharing its experience in monitoring the quality of care in Israel’s health care system with the international community. The Center has recently published a paper in the International Journal for Quality in Health Care that compares quality performance in Israel and the United States, and a paper in Health Affairs, one of the leading American health care policy journals, that shares Israel’s experience in successfully using the indicators and how it might be adapted to the American context. A third publication, in the Israel Journal of Health Policy Research, reports on the experience of the physicians in using the data on quality. These publications are contributing significantly to the international dialogue, particularly because there is very limited documentation of similar efforts to monitor quality.
The Smokler Center’s research on health care disparities has been supported by a grant from Andrea and Michael Dubroff, Massachusetts, USA. The research on health care quality has been supported by the Maurice and Vivienne Wohl Charitable Foundation.