|Implemented in this survey?|
In pilot towns, responsibility for family health centers and preventive care in schools will be transferred from the MOH to the health plans to reduce government involvement in service provision, and deficit. It is expected to reduce duplication of services; increase continuity of care; and give health plans an incentive to provide preventive care and achieve standards. Concern has been raised about the effect on comprehensiveness of care, vaccination rates, and other quality parameters.
Objectives: To reduce Ministry of Health involvement in service delivery; reduce duplication of services; increase continuity of care; create incentives for the health plans to provide preventive care and achieve standards; and reduce the ministry's public health budget deficit.
Characteristics: Under the NHI Law, the Ministry of Health is responsible for the services provided at family health centers, and for preventive care in schools. At present, 64% of all infants in Israel receive care at family health centers operated by the ministry, 20% receive care at centers operated by the health plans, and 16% receive care at centers operated by municipalities. Health plan and municipality centers receive vaccinations from the Ministry of Health, but no additional funding (for manpower, facilities etc.); they collect fees from families.
As part of the pilot program, which will be implemented in 9 towns and 30 settlements, responsibility for providing care to mothers and infants, and in schools, will be transferred to the health plans, which will be remunerated in the sum of up to NIS 50 million annually.
Remuneration will in part depend on the achievement of explicitly defined service targets (e.g. vaccination, hearing and vision tests, home visits, counselling for mothers, and screening and vaccination of school children). A basic sum of NIS 1,000 will be allocated per infant, and NIS 45 per school child. In these towns, the health plans will be responsible for about 14,000 infants (who constitute 10% of those born per year) and 130,000 school children.
In small towns and villages, one health plan will provide services to all residents (chosen following bidding). School services will be divided among health plans (such that one health plan will provide services in each school).
The pilot program is part of an agreement between the Minister of Finance and the Minister of Health regarding the health budget, as part of general budget legislation. However, it is still uncertain whether the pilot will in fact be implemented, given the strong opposition to it within the Ministry of Health and among public health professionals – in spite of the Ministry's formal support of the change.
Incentives: Since health plans would be remunerated for meeting performance goals, they would have an incentive to provide high quality care at least with regard to those dimensions of quality which will be rewarded. They would also have an incentive to provide care efficiently, as payment would be global and unrelated to the resources they invest in providing services. Those health plans that want to take on wider responsibility for this service in the future would have an incentive to do well in order to facilitate transfer of these services to them in additional districts.
Outcomes: the outcomes are as yet uncertain. The health plans may respond as expected, and provide high quality care efficiently. However, there is concern that since the health plans take a curative approach, they may not invest in outreach and therefore may not achieve the current high rates of immunization (90%-92% coverage of infants for DPT, Polio, MMR, Hepatitis B and Hepatitis A). This is expected to affect vulnerable populations, in particular. Concern has also been raised regarding the health plans' ability to provide individual health education to mothers and development screening for infants, as they lack the specialized manpower and time to do so. (Population-based health education programs will remain the responsibility of the Ministry of Health). We should note that the timetable for the pilot will depend upon the preparations and readiness of the health plans. It is not clear how quickly some of the health plans can mobilize to take on responsibility in new areas; not all have the necessary manpower and logistical support (e.g. refrigeration facilities) which will be needed. The Ministry of Health will also need to mobilize to assume supervisory responsibilities, including the establishment of quality standards.
To reduce Ministry of Health involvement in service delivery; reduce duplication of services; increase continuity of care; and create incentives for health plans to provide preventive care and achieve standards. To foster macro-level efficiency, such that services will be provided at lesser cost to the health system as a whole.
Since health plans are remunerated for achieving performance goals, they have an incentive to provide high quality care. They also have an incentive to provide care efficiently, as the payment will be global and unrelated to the resources they invest in providing service. Those health plans that want to take on wider responsibility for this service in the future will have an incentive to do well, so as to facilitate the transfer of these services to them in additional districts, as well. The health plans will have an incentive to win the bidding process, in order to receive a larger portion of the remuneration.
There will be a gradual cutback in MOH family health center nursing staff. Some may be hired by health plans., Health plan primary care clinic staff will need to provide additional services that will increase their work load if additional staff not hired. May be remunerated for it., Mothers and infants in the pilot sites will now receive care at Health plan centers which also provide curative care. School children will receive care from health plan staff. Effect on qulity and satisfaction unknown yet.
|Medienpräsenz||sehr gering||sehr hoch|
Innovation – high – The health plans already provide these services, although under different terms: they are not reimbursed, they do not have an incentive to achieve quality standards, and the Ministry of Health does not monitor their performance. Transfer of responsibility for school children to the health plans will be entirely new.
