Responsibility for mental health care

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The new policy aims to promote quality of care, efficient use of resources, deinstitutionalization and community based treatments and to reduce stigma of patients with mild psychiatric conditions. It creates incentives for SFs to improve continuity and comprehensiveness of care; shift patients from hospital to community care facilities and negotiate low prices with providers. Concerns are that SFs shift funds to treat general conditions, restrict access or treatment in order to reduce costs.

Purpose of health policy or idea

Objectives: 

1. Integrate mental and general health care in order to improve quality of care, quality of life and integration into the community, reduce stigmatization of the mentally ill, and promote efficient use of resources (the latter is expected to be achieved only at the end of the process).
2. Deinstitutionalize and encourage the utilization of community-based mental health care services and rehabilitation facilities. 
3. Resolve the conflicting role of the Ministry of Health (MOH) as both service provider and regulator, and strengthen its regulatory role.
4. Improve access to care for  mild psychiatry patients, and double the percentage of the population which use mental health services.

Content:

1. Mental health services will be added to the mandatory basket of services that the sick funds provide under the National Health Insurance (NHI) law.
2. Funds from the  MOH budget will be transferred to the sick funds, and will be allocated  through a capitation formula.
3. Rehabilitation services for chronic mental patients will remain the responsibility of the Ministry of Health.
4. The development of community-based mental health services and rehabilitation services will be accelerated.
5. The number of chronic psychiatric beds, and government- owned ambulatory clinics will be reduced , and  funds will be allocated to SFs to develop their own community services or purchase services from private providers.

Expected outcomes: Improvement in continuity and comprehensiveness of care for the mentally ill; decreased stigma of mental illness and mental care; better regulation of the system by the MOH; shift of patients from hospitals to community care facilities; more efficient use of resources for mental health care (via contracts between SFs and providers, and reduction in hospitalization). Use of ambulatory services is expected to increase if SFs provide them (easier access, less stigma). However there are concerns that SFs might restrict access to care or limit treatment in order to reduce costs.

Incentives: If SFs assume responsibility for mental health care they would have an incentive to provide the care in community settings which are less expensive. They will also have an incentive to negotiate lower prices with providers. However, SFs would also have an incentive to provide inexpensive care and that might compromise the quality of care (restricting access, limiting treatment). Furthermore, the MH funds are not earmarked therefore SFs might limit care and transfer funds for developing services to attract young healthy populations. On the other hand, SFs would be responsible for the whole continuum of care for the mentally ill and therefore would have an incentive to improve care of mental illness in order to reduce the overall costs of these patients.

Mental health care providers would have an incentive to improve quality of care as well as offer lower prices in order to obtain contracts with the SFs.

Main points

Main objectives

To integrate mental and general health care services under the responsibility of the SFs as part of the mandatory basket of services under the NHI law.

Type of incentives

This organization of the service is expected to provide an incentive for more efficient use of resources (prospective payment to SFs) and improved quality of care  (continuity and comprehensiveness of care).

Groups affected

Sick funds.- will be responsible for providing MH care services, Ministry of Health - will be relieved from responsibility to provide MH services, Mental health care providers will have to be in contract with SFs instead of receiving a budget from the MOH: Patients: the mentally ill can benefit from continuity of care and decreased stigma, but can also be more restricted in access to services.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Innovation - Formerly  MH services have been under the responsibility of the MOH operating as a NHS regarding provision of mental health care, while operating in a Bismarkian model based on SFs regarding provision of general medical care. Furthermore the reform creates for the first time a payer-provider split in the mental health care system, enabling the MOH to assume a regulatory role.

Consensus - the idea has been heatedly debated since first presented in 1990. The different actors disagreed about the level of funding to be allocated to the SFs and about the effect on quality of care. Psychiatric hospitals opposed the idea fearing the effect on their financial resources, and employees contested it fearing loosing their jobs.  In spite of that, most actors agreed that professionally and ideologically it is a much needed change already overdue.

Status quo- The reform is expected to have a fundamental effect on the status quo since it will significantly change the incentive system for the SFs, and the "rules of the game".

