Background
The mental health insurance reform went into effect in July 2015. As part of the reform, responsibility for mental health services was transferred from the State to the health plans. For the first time since the passing of the National Health Insurance Law in 1995, the insurance reform anchored the legal right to receive mental health services as part of the basic health basket provided by the health plans.
Goals of the Research
To examine the experience of patients receiving in the community and the differences in that experience between the public and private sectors and according to patients’ background characteristics, five years after the initiation of the insurance reform.
Methodology
A cross-sectional study was carried out based on a representative sample of the adult population in Israel. The research population included adults aged 22+ who received psychotherapy treatment in the community. The data was gathered by means of an internet survey carried out in December 2020. In addition, in-depth interviews were carried between June and October 2021 with individuals who had received psychotherapy treatment during the year preceding the survey. Most of the interviews were carried out by video conference according to a semi-structured protocol.
Main Findings
The proportion of the sample who had received psychotherapy treatment during the year prior to the survey was 8.4%. Of those, 51% had received treatment in the public sector. Among those who reported having received treatment in the private sector, 20% reported that they had tried the public sector before opting for private treatment (7% reported they had first received treatment at their health plan and 13% reported that they had approached their health plan for treatment but had not actually received it). A multivariate analysis (logistic regression) in which the dependent variable was the likelihood of being treated in the private sector as opposed to the public sector showed the following results: (1) The likelihood of being treated in the private sector was higher among women, the ultra-Orthodox, university graduates and singles (as opposed to men, the non-ultra-Orthodox, non-university-graduates and married individuals). (2) The likelihood of being treated in the private sector is lower among Arabs than among Jews and among those also receiving treatment from a family physician or a psychiatrist for the same mental problem for which they sought psychotherapy (as opposed to someone not being cared for by a family physician or psychiatrist for that purpose).
Statistically significant differences were found between the private and public sectors, in the characteristics of the patients, in the waiting time for treatment, in the duration of treatment and in the reasons it was ended. Overall, respondents reported a positive patient experience (with an average score of 8.7 out of 10 on the index of patient experience), and those treated in the private sector reported a more positive care experience than those treated in the public sector (an average score of 9.1 vs 8.3). The difference remained even after controlling for the patients’ personal characteristics in a multivariate analysis.
Among those who began treatment prior to the onset of the COVID-19 pandemic, 76% reported receiving remote treatment or a combination of both remote and face-to-face treatment during the period of the pandemic. In contrast, about half of those who began treatment after the onset of the pandemic reported only face-to-face treatment. The in-depth interviews indicated that it was more difficult to start treatment remotely and to establish a therapeutic alliance with the therapist, while it was easier to continue therapy remotely if it had started face-to-face.
According to most of the patients, remote treatment is less effective in achieving the goals of the treatment (66%) and is less facilitative of dialogue on sensitive issues (58%) and creating a connection and understanding with the therapist (66%). This was true among those who had actually received remote treatment but even more so among those who hadn’t. At the same time, the in-depth interviews indicated that during a crisis and in situations where face-to-face treatment is not possible, remote treatment is preferable to no treatment.
Conclusions
The findings indicate that the proportion of patients receiving psychotherapy in the community is higher than previously estimated (8.4% as opposed to 3%). About one-half of them receive private treatment even though the service is included in the healthcare basket.
The findings also point to the existence of a population that is interested in receiving service in the public sector but is not receiving it there: 20% of those treated in the private sector previously sought treatment in the public sector but were left with unmet needs. It may be that this figure is an underestimate of the proportion of those interested in treatment in the public sector, as many assume ahead of time that they will have to wait a long time for treatment in the public sector or alternatively that they wish to have greater flexibility in choosing a therapist than is possible in the public sector. Therefore, they do not even attempt to obtain treatment in the public sector. The findings also point to differences in the characteristics of patients, the characteristics of treatment and the patient experience between the public and private sectors.
The findings indicate that one of the ways in which patients react to long waiting times is to approach a number of frameworks simultaneously in order to obtain services where the waiting time is shortest. This is far from an ideal situation for patients since the fragmentation of services requires that they approach a large number of provider organizations. This often requires them to fill out forms, obtain and submit documents and repeatedly expose their mental state, thus creating a burden for them in terms of the effort required.
Recommendations
- The availability and accessibility of public psychotherapy services in Israel should be expanded.
- As part of the effort to expand the services, consideration should be given to the population interested in receiving them in the public sector but which in the end turns to the private sector.
- The patient experience in the public sector should be improved.
- The health plans should be encouraged to offer their members assistance in locating the most appropriate framework for treatment among the existing options.
- A uniform system should be established for making appointments that will include all of the frameworks financed by the health plans, and which will make use of standardized forms.
- A mechanism should be created for monitoring the situation of those waiting for treatment and the queues should be reprioritized when necessary.
- A hybrid option for treatment should be created which will involve remote treatment following face-to-face treatment, thus facilitating the creation of a therapeutic alliance.
Citing suggestion: Samuel, H., & Kagya, S. (2023). Psychotherapy Patients Five Years after the Mental Health Insurance Reform. RR-924-23. Myers-JDC-Brookdale Institute. (Hebrew)