Controversy – very high – there are divided opinions within the Ministry of Health; some public health professionals strongly oppose the idea.
Systemic impact – high – It will induce the Ministry if Health to make a structural change (i.e. gradually abandon service provision), and develop the capabilities of a ministry, including setting standards and monitoring providers, which it has to date not had.
Visibility – low – Received no media coverage
Transferability – high – Other countries could adopt a similar structuring of preventive services, as well as measures for monitoring the quality of care.
The 1995 NHI Law stipulated that, within three years of its passage, responsibility for preventive care would be transferred from the Ministry of Health to the health plans. However in light of strong opposition in 1998, the Parliament amended the NHI Law, and stipulated that the responsibility for preventive care remain with the Ministry of Health. The current pilot program initiative was suggested by the Ministry of Finance during negotiations over the health care budget (which is part of the yearly budget legislation). It is part of the government economic program which aims to reduce government expenditures, given budgetary cutbacks and an economic downturn.
|Implemented in this survey?|
The 1995 NHI Law stipulated that, within three years of its passage, responsibility for preventive care would be transferred from the Ministry of Health to the health plans. Proposals to shift the ownership of family health centers from the government to the health plans provoked strong opposition from a variety of consumer and professional groups, which argued that there is no need for change, given the achievements of the system as it is currently run (e.g., high immunization rates). They expressed concern that the health plans would not be able to match these achievements, given their curative approach and the lack of a national perspective on health needs (in some geographic areas, services are provided by more than one health plan). In 1998, the Parliament amended the NHI Law, and stipulated that the responsibility for preventive care remain with the Ministry of Health.
This issue has continued to be widely debated. Proponents of the change argued that it would improve continuity of care and reduce costs by taking advantage of existing health plan facilities and staff. Opponents of the change argued that the achievements in vaccination coverage could not be matched by the health plans, whose curative focus would lead them to give urgent needs precedence. Concern was also raised that the health plans would not engage in outreach programs, especially in lower income areas. Public health nurses opposed the idea fearing a reduction in the number of jobs in their field, as well as in their professional autonomy, if they were to be employed by the health plans.
Debate at policy forums (e.g., the Dead Sea Conference in 2002) and in internal ministry committees, Parliament committees, and academic seminars, have yielded differences of opinion among experts. Recently, the Amorai Commission (2002) recommended that family health centers continue to be operated under the auspices of the Ministry of Health, though through a separate authority that would be responsible for a wider spectrum of public health activities, as well as for developing standards of care and mechanisms for monitoring.
The current pilot program was suggested by the Ministry of Finance during negotiations over the health care budget (which is part of the yearly budget legislation). It is part of a wider program to reduce government expenditures, given budgetary cutbacks and an economic downturn. Its main objective is to reduce the Ministry of Health's direct provision of services, thereby strengthening the ministry's regulative position, saving costs and balancing that ministry's public health budget by 2006. The program is also expected to reduce duplication (between Ministry of Health family health centers and health plan clinics), thus promoting overall health system efficiency.
The Ministry of Finance is a strong actor in the health care system; it therefore succeeded (with the support of the ministers of both health and finance) in getting the plan ratified by the Knesset, as part of the yearly budget legislation. The pilot plan is part of the government policy to reduce the size of the public sector. A major impetus for the minister of health was the erosion of funding for the ministry's public health division, relative to the increase in the number of births. Although the Ministry of Health asked for additional funds, the Ministry of Finance refused to grant them, and suggested reducing its responsibilities or transferring them to the health plans. The minister of health realized that his ministry would not be able to provide services with a reduced budget, and therefore agreed to the transfer of responsibility for preventive care and family health centers to the health Plans. Moreover, the Ministry of Finance agreed to allocate NIS 50 million from the NIS 200 million earmarked for the health plans (the "safety net", allocated according to the achievement of targets) for these services once they had been transferred. This would enable the Ministry of Health to put more resources into the family health centers that would remain under its responsibility. In fact, the pilot program represents a compromise between reducing the Ministry of Health's public health budget deficit and the concern regarding transferring the services to the Health plans, and thus a partial transfer was agreed.
The pilot program is planned to go into effect in May 2005.
The tools for achieving the goals of the pilot are
The approach of the idea is described as:
renewed: Transfer of responsibility for preventive services from the Ministry of Health to the health plans was stipulated by the original 1995 NHI Law. The pilot program therefore revives the idea, after it was eliminated from the NHI Law by a 1998 amendment.