Visibility - at this stage of the reform the media does not cover this issue probably since it concerns structural changes.  In the past, the media showed more interest in "human stories" related to the care of  the mentally ill.

Transferability - this reform is highly context-dependent on the historic structure of the MH system and the general health care system in Israel. Related to that are the specific interests and power of the different actors.

Political and economic background

Transferring responsibility for MH care from the MOH to the SFs was first recommended by the Netanyahu committee in 1990, and since was a part of several policy programs for reforming the system.

In 1995 transfer of responsibility to the SFs was included in the NHI law (to be implemented within 3 years) but in 1997 it was taken out of the law and postponed  indefinitely. The main reason for that was a disagreement between the SFs the MOH and the MOF regarding the size of the budget that should be transferred to the SFs for providing MH care (the assumption was that the demand for care would increase); and fear of the MOF that they would loose their control over  the health budget. 

In 1999 the National Council for Mental Health appointed a committee (Kotler Committee) to reassess the Netanyahu committee recommendations. This committee also recommended (among other things)  the transfer of responsibility to the SFs.

In 2000 another committee was appointed (Shani Committee) to formulate the reform goals. Their recommendations were to reduce the size of the psychiatric hospitalization system, develop the community mental health system and transfer responsibility to the SFs.

Between 2000-2003 a structural reform of the MH system was carried out which included definition and budgeting of a basket of MH rehabilitation services, expansion of community rehabilitation services and a decrease in chronic MH beds. This reform was facilitated by the 2000 law for rehabilitation of mental health patients in the community, which included earmarked funds for developing rehabilitation services, and a definition of a mandatory rehabilitation basket of services for the mentally handicapped  

In order to complement and facilitate the structural reform of the MH system, in January 2003 the Israeli government decided to transfer the responsibility to the SFs without defining the size of the budget for providing the services. The MOH initiated the decision which was in line with its strategy for improving quality of care and deinstitutionalization of the mentally ill. Moreover, the MH budget was eroded during the years 1997-2003 as there was no mechanism for updating it (similar to the mechanism that does exist for updating the budget allocated to the SFs). Therefore, the MOH expected that by transferring the budget to the SFs it would be updated yearly, together with the rest of the SF budget. The  MOF supported the decision to transfer responsibility to the SFs as part of it's economic strategy to improve efficiency in the health care system. Transferring the responsibility to SFs would reduce government expenses, and would provide an incentive for the SFs to provide these services at minimal costs.

A working group headed by Professor Shani was nominated in 2003  In order to negotiate an agreement between the SFs, MOH and MOF about the terms for the transfer of responsibility to the SFs and the size of the budget that would be given to the SFs for providing MH care.

A draft agreement was reached in June 2004 with a target date of January 2005 for the transfer of responsibility from the MOH to the SFs. However, the agreement has not been signed due to the MOF's insistence on approving additional funds for developing ambulatory services by the SFs conditional on closure of the Abarbanel psychiatric hospital.  Families of mentally ill patients with the Abarbanel hospital staff  have filed a claim to the high court of justice to prevent closing that hospital.  Objection to closing the hospital was also voiced by a parliament committee and consequently by the Minister of Health.

Change based on an overall national health policy statement

Government decision to implement reform recommended by National Inquiry (Netanyahu) Commission on the functioning and efficiency of the HC system, 1990; 2000 Law for Rehabilitation of Mentally Ill Patients in the Community

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The recommendation to transfer responsibility for mental health care from the MOH to the SFs was first presented in the 1990 state commission of inquiry on the health care system  (preceding implementation of the  NHI law). This report provided a comprehensive health policy program for improving the functioning and efficiency of the health care system. The recommended reform in the mental health system was based on data indicating the need to improve quality of care and better adapt these services to the needs of the population (e.g. lack of sufficient community-based services and overuse of hospital-based care, fragmentation of care, restricted access to care especially in peripheral areas and for non-severely mentally ill). Another reason for this recommendation was the need to improve the functioning of the MOH by resolving the conflict of interest within the MOH as both major provider of services and regulator.

