Strong government influence over the Israeli health care system has led to low rates of spending growth

Israel reformed its health care system in 1995. In contrast to many other developed nations, it has since experienced relatively low rates of growth in health spending, even as health outcomes have continued to improve. This paper describes characteristics of the Israeli system that have helped control rising costs. We describe how the national government exerts direct operational control over a large proportion of total health care expenditures (39.1 percent in 2007) through a range of mechanisms, including caps on hospital revenue and national contracts with salaried physicians. The Ministry of Finance has been able to persuade the national government to agree to relatively small increases in the health care budget because the system has performed well, with a very high level of public satisfaction. It is unclear whether this success in health expenditure control can be sustained because of growing signs of strain within the system, the rapid increase in nongovernment financing for health care services, and the growing prosperity of Israeli society.     

Workforce planning—going beyond the count

Every country struggles with how best to meet the demand for health care services with the available resources. This commentary offers a perspective on the Israeli physician workforce and the analyses of Horowitz et al., which found age and gender differences in physician productivity and career longevity, differences across specialties, and a sizeable fraction of licensed Israeli physicians living abroad. Workforce planning can be subject to data collection and statistical uncertainties, but even more important are the assumptions and forecasts related to demand for services and organizational arrangements for care delivery. Readers should be cautious in analyzing productivity just by counting hours or years worked, and comparisons across countries may not account for differences in the nature of physician work. The question of whether Israel has enough physicians for the future has to go “beyond the count” to looking at the roles of other health professionals, the use of new technologies and new team configurations, and the overall efficiency and effectiveness of health care delivery systems such as hospitals, ambulatory care clinics, and community-based care.     

Physician unions: any doctor can join, but who can bargain collectively?

Employees in the health care industry, including physicians, have recently taken more interest in unions and collective bargaining. At the present time the health care industry is approximately 20 percent unionized. Labor leaders believe that existing conditions are fertile ground for significant union activity that has been on a recent upswing after a decline during the early 1980s. While current attention is being drawn to the shortage of and increased union organizational activities by nurses, physicians may not be far behind. It is conceivable that by the year 2000 the majority of physicians in the United States will work in full-time salaried positions. In addition, the antitrust laws that currently restrain independent physicians from collective bargaining are being challenged and are likely to change as more physicians become salaried and begin to resemble other professional employee groups. The ruling determining that interns and residents are students rather than hospital employees is also certain to be challenged and changed, especially as pressures on the National Labor Relations Board (NLRB) are brought by house staff union organizations. After a 1987 ruling that the NLRB had been improperly interpreting the 1974 amendments to the Taft-Hartley Act, the NLRB was ordered to exercise its rule-making power in defining bargaining units for health care workers in acute care hospitals. Physicians would then be one of eight occupations defined as a separate health care bargaining unit.     

The role of the primary care physician in the Israeli health care system as a 'gatekeeper'--the viewpoint of health care policy makers

The aim of the study was to determine the attitudes of policy makers in the health care system in Israel to a change in the role of primary care physicians (PCP) and to ascertain the conditions under which they would be ready to adopt the model of PCP as gatekeeper. The study design was qualitative, with analyses of in-depth structured interviews of 20 policy makers from the Ministry of Health, the Sick Funds' central administrations and the Israel Medical Association (IMA) central office. The majority of the respondents claim that they want highly trained PCPs (family physicians, pediatricians and internals) to play a central role in the health care system. They should be co-ordinators, highly accessible and should be able to weigh cost considerations. However, only about half of the respondents support a full gatekeeper model and most of them think that the gatekeeper concept has a negative connotation. They also feel that it would be difficult to implement regulations regarding primary care. The barriers to implementation of the gatekeeper model, as cited by the respondents include loss of faith in PCPs by the general population, dearth of PCPs with adequate training, low stature, lack of availability on a 24-h basis, resistance by specialists, strong competition between the sick funds including promises of direct access to specialists, the medical care habits of the general population many of whom do not settle for only one opinion, and a declared anti-gatekeeper policy by one of the sick funds. Ways to overcome these obstacles include implementation of fundholding clinics, patient education on the importance of having a personal physician, appropriate marketing by family medicine and primary care advocates, and continued training in primary care. Israeli health care policy makers have an ambivalent attitude to strengthening the role of primary care. In theory, they profess support for placing primary care physicians in a central role in the health care system. However, in practice almost half oppose the full gatekeeper model. Therefore, introduction of a gatekeeper model into the Israeli health care system should be implemented gradually, based on incentives rather than regulations. Furthermore, the idea should be marketed by the primary care physicians' professional organizations, the Ministry of Health and the sick funds to physicians as well as to patients, in order to garner their support. In light of the broad consensus that competent primary care physicians are the basis for implementation of the gatekeeper model, board certification should be gradually required by employers of primary care physicians. The process of training physicians currently working in the system should be encouraged and supported by the Ministry of Health. Given the existing opposition of policy makers to giving primary care physicians exclusive referral rights to specialists, the current policy of direct access to a limited number of specialties should be continued but not extended to other specialties.     