Ministry of Finance: As noted above, it initiated the policy and supports it as part of a broader program to reduce government expenditures, given budgetary cutbacks and an economic downturn. The policy's objective is to reduce the Ministry of Health's direct provision of services, thereby strengthening its position as regulaor, saving costs and balancing the public health budget by 2006. The policy is also expected to reduce duplication (between Ministry of Health family health centers and health plan clinics), thereby promoting overall health system efficiency. The Ministry of Finance believes that the health plans have the ability to provide high quality services. In addition, the pilot includes remuneration related to achieving performance targets, which will provide an incentive to offer high quality care.
Ministry of Health: Most of the professional staff of the ministry, led by those in the public health division, opposed the initiative. They argued that the achievements in vaccination coverage could not be matched by the health plans, whose curative focus would lead them to give urgent needs precedence. Concern was also raised that the health plans would not engage in outreach programs, especially in lower income areas. In addition, over time, the proposed policy will result in a decrease in the budget and activity of the public health division. Moreover, the Ministry of Health will have to redefine its mission to include setting standards and monitoring health plan activities. It may also fear this new direction, as it currently lacks the necessary skills and infrastructure (e.g., information systems). Under the new policy as represented by the pilot program, the Ministry of Health would also be expected to initiate national health promotion activities for school children – an area in which it has not to date been active, and in which the Ministry of Education has stakes. The cooperation between the two ministries is a challenge and would need to be handled with due sensitivity.
Ministry of Health public health nurses raised the above arguments, and expressed fear about a reduction in the number of jobs in their field as well as in their professional autonomy, if they were to be employed by the health plans.
Clalit Health Services: Clalit supports the policy. It operates family health centers in many cities and towns, and has a surplus of nurses – for whom the policy might help find employment . In addition, the policy would provide reimbursement (in the pilot towns) for an activity that Clalit has so far provided without reimbursement. As families with young children are a preferred target population for the health plans, Clalit would welcome the chance to provide services that could attract young families to join it.
Meuchedet Health Services: Although it at first opposed the policy, once Meuchedet became convinced that the pilot would include appropriate reimbursement, it began to support the policy. Like Clalit, Meuchedet would like to provide services to this target population.
Maccabi Healthcare Services: Maccabi does not support the policy, although it has not expressed its objections, because the pilot would provide reimbursement.
|Ministry of Finance||sehr unterstützend||stark dagegen|
|Ministry of Health||sehr unterstützend||stark dagegen|
|Clalit Health Plan||sehr unterstützend||stark dagegen|
|Maccabi Health Plan||sehr unterstützend||stark dagegen|
|Meuchedet Health Plan||sehr unterstützend||stark dagegen|
|Public Health Professionals||sehr unterstützend||stark dagegen|
|Public Health Nurse Unions|
|Public Health Nurse Unions||sehr unterstützend||stark dagegen|
The pilot program is part of the yearly budget legislation. The cost of the health budget (to be transferred to the Ministry of Health to cover its activities, and to the health plans) is defined in the annual budget. The Minister of Finance and the Minister of Health supported including the uded the pilot program in the 2005 budget legislation, which has been approved in the Knesset in March.
|Ministry of Finance||sehr groß||kein|
|Ministry of Health||sehr groß||kein|
|Clalit Health Plan||sehr groß||kein|
|Maccabi Health Plan||sehr groß||kein|
|Meuchedet Health Plan||sehr groß||kein|
|Public Health Professionals||sehr groß||kein|
|Public Health Nurse Unions|
|Public Health Nurse Unions||sehr groß||kein|
The health plans will voluntarily agree to provide services in the 39 cities and towns chosen for the pilot program, and will be reimbursed for providing care, as well as given an additional bonus for meeting quality criteria (to be defined by the Ministry of Health). It is thus expected that the health plans will have an incentive to cooperate. Clalit has a surplus of nurses, and therefore is most eager to participate. The other health plans are currently also providing these services (on a small scale), and therefore will probably be able to organize themselves to accept responsibility in additional areas.
The main problem facing the pilot at present is that the cooperation of the Ministry of Health's public health department is needed in order for the transfer to succeed. However, it currently is the leading opponent of the pilot program. Moreover, it is the public health department that should develop the quality performance measures and information systems for gathering data, as well as monitoring health plan activities. Delay in developing this infrastructure may delay the transfer of preventive care.
