The Israel National Health Insurance Law went into effect in 1995. The law entitles every Israeli citizen or permanent resident to health services through one of four health plans, according to choice, and the health plans are obliged to provide insurees with a uniform, accessible and available basket of services.
Since the law took effect, the Myers-JDC-Brookdale Institute (MJB) has been conducting biennial surveys on the extent to which its main goals have been realized – the improvement of health services in terms of availability, accessibility and affordability, and of the extent of reduction of inter-sectoral inequality. These surveys have helped MJB researchers evaluate how the health policy changes have affected the perspective of insurees.
The MJB surveys are the major, objective data source on the current performance of Israel’s health system, providing broad, detailed and up-to-date information on public opinion about the system’s performance and the service experience of insurees. In fact, the entire health system – from senior government decision-makers to the health plans and consumer organizations – regards the MJB surveys as a reliable, unbiased tool that facilitates evidence-based planning of Israel’s health services. Dr. Shuli Brammli- Greenberg, senior MJB researcher, has been involved in the surveys since 1999 and has led them since 2002. “The research findings that are based on the survey arouse great interest among policymakers, the press and the public,” she explains. “Months before the report is published, we receive requests from people wishing to obtain the findings to help them plan and set policy.”
The biennial reports are conducted on a representative sample of Israel’s adult population (age 22+) in three languages (Hebrew, Arabic, and Russian). The surveys were initiated by the Ministry of Health (MoH) and are accompanied by a steering committee with representatives from the health plans, MoH, the Finance Ministry, the National Insurance Institute (NII), academe, and consumer organizations. A permanent series of measures was developed for the surveys to monitor trends over time. To facilitate the analysis of trends over time, the core of the survey also remained permanent and comprises key indicators of insuree satisfaction, and service availability, accessibility and affordability. Furthermore, every survey emphasizes a variety of topics on the public agenda selected by the research team and the steering committee.
In 2016, the 11th survey was conducted. The interviewees numbered 2,513 insurees and the response rate was 68%. That year, the survey comprised the following measures: trends over time of satisfaction and service level; primary and secondary medicine; an assessment of the performance of the health system; confidence in the system; and the possibility of choosing between service providers. The survey examined the following topics: hospitalization, surgery and financing agent; access to services and barriers related to cost and distance; a patient’s service experience in hospitals and community clinics; turning to the private system; applications to emergency medicine (community emergency medical centers and hospital emergency rooms); treatment with medication; importance of choice of hospital and surgeons; use of online medicine; and use of mental health services.
The survey presents a complex picture of the public’s experience, reflected by two measures: (a) satisfaction with the health plans and the health system; (b) confidence in the care received during a severe illness.
- On the one hand, the level of general satisfaction with health plan services and the health system has remained high; on the other hand, the level of confidence in receipt of help during a severe illness is low.
- The main reasons for switching health plans were: the distribution of services and possibilities of choice of service providers, quality of care, the desire to remain with a specific family physician, and the desire to be insured by the same health plan as the other family members. The main reasons for not switching were: bureaucracy, the desire to remain with one’s family physician, the desire to remain in the same health plan as the other family members, and fear of loss of rights or of non-acceptance by the health plan to which one wished to switch.
- The overwhelming majority of the interviewees had seen their family physicians in the past year, and about a third reported visits for the sole purpose of receiving a medical authorizations and/or completing forms (without the need for a check-up). Differences were found by age, for the 65+ age group, about half cited these reasons for their visits.
- About half of the interviewees reported having seen a specialist through the health plan in the last three months.
- One out of every four patients seeing a specialist through the health plan reported having waited more than a month for the appointment. A higher rate of the 65+ age group than younger patients reported having waited more than a month.
- The waiving of medical care correlates with lack of confidence in the system in the case of severe illness. A high rate of the interviewees reported waiving medical care due to the long waiting times; also, they said that they were not so sure or not sure that they would receive the best care during a severe illness, nor that they could financially afford the care.
- There was a considerable decrease in the rate who reported waiving dental care due to cost.
- The waiving of medical care correlates with income. A higher rate of insurees in the lowest quintile waived care or medication due to cost than did insurees with higher income. In addition, a higher rate of insurees in the lowest quintile waived dental care due to cost. On the other hand, a lower rate of insurees in the lowest quintile waived care due to long waiting times than did insurees with higher income.
- A considerable rate of patients turning to emergency medicine (a community emergency medical center or hospital emergency room) said that they were satisfied or very satisfied with the community care, as compared with lower satisfaction with hospital emergency rooms.
- The high rate of insurees holding voluntary health insurance (supplementary or commercial) was retained. Among insurees turning to a private physician, the rate holding private insurance is higher. In total, one out of every two people have both supplementary and commercial insurance; and one out of every nine who hold commercial insurance, have more than one insurance policy.
- 6% of the interviewees said that they had felt a need to pay a discreet, informal charge for preferential health services in the previous five years. A multivariate analysis controlling for background variables found that insurees who had undergone surgery were more likely to report such a need. A significant difference was found by locality; the chance of reporting such a need was higher among insurees living in the Jerusalem area.
One important contribution of the survey is its comparison of developments in Israel’s heath system with those in other developed countries. The international comparison is made possible by the partnership between MJB and the Commonwealth Fund of New York which conducts an international survey every three years in 11 countries, much like the MJB survey. The comparison between Israel and these countries was presented at international seminars and to the management of Israel’s MoH.