Managed care and primary care physicians' overall career satisfaction.

Salaried employment among primary care physicians (PCPs) is becoming the rule rather than the exception. Because of this trend, the consequences of employment, types of practice revenues and overall career satisfaction will have the greatest impact on this group, their employers, and the populations they serve. This article examines the relationship between managed care contracts, managed care revenues and salaried PCP overall career satisfaction. Proportion of practice revenues from managed care and types of managed care contracts were associated with PCP overall career satisfaction. The implications of these findings and their importance to PCP turnover are discussed.     

Patterns of medical employment: a survey of imbalances in urban Mexico.

This article quantifies the magnitude and correlates of the major imbalances affecting the employment of physicians in the urban areas of Mexico. Since the early 1970s the country has experienced a rapid increase in the supply of doctors, which its health system was unable to absorb fully. In 1986, we conducted a survey in the 16 most important cities based on a probability sample of households where someone with an MD degree lived. A total of 604 physicians were interviewed for a response rate of 97 percent. The unemployment rate was 7 percent of potentially active physicians; 11 percent held a nonmedical job, and another 11 percent exhibited low productivity and/or income. All in all, we project that 23,500 physicians in these cities were either unemployed or underemployed. This medical employment pattern was analyzed against five independent variables: generation (i.e. the year in which the physician started medical school), gender, social origin, medical school quality, and specialty. Apart from generation, type of specialty exhibited the strongest correlation with the employment situation of a physician. The results suggest that higher education and health care in Mexico may be producing rather than correcting social inequalities. Policy alternatives are discussed to restore a balance between the training of physicians, their gainful employment, and the health needs of the population.     

What the United States could learn from Israel about improving the quality of health care

In 1999 Israel began to implement a system for monitoring quality of care in its health plans. That system was based largely on a similar system in the United States that, until recently, was associated with steady improvements in performance. However, in recent years health plan quality in the United States appears to have reached a plateau. In contrast, health plans in Israel have continued to show improvements on many of the same measures. Between 2005 and 2007 they achieved a gain of 6.7 percent in nine measures of primary care quality, while US performance on these measures declined. These gains were achieved, in part, through intense cooperation among health plans and physicians. Israel is a much smaller country and differs greatly from the United States in how it finances health care. Nonetheless, we suggest that the Israeli experience could help the United States accelerate the move toward quality improvement-for example, through increased coordination among US employers, health plans, physicians, and physician groups.     

Monitoring quality in Israeli primary care: The primary care physicians' perspective

ABSTRACT: BACKGROUND: Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. METHOD: The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians - 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. CONCLUSIONS: The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.     

Factors in the physician practice location puzzle: a survey of New York State residency-trained family physicians.

BACKGROUND: For the past 5 years fewer medical students have selected primary care specialties, and one-third of all physicians have indicated they will move in the next 5 years. These two factors make family physicians one of the most recruited specialties in medicine. METHODS: A questionnaire about practice profiles and factors that have an impact on a physician's location decision was mailed to all physicians who graduated from New York State family medicine residencies between 1970 and 1989. Data from completed responses were analyzed by year of graduation from residency, community size, and whether the responder remained in New York State or chose to locate outside New York State. RESULTS: There were 711 (46 percent) physicians who responded. The number of minorities remained stable at 14 percent during these years, but women graduates increased from 12 percent to 21 percent. The graduates in the 1980s, when compared with those in the 1970s, were more likely to be salaried, make less money, and to believe employment for the physician's spouse to be important in practice location. The 38 percent of responders from communities of fewer than 25,000 were less likely to be salaried, were more likely to practice in a group, worked more hours, offered a broader range of services including obstetrics, made less money, and placed less importance on availability of hospital consultants. Extended family, previous negotiated obligations, and geographic or climate issues were the reasons 64 percent of out-of-state responders gave for leaving New York. Spouse's opinion, hospital consultants, hospital services, colleague interaction, and after-hours coverage were most frequently rated as important factors for family physician practice location. CONCLUSIONS: Factors important in attracting new physicians to a community include the spouse's opinion, institutional and colleague support, and lifestyle issues.     

