Dutch health system study tour

Here we are back on the road - this time in the Netherlands as part of the AUPHA sponsored study tour of the Dutch health system.  I will be blogging each night this coming week to share my thoughts and observations about the health system of this small country.  Please send me a note if you have any thoughts or questions that I might address while we are here.

What the US healthcare system can learn from Israel

Rethinking Healthcare Reform: Lessons Learned from Israel

In what seems like a lifetime ago, the United States Congress in 2010 passed and President Obama signed into law the Affordable Care Act (ACA). While the Act is certainly complex and remains the fodder of heated political debate, the basic intent of the bill is to make healthcare more widely accessible to the tens of millions of Americans who do not currently have health insurance.  The centerpiece of the ACA is the requirement that citizens purchase health insurance either through their employer or through one of several insurance exchanges.  It is reasonable to ask how a system like that might work and how other nations who have adopted similar programs have done relative to health outcomes, consumer satisfaction and eliminating or reducing health disparities.  While a number of industrialized nations provide health care through a single payer (government run) system, others have made a public-private system the model they use to guarantee health services to all their citizens. One of those nations is Israel which (as it turns out) has a lot to teach the United States on how to operate a universal health system that is based on both private and public inputs.

In close cooperation with the leadership and faculty from the Hebrew University of Jerusalem, Hadassah Hospital, and the Braun School of Public Health, seven students and two faculty members from the George Washington University School of Public Health and Health Services recently completed a two week study tour of Israel’s healthcare delivery system. The objective of the study tour was to allow these future healthcare leaders the opportunity to critically examine the organization, financing and delivery of health services throughout Israel. Through a combination of classroom and field based learning, the students discovered the following:

• ·         Israel adopted its national health system in 1995 requiring all permanent residents be provided a standard basket of services including physician care, hospitalization, prescription drugs and dental care for children

• ·         Healthcare is paid for by a combination of earmarked health tax payments, funding from the Ministry of Health and co-payments paid when services are delivered.

• ·         Four “sick funds” or HMO’s act as the insurance plan for all residents. Persons can freely choose any of the sick funds and can access any physician or hospital in the plan. The sick funds may offer supplemental coverage that is highly regulated.

• ·         Health coverage for every resident of Israel is accomplished for 8.7% of GDP in contrast to the US cost of 17.6% where there are almost 51 million without health insurance

• ·         By virtually all commonly used indicators including life expectancy and maternal and child health measures, Israel far outperforms the US.

• ·         An electronic health record ties together all the patient information for each of the four health plans and is accessible to physicians, hospitals and patients

This is not to say that the healthcare system in Israel is flawless and could not be improved.  The out of pocket costs to consumers continues to rise, there remain a number of critical health disparities particularly Israeli Arabs and peripheral populations and last year a 158 day physician strike over wages and working conditions revealed that provider working conditions must improve.

Despite the problems in Israel’s system, there are a number of important observations our students made that can have direct application to the United States and the implementation of the ACA including:

• ·         Cost control is essential particularly with respect to the payment to physicians and the reimbursement to hospitals.

• ·         The patients and their health and well being are at the heart of the Israeli system. Here in the US, the physicians, hospitals and commercial health insurance all believe that the system exists for their benefit.

• ·         An integrated electronic health record available to every one of the patients in the four HMO’s in Israel serves to reduce waste and duplication, gives physicians immediate access to clinical information and helps drive rational administrative decisions.  We are moving in this direction but progress is slow and uneven

• ·         The national standard basket of services assures that all patients, regardless of the HMO they choose, are guaranteed a uniform basic set of health services, which supports social cohesion.  Allowing each of the states to determine what services will be covered under the ACA forgoes this cohesion.

Perhaps the most important lesson learned by our students is the level of support that exists in Israel particularly around healthcare delivery.  There is an overt and covert sense that everyone is in this particular boat together and that it makes sense for everyone to have access to healthcare. In the end, this is what the ACA is trying to accomplish. All we need do is look to a small nation on the Eastern Mediterranean for an example of how to do this right.

Israel trip day 13 - 23 December

Well, this is it - our final day in Israel. We met as a group first thing in the morning to debrief the trip on a number of levels: content, culture and logistics. The comments from everyone in the group were so helpful as we begin the work of planning the next study tour to Israel. The one thing that we must do is thoroughly brief the participants about the US healthcare system if we expect everyone to be on the same page when comparing  the US system with any other. We also need to make sure that the students arrive in country first thing in the morning and then give them that day to rest and prepare for subsequent activities.