The reform recommended by the Netanyahu Commission included other tools as well: 1) integrating mental and general health services (in both ambulatory and hospital settings) on a regional basis 2) coordination between MOH and other ministries for solutions to special areas (e.g. addiction, autism) 3) redefinition or the authority of the regional psychiatrist in particular regulating the acts of forced hospitalization. 

The driving forces for this reform were poor performance of the mental health system (not enough ambulatory and rehabilitation services in the community, fragmentation, poor coordination between general medical and mental care) as well as the professional approach supporting deinstitutionalization. 

The reform was supported by professional leaders in the mental health care system who believed in deinstitutionalization and development of community services. Another impetus for change at that time was the development of new psychiatric drugs for severe conditions which allowed for shortening the length of hospitalization.  These leaders also believed that integration into the general health care system would increase the status of the profession.

However, it should be noted that at the time the idea was first proposed, there was widespread opposition from various interest groups who successfully lobbied for postponing implementation. Professionals in psychiatric hospitals and out-clinic services opposed the idea fearing loss of jobs, decline in budgets, and demands for accountability to the SFs. SF directors claimed that the budget would leave them under-funded. The MOH administration feared loosing power and discretion over provision of services. The MOF feared that legal entitlement to MH services would increase demand and result in deficits in the health budget. Mentally ill patients and families feared a reduction in hospital beds while community facilities would not be developed. Finally, NGOs providing rehabilitation services feared competition from new organizations SFs would contract with.

Overtime, the idea has gained support even though the positions of stakeholders remain ambiguous. Nevertheless, an agreement has been negotiated in 2004 and is expected to be implemented.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Patienten, Verbraucher

• Bürgergesellschaft

• Wissenschaft

• Privatwirtschaft, privater Sektor

• Medien

• Meinungsführer

• Andere

Stakeholder positions

Positions as currently  expressed towards the 2004 agreement

A draft agreement between the MOH MOF and SFs was negotiated by the Shani Committee (nominated by the MOH and MOF) as a basis for implementing the reform on January 2005. However, the agreement has not been signed (see above) and implementation will probably be postponed to 2006.

The main items in this agreement include:

1. Transfer of responsibility for providing MH services from the MOH to the SFs as part of the mandatory basket of services under the NHI law; a defined list of MH services to be provided by the SFs, the MOH the Ministry of welfare and the Ministry of education as well as an allocation of funds for each.
2. Reduction of psychiatric beds.
3. Closure of the Abarbanel psychiatric hospital, and opening of psychiatric departments and outpatient clinics in a list of general hospitals (workers would be relocated).
4. Gradual closure of MOH  ambulatory clinics that are not affiliated to hospitals, and allocation of funds to the SFs for developing ambulatory MH services
5. Definition of funding sources for the SFs and the capitation formula for allocating the funds 
6. Definition of a reimbursement method between SFs psychiatric hospitals  and ambulatory clinics
7. Psychiatric hospital budgets would be conditioned on income.
8. Monitoring the effect of the reform using selected performance measures (see below).

The positions of the main actors are still ambiguous:

Sick funds:  support the agreement and are willing to provide MH services as part of their responsibility for comprehensive care. Possibly see potential to save costs and use them for other purposes (since MH funds would not be in a separate account). However, SFs voice concern that the funds allocated are not sufficient especially in light of the forecast for considerable growth in the demand for "soft" psychiatric treatment.

Ministry of health: supports the agreement because it will improve the quality of care, increase the budget allocated for MH and link updates of the budget to updates of the general medicine budget, and will reduce conflict of interest within the MOH.  However, following the reform, the ministry will have much less funds to control, will have to reorganize the MH division and reduce workers. The MOH is also concerned that government community clinics will be closed before the SFs develop other channels for care, and that the budget allocated for rehabilitation is not sufficient, therefore compromising access and quality of care.

Ministry of Finance: supports the agreement because  believes it will lead to reduced costs of hospitalization, more efficient operation of the system, and less government based services and employees. The MOF is concerned that the MH budget would increase over time since its update will be linked to the update of the general health budget. (when the budget was part of the state budget and allocated to the MOH, the MOF had discretion over rate of growth).

