National health insurance in Israel has had major achievements, providing broad and extensive access to high-quality care at a very reasonable cost. Yet, more than two decades after universal public health care coverage was introduced, Israel’s health system is at a critical juncture amidst ongoing concerns about the growth of private medicine, inequalities in access to health services, and workforce shortages. There are significant efforts to address these challenges.
MJB’s Smokler Center for Health Policy Research plays a key national role in addressing these concerns, providing independent and objective research that informs policy and decision-making on the most important health care issues.
This is a role that the Smokler Center has played since its establishment in the mid-1990s, and it is a role that continues to evolve and expand today. According to Center Director Dr. Bruce Rosen, “the Ministry of Health has been very active in making major changes to the health care system. They see the Smokler Center as a vital resource in the development and evaluation of their initiatives.”
This partnership is expressed in part through MJB’s involvement in initiatives to expand national health insurance. (See accompanying article on the mental health care reform.) Beyond this, Rosen emphasizes four major themes that are central to the Smokler Center’s research program: quality of the patient experience, the public-private mix, closing health care gaps, and health care economics. Below are some of the key studies in these areas.
Health Care Quality: Putting Patients First
One of the core aspects of health care quality is patient-centered care (PCC), which emphasizes both the patient’s experience and their role in making decisions about their care.
Implementing PCC is not easy, however. Physicians are typically trained to solve specific medical problems as efficiently as possible, rather than to take a more holistic approach to patient care. Moreover, limited resources often create a “get-it-done-now” attitude that allocates little time or resources to addressing a patient’s broader and longer-term needs.
This past March, PCC was the focus of the annual national conference of leaders from Israel’s health care system, government, and academia. Smokler Center senior researcher Dr. Shuli Brammli-Greenberg co-chaired a track dedicated to the social and economic aspects of PCC.
Among the research presented was a study by Smokler Center researcher Tamar Medina-Artom on PCC within the context of fertility treatment programs. “The fertility treatment process requires good patient-provider communication and emotional sensitivity,” she explains. “It is a good test case to examine PCC from both the patient and the provider perspective.”
Medina-Artom’s study, along with others presented at the conference, sparked extensive discussions among the participants on how best to implement PCC policy so as to improve the overall quality of care.
The role of patient-centered care in the Israeli health care system is finding expression in other MJB studies, including the biennial national consumer health care survey. (See accompanying article.)
The Public-Private Mix in Health Care
Alongside Israel’s universal public health care system, a growing parallel private medical system has begun to draw resources away from the public system. MJB is examining the public-private mix from a number of perspectives, including the growth of the private insurance sector, the reasons for the growth, the impact on costs, quality, and equity in the public sector, and the effectiveness of policies to restrain this growth.
One major concern to policymakers is that the higher level of pay available in the private system is reducing the availability of quality care within the public system. To stem this outflow, the Ministry of Health is implementing a new “full-timer initiative” targeting new Board-certified specialists. The initiative encourages them to forego private practice and dedicate all of their time to the public system, through the use of financial and professional incentives. The goal is to reduce the practice of physicians working part-time in private clinics, and thus expand the available human resources in the public system. MJB is beginning a multi-year evaluation of this initiative, to see how successful it is in reducing the extent of this problem.
Closing Health Care Gaps
The increased awareness of the impact of health care gaps is a third area where the Smokler Center has expanded its work. Beginning in 2011, the Ministry launched a concerted effort to reduce health care gaps between the center and the periphery of the country, as well as to reduce physician shortages in certain medical specialties. Among the new policies were the introduction of higher monthly salaries and large one-time bonuses to physicians who moved to the periphery for their residency and committed to remaining there for several years.
Smokler Center researcher Yael Ashkenazi assessed the impact of these financial incentives, with a particular focus on the places where new physicians are choosing to undertake their residency. “After the 2011 agreement, there was a large increase in the number of new medical residents working in the periphery,” Ashkenazi explains. “This happened because of a combination of factors, including a surge in the overall number of residents. The bonuses also made a difference for some of the physicians.”
The next phase of the research will focus on whether the physicians stay in the periphery, and the factors influencing their decision.
Ashkenazi’s research, and the broader issue of health care gaps between the center and the periphery, will be the focus of the Smokler Center’s annual Lewin Memorial Symposium in June, sponsored by Marion Ein Lewin in memory of her late husband Larry Lewin who was a leader in health care policy and a long-time supporter of the Smokler Center.
Health Care Economics
Narrowing the gaps in the health care system is closely related to the question of health care economics. “Health care systems around the world have long been challenged by the need to balance costs with the efforts to promote high-quality health care, and Israel is no different,” explains Dr. Shuli Brammli-Greenberg.
Over the past few years, Brammli-Greenberg has conducted a number of studies to examine key issues in how the government funds the health care system and to learn from the experiences in other countries. Through this work, the Center has developed expertise in reimbursement mechanisms, with a focus on how the government pays hospitals for their services.
One important result has been a proposal for a comprehensive model that more accurately measures the services provided by the hospitals and compensates them more fairly for these services. The Ministry has decided to adopt and implement the model in the country’s 35 public hospitals.
As Brammli-Greenberg explains, “if hospitals are compensated more fairly and are more financially stable, they can focus on delivering quality care rather than on worrying excessively about the balance sheet.”
The compensation model that Brammli-Greenberg and her colleagues developed drew heavily from the lessons learned in the international arena. This emphasis on looking beyond Israel’s borders is a fundamental part of the Smokler Center research.
This international perspective is most clearly expressed through the Center’s international Health Advisory Committee, chaired by Prof, Gary Freed of the University of Michigan. The Committee includes many of the leading figures in health care policy and health services research from the United States and Europe. The Committee works closely with the Smokler Center researchers, providing advice and guidance to maximize the quality and impact of their research.
International exchange is also a fundamental role of the Israel Journal of Health Policy Research, co-edited by Smokler Center Director Dr. Bruce Rosen. Now in its sixth year of publication, the journal plays an important role in linking research and policy within Israel, helping Israel learn from other countries, and vice versa. Contributions to the journal have come from the academic and policy-making world within Israel, as well as from internationally renowned scholars primarily from the US and the UK but also from other parts of the world such as China and India. According to Rosen, the journal has helped foster greater international interest in Israel’s health care system and health care policy.
Another important vehicle for international exchange is the Smokler Center’s participation in the European Observatory of Health. The Center prepares Israel’s country report for the Observatory, and provides periodic updates on the health care system (co-authored by Bruce Rosen and Center researcher Ruth Waitzberg).
As well, Center researchers have recently made presentations about Israel’s health care system at international forums of the World Bank, the International Health Economics Association, the Canadian Academy of Health Sciences, Academy Health, and the Digital Health Conference in Hangzhou, China.
Rosen notes that “policy changes are moving at an even faster clip these days, and we are increasingly being asked to respond even more quickly,” Rosen said. To support these requests, the Center is creating a rapid response capability for intensive, quick-turnaround analyses related to policy issues that are at critical junctures in the decision-making process.