I want to be sure to thank Orly Manor, Director of the Braun School of Public Health at Hebrew University for making herself and her faculty available to us at every turn. All of the Braun School faculty are truly wonderful and dedicated teachers and scholars. Dr. David Chinitz is truly a mensch. His vision and energy gave us access to the breadth and depth of the Israeli health care system in a way I could have never imagined. He is also a passionate and inspiring teacher and is someone who I look forward to working with long into the future.  Thanks to Vardit Luzon who worked so hard to put together a travel package that came in under budget while at the same time meeting and exceeding all of my expectations.  Thanks to Nathan our guide whose encyclopedic knowledge of Israel was something to behold. Thanks as well to Sami whose skill at maneuvering our bus through impossibly crowded and busy streets was nothing short of magical.  Thanks to Laura Ochs at the George Washington University International Studies Office for all of her efforts to keep me calm and focused during the planning of the trip.  Thank you to Bob Burke, Chairman of the Department of Health Services Management and Leadership and Lynn Goldman, Dean of the School of Public Health and Health Services for your trust, confidence and commitment.

Special thanks and appreciation must go to Arthur Shorr. Three years ago, Arthur had a vision to bring a group of students to Israel and provide them with an opportunity to learn about the way health care is delivered in this very special nation. He remained persistent and focused throughout. I am glad that we gave him a chance to upgrade his Hebrew since he was speaking it like a native at the end. Arthur is an inspiration to me and I am so grateful he was here with us.

Finally, thanks to Teke, Vincent, Karen, Bijay, Morgane, Jeremy and LeMia - our students for whom this trip was intended and who were always fully engaged and energized even when it seemed like the days would never end.  The seven of you are truly wonderful and special people and without you, none of this would have happened.  Thanks to the seven of you for helping me to learn more.

So, on this early Saturday morning 24 December, let me wish all of you Shabat shalom and best wishes for a happy and healthy 2012.

Israel trip day 12 - 22 December

I have difficulty believing that we are just about done with our trip to Israel.  The last 12 days have flown by in a blur.  Today we began with a visit to the National Library of Israel which is on the campus of Hebrew University of Jerusalem. The National Library is equivalent to our Library of Congress.  It is housed in a building that is clearly too small for the collection and the many scholars, librarians and visitors that come in each year.  We spent the large part of our time in the archives and rare books section where we were treated to an up close view of a number of books that focused on the history of medicine including a first edition of the book written in 1543 by the Flemish anatomist Andreas Vesalius.

Our visit to the National Library was done too soon and we took the short walk to the Israel Museum. This is truly one of the most magnificent museums in the world that combine multiple worlds including art, culture and history.  Spending 3.5 hours at the was far too short a time to take in everything from the Dead Sea Scrolls, the extensive archaeology section, sculpture throughout the exterior, Impressionist galleries, Jewish art and life and the Second Temple Model.

In mid afternoon, we met up with David Chinitz and walked to the Brookdale Institute for Applied Social Research.  There, we were met by Dr. Bruce Rosen, Director of the Smokler Center for Health Policy Research. According to their website and verified by David Chinitz and others, "The main objective of the Smokler Center for Health Policy Research is to contribute to reforms and the development of Israel's national health services by offering objective data and independent analysis to improve the organization, delivery and financing of health services. In addition to hearing about the important work done by the Smokler Center, Dr. Rosen was particularly interested in hearing from our students about their impressions of Israel's health care delivery system.  Wanting to hear from our students was so gratifying to me as I listened to what they shared with some of the leading figures in health services research in Israel.


Leaving the Brookdale Institute, we had come to the end of our formal academic segment of the trip. One more day on Friday and then it is time to depart.

Israel trip day 11 - 21 December

We were packed and on the bus early today for our 8:00 AM appointment with the chief medical officer at the 669th Airborne Division of the Israeli Air Force housed at Tel Nof Air Base located about a half hour south of Tel Aviv. We were not permitted to take photographs while on the base and while the CMO was giving his presentation, there were two intelligence officers present to make sure he did not say anything against the rules. We were given a very thorough briefing of the activities of the 669th including a lengthy discussion of the role they played in the immediate aftermath of the Haiti earthquake in 2010 when the physicians and medics were sent to Port au Prince to establish a field hospital that treated hundreds of victims during the time they were in country. We were shown their search and rescue gear and got to see their training hanger where they can simulate virtually any environmental condition to allow their paramedics to practice their skills at rescue and patient evaluation.

Once we were escorted out of Tel Nof, we drove back to Tel Aviv where we bid farewell to our guide, Nathan. He was wonderful and was an absolute treasure trove of insights and information.  We headed for lunch at a wonderful seafood restaurant in Old Jaffa named, Old Man and the Sea (note the Ernest Hemingway allusion).  Small plate after small plate of Mediterranean inspired salads and wonderful pita bread  followed by your choice of whole fish that was likely swimming nearby not long before.  Simply seasoned and grilled, the only hassle was that you had to work around the bones.