Directors of psychiatric hospitals: support the objectives of the reform and integration with general health services but fear the consequences to the hospital - e.g. downsizing of hospital beds; lack of  a fixed budget; need to negotiate with SFs ; and fear that SFs will restrict access and compromise quality of care.

Government-employed mental health care providers (practitioners):  support objectives but fear for their positions in light of reductions in government system; staff in community clinics fear change of employer;  practitioners are concerned that the  quality of care may be compromised if SFs would restrict access, length of treatment etc.

Patients, patients' families, and patient advocacy groups: support the objectives but fear that access to care would be restricted and that there will be a shortage in hospital beds and community services for the severely ill. Also fear that SFs would shift funds to general medical patients.

Scientific community:  believes the reform would achieve the major objectives but is aware of the risks regarding quality of care if SFs would try to restrict access or try to save costs by restricting treatment.

In spite of the concerns of the various actors, the process has achieved a momentum and the transfer of responsibility is expected to take place within a year.  This can be attributed to the support of leaders within the MOH and MOF as well as the strong position of Professor Shani who headed the committee that prepared the 2004 agreement and mediated differences of opinion between the SFs, MOF and MOH.

Actors and positions

Regierung
Ministry of Health	sehr unterstützend		stark dagegen
Ministry of Finance	sehr unterstützend		stark dagegen
Leistungserbringer
Public sector mental health workers	sehr unterstützend		stark dagegen
Kostenträger
Sick Funds	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Otzma - families of patients	sehr unterstützend		stark dagegen
Bürgergesellschaft
Patient advocacy groups	sehr unterstützend		stark dagegen
Wissenschaft
Israeli Psychiatric Association	sehr unterstützend		stark dagegen
Privatwirtschaft, privater Sektor
private mental health providers	sehr unterstützend		stark dagegen
Medien
non-specified	sehr unterstützend		stark dagegen
Meinungsführer
Prof. M. Shani, director Shiba medical center and member of the Netanyahu commission	sehr unterstützend		stark dagegen
Psychiaric hospital directors (Prof M. Kotler, Prof Z. Zemishlani, Dr. M. Schneidman)	sehr unterstützend		stark dagegen
Andere
Directors of psychiatric hospitals and ambulatory services	sehr unterstützend		stark dagegen

Influences in policy making and legislation

To date, there has not been formal legislation. Since the 2004 agreement has not been signed yet (see above), the legislation would probably not be included in the 2005 budget legislation but postponed to 2006.

The professional assessment is that if the MOH will show a significant reduction in the number of beds and implementation of other parts of the 2004 agreement, the MOF would sign the agreement without insisting on closing the Abarbanel hospital. This assessment takes into account that 2006 will be an election year and the Minister of Finance would like to show cooperation in a structural reform that improves quality of care.

Another impetus for change is that in spite of the concerns of the different actors they are unanimous in their assessment that the current situation and ongoing uncertainty and under-funding is a danger to the system, demoralizes practitioners, and is harmful to the quality of care. Therefore, the major actors are willing to implement reform in spite of their concerns.

Actors and influence

Regierung
Ministry of Health	sehr groß		kein
Ministry of Finance	sehr groß		kein
Leistungserbringer
Public sector mental health workers	sehr groß		kein
Kostenträger
Sick Funds	sehr groß		kein
Patienten, Verbraucher
Otzma - families of patients	sehr groß		kein
Bürgergesellschaft
Patient advocacy groups	sehr groß		kein
Wissenschaft
Israeli Psychiatric Association	sehr groß		kein
Privatwirtschaft, privater Sektor
private mental health providers	sehr groß		kein
Medien
non-specified	sehr groß		kein
Meinungsführer
Prof. M. Shani, director Shiba medical center and member of the Netanyahu commission	sehr groß		kein
Psychiaric hospital directors (Prof M. Kotler, Prof Z. Zemishlani, Dr. M. Schneidman)	sehr groß		kein
Andere
Directors of psychiatric hospitals and ambulatory services	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Most of the work in implementation concerned the structural reform which laid the ground for transferring responsibility to the SFs, and reaching an agreement on terms of operation (outlined in the 2004 Shani committee agreement).  Additional work is needed in fine tuning the terms.

