While visiting in the United States, an Israeli woman fell and hurt her ankle. Her family took her to the nearest hospital emergency room where a technician x-rayed her foot, a radiologist examined the results and a physician bandaged her bad sprain. After some of the stories she had heard, she felt fortunate that the entire treatment took only two hours. Somewhat less pleasurable was the $3,000 bill she received, itemized down to the minutest detail – and the demand for payment before she departed. Ultimately, the travel insurance she had bought from her Israeli HMO paid the entire amount, but not before she received a series of bills and threatening letters – one from the attorney general of the state involved.
Many aspects of life in Israel can’t compare with the American experience, but even without the current debate about the Affordable Care Act, when it comes to healthcare, almost all
Israelis consider themselves blessed.
Israel’s National Health Insurance Law mandates that all residents of the country – not just citizens, but residents – receive basic coverage. Christian, Muslim or Jew, religious or secular – no one can be denied this level of treatment.
The healthcare basket, as it is known, covers an extensive list of goods and services that includes:
• primary care: pediatrics, internal medicine, gynecology;
• full range of specialists (ophthalmology, dermatology, ENT, etc.);
• consultations with outside specialists (with a co-payment);
• preventive medicine: colonoscopies, mammograms, flu shots, pneumonia vaccine and other procedures for people at risk;
• paraprofessional services, such as physical, occupational and speech therapy;
• all lab tests;
• all diagnostic imaging;
• hospitalization, including all procedures performed;
• pharmaceuticals as detailed in the basket, with very reasonable co-
• a cap on drug copayments for certain chronic illnesses such as cancer and diabetes;
• home care visits for those unable to travel;
• dialysis for all ages;
The system’s multi-tiered approach is built around mandatory membership in one of the country’s four nonprofit HMOs, whose clinics and treatment centers can be found everywhere, from the smallest village to the big cities. In addition to the mandatory coverage, each HMO offers its members the opportunity to purchase an array of upgrades, each with expanded supplemental services.
The HMOs are funded by a somewhat modified version of “each according to his means.” For those who receive paychecks, up to 5 percent of their gross salary is automatically deducted. Those who are self-employed pay directly to the National Insurance Institute – the equivalent of the Social Security Administration – which also funds people below a certain income level.
By most Western standards, the care and the coverage are exemplary; however, the provisions of the National Insurance Law are not sufficiently re-evaluated and readjusted to meet the country’s changing needs and demographic data.
The medical insurance fees only cover about 55 percent of the actual costs. As the population both grows and ages, the gap between income and expenditures is increasing each year, as are expenditures. The HMOs adjust the charges they legally control, which means that the amount of money people pay out-of-pocket grows annually. At the end of the day, the government has to make up the shortfall from other taxes, which continue to rise.
Nonetheless, the cost of healthcare in the United States is about 18 percent of the gross national product (GNP). In Israel it is only 8 percent, a rather unrealistic amount, one health care economist said. “The Finance Ministry is married to that figure, but it doesn’t reflect the actual costs. It should be closer to 12 percent of GNP like most European countries.”
Had her injury occurred in Israel, she would have been taken to Terem, a national network of private urgent ambulatory care centers that fills the niche between the HMO primary care clinics and hospital emergency rooms, freeing up the latter to deal with more acute patient needs. National Health Insurance doesn’t cover emergency room visits, unless the patient is hospitalized, was referred by a physician or has one of the 13 diagnoses, such as fractures, that are exempt. If a person does not meet those criteria, the cost is quite high – 800 shekels, or about $200 a visit. The charge for a patient visit to Terem varies depending on the HMO, but the maximum is 80 shekels, or about $20 a visit.
Dr. David Applebaum, an American-born and American-trained emergency medicine physician, who headed Jerusalem’s mobile intensive care units and the Department of Emergency Medicine at Jerusalem’s Shaare Zedek Medical Center, conceived of Terem as a solution to the country’s overcrowded emergency rooms. A world-renowned expert in the field of mass casualty attacks, he and his daughter Nava, were killed in a terrorist attack on the Jerusalem café where they were sitting the night before her wedding.
Terem’s co-founders and senior management continue to fulfill his vision of efficient and effective ambulatory and urgent care clinics – open around the clock, every day of the year. Last year, its 15 clinics handled close to 600,000 visits – with 96 percent of the patients triaged within 15 minutes of their arrival. Since Terem has expanded, there has been a 35 percent decrease in emergency room referrals in the regions where Terem operates, saving the patient, the hospitals, the HMOs and the government time and money.
“The United States has a number of different types of urgent and ambulatory care services, but none like Terem,” says Dr. Gabriel Polliack, Terem’s Director of Strategic Services. Unlike the HMOs, Terem is a for-profit undertaking, “with a very thin profit margin,” he says with a grin.
The need to be profitable is what makes Terem so efficient, he says.
Specialized training of the staff members and streamlined specific protocols provide quick and uniform treatment throughout the branches. Software developed specifically for the network makes it function both efficiently and effectively. It presents automatic guidance for triage procedures, online records of previous visits and a decision-support system. Physicians can provide advice – solicited or not – from anywhere in the country. It provides automatic alerts for patients with unusual cases or suspicious symptoms, demanding that the attending physician seek a second opinion. Between 35 and 40 percent of patient visits set off an alert and undergo quality assurance, Dr. Polliack said.
Dr. Polliack and other experts are quick to acknowledge that what works in a country of 8 million people does not necessarily work in a country of 316 million; what is effective in a small geographical space with one government ministry overseeing the system is not necessarily applicable to a country with 50 states and an equal number of local and federal governing authorities. Yet, they say, just as
Israel has learned from other countries’ systems and structures, aspects of the
Israeli healthcare system can be adapted to American needs. ■
The woman with the sprained ankle returned to Israel where she was treated by her HMO’s primary care physician and received physical therapy to literally put her back on her feet. Her only cost: the 10 shekel co-payment, about $2.50, for the visit to the doctor.
The writer is an American-Israeli journalist who lives in Jaffa.