How sensitive is physician performance to alternative compensation schedules? Evidence from a large network of primary care clinics

Despite its centrality for the provision of health care, physician compensation remains understudied, and existing studies either fail to control for time trends, cover small samples from highly particular settings, or examine empirically negligible changes in reward levels. Using a four‐year sample of 59 physicians and 1.1 million encounters, we study how physicians at a network of primary care clinics responded when their salaried compensation plan was replaced with a lower salary plus substantial piece rates for encounters and select procedures. Although patient characteristics remained unchanged, physicians increased encounters by 11 to 61%, both by increasing encounters per day and days worked at the network, and increased procedures to the maximum reimbursable level. Copyright © 2009 John Wiley & Sons, Ltd.     

Medicine and health care in the Israeli kibbutz: a survey of physicians

This paper presents the results of a survey of the practice of primary care in the Israeli kibbutz, a unique social setting. Its aims were: (1) to obtain basic data on physicians living in kibbutzim; (2) to examine the functioning of the kibbutz health care system; and (3) to learn how the kibbutz physician perceives the system. A mail survey, using a 125-item questionnaire, was conducted of all 251 physicians identified as living in a kibbutz. Completed forms were received from 124 physicians (49.4%), 33 of whom are kibbutz members. Data on the physicians and on the kibbutzim in which they live show this to be a representative sample. Results are presented showing characteristics of these physicians and their involvement with patients and how health care is delivered. The discussion centres on three issues raised by study of kibbutz physicians which may have clear implications for primary care practitioners throughout the world: the relationship of the practitioner and her/his family to the community in which she/he works and lives; the potential for expansion and deepening of the scope and role of general practice; and the problematic question of the nurse-primary care physician relationship.     

Practice compatibility and type of framework: Essential dimensions in the salaried primary care practitioners'' approach to practice

A multivariate paradigm, aimed at furthering the understanding of the factors underlying the devotion to practice of salaried primary care practitioners, has been developed and subjected to empirical verification. A study among a sample of Israeli primary care practitioners (N = 134) revealed an empirical structure of "Practice Compatibility', suggesting that the devotion to practice is conditioned by the clinical and professional role compatibility. Compatibility in turn is contingent on the practitioners' conviction in the sincerity of manifest health care oriented goals of the care-providing-framework. The herein developed notion of "Practice Compatibility' facilitated the distinction between types of employing frameworks according to the factors predicting the salaried primary care practitioners' devotion to practice. In this respect the contribution of the present study is in identifying the factors underlying the salaried practitioners' motivation to practice. However, contrary to the expected, practice compatibility does not predict the primary care practitioners' likelihood to demonstrate affective behavior. Thus the data were unable to repudiate earlier evidence regarding the significance of the private fee-for-service framework in predicting affective behavior.     

The healthcare experiences of Arab Israeli women in a reformed healthcare system

Arab Israeli women are subject to unique social stresses deriving from their status as part of an ethno-political minority and from their position as women in a patriarchal community. Collectively, their health profiles rate poorly in comparison to Jewish Israeli women or to women in the vast majority of developed countries. OBJECTIVES: To examine the experiences of Arab Israeli women in the contemporary Israeli healthcare system, following implementation of the National Health Insurance Law (NHIL). METHODS: The study combined quantitative and qualitative research methodologies. A telephone survey utilizing a structured questionnaire was conducted during August-September 1998 among a random national sample of 849 women, with a response rate of 83%. Between the months of January and July of 2000, qualitative data was attained via participant-observation, long and short semi-structured interviews, and focus groups in one large Muslim Arab Israeli village. FINDINGS: Arab Israeli women in the national survey reported poorer self-assessed health, lower rates of care by a woman primary care physician, lower satisfaction ratings for primary care physicians and more frequently foregoing medical care than did native or immigrant Jewish Israeli women. Three major factors contributing to Arab Israeli women's healthcare experiences were elucidated by the qualitative study: (1) the threat of physical and social exposure (2) difficulties in communicating with male physicians and (3) the stifling effect of family politics and surveillance on healthcare. DISCUSSION: We discuss our findings in relation to structural changes associated with the recent reform of the Israeli health care system. We conclude by suggesting policy measures for better adapting primary care services to the needs of Arab Israeli women, and note the relevance to other systems that aim to provide service to cultural and ethno-political minorities, in which healthcare delivery is shaped by unique local circumstances.     

Salaried physicians' intent to retain hospital membership: the effects of position and work attitudes

This study examined the anticipation of salaried hospital physicians in Israel to retain hospital membership for a long term until their retirement. Examined are attitudinal and position factors, as well as hospital standing personal and situational factors that relate to this anticipation. The data collected from 195 full-time salaried physicians in Israeli hospitals indicated that about one-third of the physicians anticipate to retain hospital membership until retirement. It was found that factors reflecting the physician's standing within the hospital were the main predictors of this anticipation, whereas work-related attitudes had little or no effect on it. The implications of these finding to hospital-physician integration strategies in the United States are discussed.     