Then, after resolving the dispute with the MOF (regarding closing Abarbanel hospital) transfer of responsibility to SFs is expected to be immediate.

The necessary preparatory steps for implementation are:

Psychiatric hospitals and psychiatric departments in general hospitals:

a) definition of a uniform hospitalization rate for each of four types of bed as a basis for remuneration agreements with SFs (active acute, active long term care, children and youth, violent patients);

b) measurement of performance indicators (e.g., length of stay, re-hospitalization after 30 and 180 days) and fines for excess re-hospitalizations or excess length of hospitalization;

c) reduction in number of beds.

Private sector:

a) negotiating changes in case-mix so that they will concentrate on  rehabilitation 

b) defining indicators of successful rehabilitation

c) opening several community clinics to demonstrate the feasibility of operating such private facilities

d) SF contracts with private practitioners

Patients and the General Public:

a) improving the attitudes of the media to the transfer of responsibility to SFs, in order to create public support

b) cooperation with patient advocacy groups to engage their support.

Sick Funds:

a) define indicators for monitoring increase in ambulatory care

b) finalize procedures for remuneration of hospitals.

The MOH will lead and moderate these negotiations and processes.



In order to convince and appease  the opponents to the policy intensive negotiations were carried out with psychiatric hospital directors (on number of beds); sick funds (on content of basket of services,  funding levels and accountability, and regulations for purchasing services); and the MOF (regarding additional budget and cost containment measures). In addition patients' families took an active part in the process. Professor Shamir represented the families, advocated the reform, was an important participant in the process, and has had articles published in the media advocating the reform.  Involving families provided visibility and served to alleviate their concerns.

The main incentive for implementation of the reform at this time is the erosion of the MH budget, in particular the budget of psychiatric hospitals. The reform (which includes additional funding and a mechanism for regular budgetary updates) is expected to improve the financial situation of psychiatric services and therefore the main actors support it despite their concerns.

Monitoring and evaluation

The 2004 agreement includes a chapter on monitoring implementation. The agreement states that the Minister of Health will appoint a formal committee (minhelet) which will collect data and examine the extent to which the objectives of the reform are achieved.

The indicators will include:

• number of psychiatric beds by hospital and department; 
• number of day hospitalisations and day care by hospital and department;
• number of hospitalisation days by SF hospital and department;
• number of day hospitalisations and day care by SF hospital and department;
• average length of stay in acute psychiatric departments;
• number of circular hospitalisations during 30 and 180 days from discharge;
• rate of short (less than 7 days) hospitalisations by hospital;
• allocation of funds in each SF between hospitalisation day hospitalisation day care and ambulatory care;
• number of patients by SF,
• number of ambulatory treatments and the distribution of treatments between clinics and independent practitioners;
• number of referrals for treatment by type of treatment (e.g. intake, cognitive therapy, monitoring pharmaceutical treatment).

Dimensions of evaluation

Struktur

Expected outcome

It is difficult to give a definitive answer at this stage. We believe that outcomes will be apparent in about 5 years following implementation. Only at that time the changes in demand and the reaction on the supply side would be apparent. However  success is already apparent in the fact that although a huge reduction in psychiatric  hospital beds has been implemented , there is no increase in the number of homeless people. That is attributed to the implementation of the law for  "rehabilitation of the mentally ill in the community".

If sick funds assume responsibility for mental health care both continuity of care and comprehensiveness of care are likely to improve. However, fragmentation will still exist since the SFs would not assume responsibility for rehabilitation services.  There is concern that since the mental health funds are not earmarked and the SFs do not have an incentive to attract these (expensive) patients,  they may shift funds for developing services to other sectors. Thus, the quality of care for the mentally ill may be compromised.  Furthermore, there is concern that SFs would try to reduce costs of mental health care by restricting access, limiting treatment, referring to least expensive care option etc.

