|
Israel's Health Care System - an Overview
Beverley Damelin, MPH
|
On the First of January 1995, the National Health Insurance Law (NHI) went into effect in Israel. The NHI is the principal component of the structural reform in the health care system, undertaken during the 1990's.
It secures the right to health insurance for each and every resident of Israel and defines a basic basket of health services. Residents are given greater choice of health care providers, since the law provides the right to transfer between the four health funds. Health funds may no longer discriminate among insurees according to age, state of health or other potential risk factors.
The four health funds, which are the providers of health care services are: Clalit (60% market share), Maccabi (20%), Meuchedet (10%) and Leumit (10%). At the time of enactment of the new law, 5.2 million Israelis were covered by these health funds, some 25,000 of which were insured by more than one fund. More problematic, almost 200,000 residents had no health insurance at all. The law directed those who were double-insured to resign from one of their memberships and the uninsured were distributed among the four health funds.
|
|
Basket of Services
The concept of a basket of services pledges standard health care provision on an equal basis, regardless of health fund membership. The quality of the standard provision, however, is dependent on equitable updating of the basket as new technology becomes available and as conditions on the ground necessitate. The challenge here is that while budget shortages are intrinsic, health care development is unrelenting. Lobbies, interest groups and watchdog organizations need to vie against one-another and against the treasury, for additional funding, in order to advance their particular causes.
The law states that health services included in the basket must be provided in Israel, when deemed necessary by medical opinion, of reasonable quality and within a reasonable time frame.
|
|
Capitation
The Ministry of Health finances the four health funds according to a capitation formula. Each health fund receives payment according to a formulated risk calculation. The relatively simple capitation formula is based upon the number of members in a given health fund and members' ages. The health fund then covers all costs of supplying the legally-instituted basket of services.
The capitation model, as opposed to a system where the health fund is compensated by pure membership numbers, is supposed to provide a more equitable allocation to the health funds, reflecting the health needs of their members. Moreover, it should promote greater equity between regions and populations, which have different age structures.
Ultimately, by increasing the fiscal capacity of the weaker links in the health care provision chain, the health system as a whole is expected to gain greater stability.
In an attempt to draw lower-risk members, the health funds offer special services to attract young, healthy members, who constitute better investment opportunities. This is legal, and even useful, to enhance the level of the services offered. Prior to 1995, the practice of selecting members often led to discrimination against the elderly and other individuals or population groups stigmatized as sickly or needy. Although this is a contravention of the NHI, indirect procedures are still employed to discourage unattractive requests for membership, presenting a form of de facto selection.
A problem that continues to present a financial burden to the Clalit Health Services, is its heavy concentration of high-risk population. Clalit's characteristic older member population, which previously had no choice but to remain under its coverage, is a predominant factor threatening to preserve their long-time debt. Demographic stability, in their case, can only propagate institutional inequalities, instead of prompting them to abate - this being the primary vision of the NHI.
|
|
Supplementary Coverage
In order to augment their income, health funds are permitted to offer their members supplementary services, inaccurately termed "complementary insurance" or "bituah mashlim". This additional coverage includes services and products not included in the basic basket of services. Coverage differs from insurance in two key ways: it is not individually tailored, but rather a predefined package where the premium is defined by age alone; secondly, the fund is permitted to change the costs and the conditions from time to time, without the mutual agreement of the customer. Nursing care is not included in supplementary coverage, and is thus charged separately.
|
|
Funding
The Health System is funded by several sources:
¤ The Ministry of Health budget
¤ Premiums from every resident, earmarked for health insurance
¤ Employers and the self-employed make parallel tax payments
¤ The National Insurance Institute (Bituach Leumi) funds
¤ Health fund members' participation in the costs of treatments
Compulsory premiums are collected by the National Insurance Institute by the same mechanism that is used for national insurance premiums. Parallel tax is deducted from employees by their employer. The calculation of the health insurance premiums is progressive, and based on the average wage [approx. NIS 7,000 in 2002]: payments range from a minimum of one quarter of the average wage, to a maximum of four times the average wage.
|
|
Public Satisfaction
A 1995 study undertaken by JDC-Brookdale Institute (Berg, Gross, Rosen & Chinitz) found that less than a year after the implementation of the new law, the vast majority (78%) of residents did not notice a change in the level of services; 18% experienced an improvement in the level of services of their health fund, and only 4% of respondents noted a deterioration.
General satisfaction with health funds was expressed by 78% of respondents, but this varied by health fund. Members of Meuchedet Health Fund expressed the highest level of satisfaction (94%) followed by Maccabi (93%) and Leumit (89%), whereas only 80% of Clalit members were satisfied. Nevertheless, the law may be achieving its objective of reducing the inequalities between the health funds: the study showed that 23% of Clalit members perceived an improvement in health care services since the law took effect, whereas 13% of Maccabi member sensed that the level of services declined.
During the six-month period following the implementation of the National Health Insurance Law, only 2% of the respondents had transferred to another health fund, indicating that the law did not produce a large-scale transfer of members between health funds.
|
|
Patient's Rights Law
In accordance with the National Health Insurance Law, which states "Health services will be given while preserving human dignity, privacy and medical confidentiality", the Patient's Rights Law was enacted on May 1, 1996. The law's objective, in its own words, is "to establish the rights of every person who requests medical care or who is in receipt of medical care, and to protect his [or her] dignity and privacy".
The Patient's Rights Law contains twelve basic principles
1. The right to medical care
2. The right to appropriate medical care
3. Information on clinician identity
4. A second opinion
5. The right to continuity of appropriate care
6. Patient dignity
7. Patient privacy
8. Care under emergency or grave danger
9. Informed consent
10. Access to medical information
11. Medical confidentiality
12. Disclosure of information to a third party
Further details of these rights are available from The Israel Society for Patient's Rights.
A public complaints office that receives complaints on medical negligence functions within the Ministry of Health whereas any litigation related to Patient's Rights Law belongs in the Labor courts.
A qualitative analysis that surveyed physicians' general opinion of the Patient's Rights Law (Steinmetz & Tabenkin, 2000) found that most physicians thought that it is a constructive law that contributes to good relations between patient and doctor. On the other hand, physicians stated a number of issues that they claimed challenged their ability to implement components thereof, including the time and the conditions required to adhere to it.
|
|