The plight of primary medical care: the problematics of 'committedness' to the practice

A multivariate paradigm, aimed at furthering the understanding of the factors underlying the problematics of practising primary medical care, has been developed and empirically supported. A study among a sample of Israeli primary care physicians and a comparison group of hospital physicians revealed an empirical 'structure of committedness', ascertaining that the committedness to practice primary care is contingent on the 'intrinsic' satisfaction and rewards as well as the 'extrinsic' rewards from the professional community (namely, prestige), derived from bio-medical (but not psycho-social) intervention activities. The data ascertain that salaried general practitioners and specialists employed in Sick Funds primary care clinics perceive themselves the least rewarded both intrinsically and extrinsically, and consequently the least committed to their field of practice. Specialists in family practice perceive themselves more rewarded, both intrinsically and extrinsically, the general practitioners (i.e. enjoy higher prestige), and hence are more committed to their field of practice.     

Physician unionization in the United States: fad or phenomenon?

This article explores the current trends and issues surrounding physician unionization in the United States, using data from secondary sources and nine interviews with leaders of organizations at the forefront of physician unionizing efforts. Several key points are supported by these data and prior unionization research. First, unions should become a viable organizing alternative for the almost 50% of doctors who are salaried employees because of fewer legal barriers to collective representation, the involvement of national labor unions with resources to spend on organizing, more physicians belonging to demographic groups less hostile to organized labor. and work-related pressures faced by physician-employee under managed care. A second key point is that unions will find it difficult to represent self-employed physicians because of the influence of organized medicine and legal barriers to gaining collective bargaining rights for this group. This discussion is intended to raise awareness of the physician union issue among health care policy-makers and researchers.     

The care of family physicians and their families: a study of health and help-seeking behaviour

Physicians in general are at risk for the development of stress, drug and alcohol abuse, as well as for suicide. Furthermore, the treatment of the sick physician is more difficult than that of a 'regular' patient. These difficulties may cause the postponement of diagnosis and treatment to critical stages of the disease. This paper presents a study of self-rated health and health-seeking behaviour of Israeli family physicians and their families. Our major finding is that two-thirds of the physicians do not have a regular family physician, and physicians who suffer from chronic diseases are even less likely to be treated than the 'healthy' ones. Twenty eight per cent of the physicians did not use any kind of medical consultation. However, each physician's family did receive some form of medical consultation, although in some cases this was not the usual form of medical care. The physicians who treated themselves tended to treat their own families and vice versa. Eighty-eight per cent of the physicians reported stress owing to their work (work overload, poor relationships with the medical team or with the patients), and 20% said that their work as physicians negatively affected their marital life. The relationship between the help-seeking behaviour of the family physician and the quality of care they give is as yet unclear. Various alternatives are raised for changing family physicians' behaviour as well as the primary care health system in order to possibly provide better care for the physicians and their families.     

The socialization of newly hired medical staff into a large health system

The acquisition of private medical practices by large health care systems often results in the transition of the physician from self-employment to salaried employee. In order to be successful, new physicians must be socialized into the new environment, requiring both concrete information and cultural orientation. This Mayo Clinic study of recently hired physicians yielded information about both content and delivery mechanisms that will help in planning an integrated system of orientation experiences.     

National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.     

Knowledge of patient's method of payment by physicians in a group practice.

Physicians generally know how patients pay for their medical care. At the Marshfield Clinic, however, a group practice in Marshfield, Wis., physicians did not know the source of payment for the vast majority of their patients (79.3 percent). Also, even for the approximately one-fifth of the patients whose payment status they reported knowing, the information was incorrect for a small proportion. The patient''s age and sex, length of time the physician had provided care, patient''s place of employment, reason for patient''s visit, and whether the physician was in the medical or surgical department apparently affected the physician''s knowledge of the patient''s payment status. Twenty-five of the 49 physicians studied reported they knew the payment status of none of their patients about whom they were asked; 24 knew the status of at least one patient. Only one physician in seven, however, reported having this knowledge about all the patients about whom he was asked. Physicians in medicine were more likely than those in surgical sub-specialties to know the patient''s payment status. About one physician in five said such knowledge would be helpful for at least one patient; about one in seven said it would be helpful for all patients about whom they were asked. The Marshfield Clinic physicians, who receive salaries, emphasize comprehensive care and increased access to care, rather than maximization of income. The clinic offers medical care to patients in a prepayment health plan while continuing to serve other patients on a fee-for-service basis. Arrangements like this may help ease the transition to repayment if health-maintenance organizations become predominant in the delivery of health services in the United States.