The objective of deinstitutionalization may be achieved if the costs of providing care in the community would be lower than hospitalisation. However, it is not yet clear if that would be the case.

The objective of efficient use of resources is likely to be achieved since the SFs have an incentive to save costs.  Again, it is yet unclear how the legal entitlement to MH services through the SFs (as part of the NHI law) will affect utilization rates. Current estimates forecast a growth of 100% in utilization (2% among children and youth and 4% among adults). However, if utilization rates will be higher the current budget would not suffice and it is unclear whether the MOF would allocate additional funds. A deficit might lead to restriction of services, longer waiting times etc.

Regarding the conflict of interest within the MOH, although they would not be responsible for providing care, still they will be the owners of psychiatric hospitals and therefore be in an ambiguous position.

Therefore, the outcomes of implementing this reform depend to a great extent on the infrastructure for monitoring  SFs activites; control of number of  beds in psychiatric hospitals and departments; continued development of adequate rehabilitation facilities; and mechanisms for coordination of care between the health and welfare system which is responsible for rehabilitation.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Quality -  Unclear, as explained above. However we should note that an integral part of the reform is measurement (for the first time) of quality indicators in hospitals.

References

Sources of Information

Mark M. Rabinowitz J. Feldman D. Gilboa D. Shemer J. 1996. Reform in the mental health services in Israel: the changing role of government, HMOs and hospitals. Administration and policy in mental health 23(3):253-259.

Feldman D. Gross R. Nirel N. Barasch M. 1996. Staff attitudes toward the reform of the mental health system in Israel. RR-260-96, JDC-Brookdale Jerusalem.

Aviram U. 1996. The mental health services in Israel at a crossroads: Promises and pitfalls of mental health services in the context of the new national health insurance. International Journal of Law and Psychiatry 19(3-4):327-372.

Aviram U. 1997. Mental Health Care Services on the Cross-Roads: opportunities and risks in light of the National Health Insurance Law, The Center for Social policy Research, Jerusalem  (Hebrew).

Mark M., Rabinowitz J., Feldman D. 1997. Revamping mental health care in Israel: from the Netanyahu commission to National Health Insurance Law. Social Work in Mental Health: Trends and Issues 25(3):119-129.

Kaplan Z., Kotler M., Viztom A. 2001. Mental Health Care Services in Israel - directions and changes. Harefoa 140(5):440-445 (Hebrew)

Haver E., Baruch Y., Kotler M., 2003. The structural reform of mental health services Israel journal of Psychiatry 40(4)-2003; 235-38

Sykes I. ,2003. The use of data in the effort to transfer mental health services in Israel from the Ministry of Health to the Health Plans, JDC-Brookdale, RR-404-03 Jerusalem.

Elizor, Lerner, Baruch, 2004. The reforms in the mental health care system, Taub Center for Social Policy in Israel. (Hebrew)

National inquiry commission on the functioning and efficiency of the health care system (Netanyahu Commission) 1990.

Government of Israel, 2000. Law for rehabilitation of mentally ill patients in the community.

Ministry of Health, June 2004. Draft Contract between the sick funds and the State.

Author/s and/or contributors to this survey

Prof. Revital Gross, Myers-JDC- Brookdale Institute, and Dr. Yehuda Baruch, Ministry of Health; Reviewers: Prof. M. Shani Sheba Medical Center, Israel Sykes Myers-JDC- Brookdale Institute, Gabi Bennun and Dr. Boaz Lev, MoH, Raviv Sobol, MoF

Empfohlene Zitierweise für diesen Online-Artikel:

Prof. Revital Gross, Myers-JDC- Brookdale Institute, and Dr. Yehuda Baruch, Ministry of Health; Reviewers: Prof. M. Shani Sheba Medical Center, Israel Sykes Myers-JDC- Brookdale Institute, Gabi Bennun and Dr. Boaz Lev, MoH, Raviv Sobol, MoF. "Responsibility for mental health care". Health Policy Monitor, 28/10/2004. Available at http://www.hpm.org/survey/is/a4/5