Background to the Reform and MJB’s Involvement in its Evaluation
In 2015, the State of Israel undertook significant reform in its system of mental health care, transferring the responsibility for the provision of such care from the state to the health plans. The implementation of the reform regulated the legal right to mental health care for the first time since the National Health Insurance Law took effect in 1995. A mandatory basket of treatments and services was set for the health plans to provide to all their insurees within a reasonable time and distance.
The initiators of the reform sought to strengthen the connection between physical and mental health services, to improve the availability, access and quality of mental health care services for those in need, to alleviate the stigma attached to the provision and receipt of such care, and to render the system more efficient.
Today, more people benefit from publicly-funded mental health services. Moreover the health plans have taken steps to provide culturally-appropriate services to the Arab population, the ultra-Orthodox, and other groups with unique needs.
In the past decade, MJB has played a key role in evaluating the mental health care reform. This has been a collaborative effort between the Smokler Center for Health Policy Research, the Center for Research on Disabilities and additional MJB units, amid consultation with the Ministry of Health, the health plans, consumer representatives, mental health professionals, and other relevant parties.
In 2008, MJB hosted a workshop to discuss research issues of the evaluation of the mental health insurance reform. The workshop was co-initiated by MJB, the Ministry of Health, and the Israel National Institute for Health Policy Research. It aimed to identify the important topics and parameters to be addressed in the evaluation. The document summarizing the main points of the discussions at the workshop presented a model to evaluate the extent of achievement of the goals of the reform and/or of the realization of the concerns raised about the reform. The evaluation model was described in an article published in the Journal of Mental Health Policy and Economics. Several MJB studies subsequently provided a comprehensive picture of the pre-reform mental health system.
MJB Studies Conducted before the Reform
In 2007, MJB and the Ministry of Health conducted a series of studies on the question of stigma faced by people coping with mental health issues. The studies were designed to point to directions for intervention programs to reduce stigma and examine the aims, intervention methods and the target sub-populations. The series investigated attitudes among the general population to psychiatric patients and care, the perceptions and experiences of people treated at public mental health clinics, and the experiences of parents of people coping with psychiatric illness.
In 2011, MJB conducted a study assessing the factors affecting the use of community mental health services on the eve of the reform, and the gaps in use between different groups.
At the same time, another MJB study mapped the mental health services at the health plans on the eve of the decision to implement the reform, examining their preparations for the reform before and after the decision to implement.
In 2012, a comprehensive MJB study was conducted on professionals in mental health care. It examined the work practices of psychologists, psychiatrists and social workers as well as their attitudes to the reform on the eve of its implementation. The goal was to evaluate the extent that their work practices suited the principles of managed care characterizing the health plans, and the extent of change expected by professionals in their work and in the provision of care due to the reform.
In 2013, a comprehensive MJB survey of the general population examined the scope of prevalent mental and emotional distress, the practices of referral for professional help, and the satisfaction with mental health care services on the eve of the insurance reform. The analysis of the findings focused on characterizing the populations reporting high rates of mental and emotional distress and on identifying factors that influenced people to turn to professional help.
MJB Studies Conducted Since Launch of the Reform
The MJB staff continues to play an important role in evaluating the implementation of the reform by means of a series of studies focusing on key related topics, such as the mental health labor force and the impact of implementation on service consumers.
Mental Health Service Consumers
To examine the impact of the reform on the general population, in 2016 questions about mental health were added to the MJB survey of Public Opinion on the Level of Service and Performance of the Health Care System. The survey is part of a biennial series conducted at the Institute since 1995, and following the system’s functioning from the perspective of insurees. The questions added to the survey dealt, among other things, with the scope of mental and emotional distress among the general population, patterns of turning to professional help (psychiatrists, psychologists/ therapists or family physicians), and the availability and accessibility of mental health services following the reform. (link to document comparing with population survey findings of 2013).
In addition, the research staff is currently exploring the possibility of conducting an in-depth survey of mental health service consumers in 2019, to examine patient experiences in the public mental health system. Among other things, it will address the route to treatment, and the degree of satisfaction with various aspects concerning the treatment, the therapists and the system itself.
One unique target population concerns people coping with severe mental illness and consequently receiving a general disability benefit from the National Insurance Institute. On the whole, their needs are varied and complex, requiring a variety of tailored services. To this end, at the start of the reform’s implementation, MJB conducted a consumer survey among people with severe mental illness, examining the scope, practices, and experience of consumption of a variety of mental health services – psychiatric hospitalization, psychiatric rehabilitation (rehabilitation basket) and community mental health care. Meanwhile, the factors encouraging or inhibiting use of services were also investigated, distinguishing between factors relating to the individual (such as socio-economic characteristics, medical condition, knowledge and beliefs concerning mental health) and factors in the system (such as availability, accessibility and coordination of treatment). These findings shed light on possible improvements to the services provided to this group.
Primary Physicians and Mental Health
One study examined the role of primary physicians in the treatment of patients with mental and emotional problems. Many people who find themselves in severe emotional distress do not turn to mental health services but for various reasons, to their primary physician. Thus, this encounter is often the only opportunity to identify a problem, begin treatment or refer the patient to a specialist. The study examined the role of primary physicians in this area, their interface with the mental health system, and the impact of the reform on their work.
Shortage of Arab Professionals
Another study investigated the causes of the existing shortage of Arab professionals in the area of mental health. The study was designed to identify the barriers to the integration of Arab students in training tracks for the therapeutic professions of mental health – psychology, psychiatry and social work, and the factors promoting such integration. Additional study goals were to learn of the existing solutions on the ground to deal with these barriers, and to recommend further modes of action to increase the supply of Arab professionals in these professions.
Mental Health Professionals
A study is now under way to examine the work practices of professionals, following up on one conducted on the eve of the reform. It is examining the changes that have occurred in the work of professionals following the reform and their perceptions of the extent to which both the promises inherent in the reform and the concerns that it harbored have been realized. The purpose it to identify gaps between the professionals’ present work practices and what is still required to achieve the goals and aims of the reform.
MJB staff have been researching the field with the collaboration of several leading international experts. These include a special collaboration with the Schneider Institutes for Health Policy at Brandeis University, aimed at an exchange of ideas on the question of recommended work methods in mental health care policy in Israel and the United States.