Once lunch was done, we went to headquarters of Maccabi Healthcare System in Tel Aviv where we were met by Dr. Rachelle Kay, Deputy Director of the Division of Finance and Planning and Director of the Maccabi Institute for Health Services Research.  Maccabi is the second largest HMO in Israel with 1.9 million members and 5,000 employed physicians.  They have contracts with every public hospital in Israel and owns Assuta Medical Centers.  Last year, Maccabi rolled out a comprehensive electronic health record connecting every one of their physicians to their hospitals. This EHR allows every physician access to a dashboard looking at multiple quality indicators. Data is pulled from a data warehouse that contains comprehensive clinical information for each and every Maccabi patient. We were joined by a number of other key Maccabi staff members who shared with us the work they were doing in medical informatics, telemedicine and quality management. The only comparable non-federal US health care organization doing similar work is Kaiser-Permenante. I was very impressed with their dedication to using data to make good clinical and administrative decisions. Dr. Kaye did acknowledge that for the first time Maccabi was running a deficit and this was an important focus for the organization.

Just as the lights for the second night of Hanukkah were being lit, we got back on the bus for the long drive back to Jerusalem.  It was comforting to get back to Jerusalem where we knew our way around.  It was a bit like coming home.

Israel trip day 10 - 20 December

This was a bit of an out of the ordinary day.  Up until now, we had focused on the delivery and payment of health services in Israel. This morning, we were dropped off near a local shopping area and walked to the offices of the Migrant Workers Hotline. We received an in-depth briefing from one of their senior staff on the plight of foreign workers who enter Israel to typically work in a variety of service or agricultural activities. There are over 100,000 legal migrant workers in Israel who are typically here from either the Philippines or China.  These workers are allowed to be in the country for up to five years if they have a contract from their employer who is responsible for purchasing health insurance for these workers. We learned that these workers can not become Israeli citizens even if their children are born in Israel. 

Another group we learned about were refugees, typically from Eritrea. Israel has a relatively open border to the non-Arab parts of Africa and many refugees enter the country by crossing into the Negev Desert. While the living conditions of the refugees is pretty sad, it is far better than what they left behind in Eritrea. Many of these people earn a living as a day laborer or in some cases, run their own businesses in an area close to the Central Bus Station. Walking through this area was certainly not something typically found in the tour books.

After our morning walk and post graduate education about a part of Israel most people don't think about, we stopped for lunch and then gave everyone the rest of the afternoon off. While the students went off in various directions to explore Tel Aviv, Arthur Shorr and I went to the old city of Jaffa. This is a beautiful destination that hugs the coast just south of Tel Aviv. Lots of art galleries, shops, museums and places to stop and enjoy a cappuccino at a sidewalk cafe. 

The evening was spent grading final exams and posting grades. Later in the evening, was met by the brother and sister in law of the travel agent who set up the trip.  Both Ruthie and Miky are pediatricians who work for one of the large health plans in Tel Aviv.  They were absolutely lovely people and I thoroughly enjoyed my time with them.

Israel trip day 9 - 19 December

The Madison Nahariya hotel won the prize with the students for the best dinner and breakfast so far on trip.  We packed up and boarded the bus for a short drive to the Western Galilee Hospital.  We were met by their director Masad Barhoun who shared with us the history and interesting attributes of the hospital.  In contrast to Hasassah Hospital, Western Galilee is a public hospital dependent almost totally on funding from the government. The hospital has 660 beds and is considered a rural hospital despite its size. One other thing of note, is that the hospital is just six miles from the border with Lebanon and came under fire during the 2006 war with Lebanon.  Over 800 rockets fell in the vicinity of the hospital and one struck the ophthalmology wing.  Fortunately no one was killed since the hospital had moved all the patients and staff into a subterranean hospital that had been designed just for this type of event.  We took a tour of the hospital including the new ER which is designed to withstand virtually any type of attack scenario as is the new women's health center and cardiac wing.  One of the things that was emphasized over and over was the drill and training all the staff go through to confront any type of emergency.  This continuous drilling gives the hospital and the staff the resilience to respond to essentially any type of disaster scenario.  How amazing would it be if US hospitals were equally prepared to deal with a disruptive event?

After departing the hospital we, made the short drive to a community clinic run by Clalit, the largest of the four national HMO's in Israel.  We got to meet the director, Dr. Saab Anwar who took us through the organization and operation of Clalit and his clinic in Nahariya. One of the notable attributes to Clalit is their dedication to health and wellness with the focus on the patient first and foremost. We visited with the staff from the pediatric clinic, women's health clinic and pharmacy. Their electronic health record ties together all patient encounters whether with a physician or a hospital.  I think that all of us came away impressed by the passion and dedication shown by all the persons we met at the Nahariya Clalit clinic.

When finished at Nahariya, we drove south into Tel Aviv. With afternoon traffic it took two hours but we would our hotel adjacent to the beach and close to Ben Yehuda Street. Thankfully, there was a coffee shop nearby that had blazing fast internet access since the hotel's router was down and out. 13 shekels for a cappuccino and internet access until they closed at 10:00 is a great deal.