In light of this, the Ministry of Finance (with the consent of the Ministry of Health) insisted that the pilot be extensively evaluated to compare the performance of the health plans to that of the Ministry of Health (in the areas remaining under its responsibility). This evaluation will include monitoring process and outcome indicators (see below), and thus will facilitate the pilot, even if the Ministry of Health does not complete the development of information systems for monitoring the health plans. In addition, the Ministries of both Health and Finance expect that the evaluation will help the Ministry of Health develop the ongoing monitoring tools it will need in the future. The evaluation will be monitored by a steering committee comprising professionals and members of both ministries, who will consult on developing the performance measures and evaluation design.
The pilot is to be accompanied by an evaluation. There have been negotiations with the Myers-JDC-Brookdale Institute to conduct the evaluation, but a contract has not yet been signed. A joint committee has been set up to define the evaluation design and indicators, but they have not yet been decided. A semi-experimental design was suggested comparing the pilot sites with similar towns and settlements in which the services are currently provided either by the Ministry of Health or the Health plans (under current terms which differ from those of the pilot).
Following the initial discussions, some indicators for measuring success have been suggested, but these have not been approved yet (Source: Rosen, 2005):
A. Health Plans' organization for the pilot (e.g. expectations and concerns)
B. Inputs and expenditures per number of babies and school children
C. The service provision process (e.g. degree of separation from curative care in locus and hours of care provision, staff, etc).
D. Interim outcomes/products (e.g. meeting defined standards of preventive care for the individual: tests, vaccinations, consultation)
E. Outcomes (e.g. client satisfaction)
Halbzeitevaluation, Abschlussevaluation (extern)
Struktur, Prozess, Ergebnis
The evaluation has not yet begun.
We cannot be definite at this stage, since there is a great deal of uncertainty regarding implementation. It is unclear whether concerns about the coverage of services, outreach (especailly to vulnerable populations), and the precedence given curative versus preventive needs are justified.
It is also unclear at this stage whether the health plans will indeed be able to supply services more efficiently, or how the population will react to this change. Greater uncertainty exists regarding services for school children – an area in which the health plans have not to date been active.
A recent study (Palti et al., 2004) compared the family health services currently provided by the Ministry of Health, the health plans, and municipalities, and found no significant difference in the rates of preventive visits (although a slightly higher rate of physician visits was noted to centers run by the health plans) or of routine examinations by nurses. No differences were found in the satisfaction rates of mothers visiting family health centers run by the ministry as opposed to by the health plans. This portends that the results in pilot clinic may be similar (i.e. no significant change in services, even after responsibility for them has been transferred to the health plans).
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
Quality – Indefinite. Based on a recent study (Palti et al., 2004) we do not expect significant deterioration; there may be an improvement, if there is monitoring and a bonus is provided for achieving targets that exceed current coverage. If the health plans compete to attract young families, the level of service may rise.
Equity – Indefinite. Depends on quality standards, including outreach to vulnerable populations. Different services provided by the different health plans create inherent differences in services to members. However, if differences are notable, people will likely transfer to a health plan that provides better care.
Cost efficiency – Indefinite. However, the health plans currently provide services without reimbursement, and therefore, when reimbursed, may be able to provide them more efficiently than does the Ministry of Health. On the other hand, investments may be needed in infrastructure and training new staff. At the macro-level, efficiency is expected since the services will be provided by the health plans with no additional budget (the existing "safety net" funds would be allocated to this); thus the cost to the health system as a whole will be lower as the Ministry of Health would reduce expenditures.
Bruce Rosen. Israel. In Health Care Systems in Transition, edited by S. Thomson and E. Mossialos. Copenhagen: European Observatory on Health Care Systems, 5(1) 2003.
Palti, H., R. Gofin, and B. Adler. 2004. Evaluation of use of family health centers: personal and systemic factors. Harefu'a 134 (3): 184-188, 2004. (Hebrew)
Rosen, Bruce. Proposal for an Evaluation of the Pilot Program in the Public Health Care Services. Jerusalem: Myers-JDC-Brookdale Institute, March 2005. (Hebrew)
State of Israel. Report of the Commission to Examine Public Medicine and the Physician's Status. (Amorai Committee). Tel Aviv, 2002. (Hebrew)
Ministry of Finance. Pilot Plan for Transferring Responsibility for Family Health Centers and Preventive Care in Schools to the Health Plans. Jerusalem, February 2005. (Hebrew)
Authors: Revital Gross, Bruce Rosen, Reuven Kogan Reviewer: Gabi Ben Nun