Newsgroup: it.politica.internazionale
Titolo: il sistema sanitario israeliano

un modello per tutte le democrazie
http://www.jpost.com/JerusalemReport/Article.aspx?id=175612
Health Care for All
By ZIV HELLMAN
15/05/2010 14:25
Israel's healthcare system, with full, lifetime health insurance for 
every resident, is widely considered a success.
This article was published in The Jerusalem Report on May 2, 2010. To 
subscribe to The Jerusalem Report, click here.
ded, a software engineer in central Israel, was diagnosed a couple of 
years ago as needing to undergo surgery to correct a potentially 
life-threatening condition.
To prepare himself for the procedure – involving more than eight hours 
of surgery, followed by months of recovery – he joined an Internet 
support group for people suffering from the same condition, but quickly 
felt out of place. “The conversations were always dominated by 
Americans,” he explains, “who spent most of their time complaining about 
the difficulties of financing the surgery.
“It seemed like insurance companies [in the US] routinely turned down 
coverage of the procedure, costing upwards of $60,000. Some wondered if 
their doctors had recommended the surgery just to make money off them. I 
had first-class and sympathetic surgeons treating me in Kfar Saba, and 
it was inconceivable even to question whether I would be covered by our 
national health system. I got annoyed when I was sent a bill of a couple 
of hundred dollars for X-rays and lab tests.”
Oded’s case is typical. In January 1995, at about the same time 
president Bill Clinton’s health reform bill failed in the US, Israel put 
into effect a national health law that guaranteed full, lifetime health 
insurance to every resident. Fifteen years later, the overall consensus 
on the impact of national health reform in Israel is almost universally 
positive.
 From the perspective of the bottom line, the figures are impressive: 
Israel’s per capita health costs are half those of the United States, 
and the country expends a much smaller proportion of its GDP on health 
care, yet it provides universal health coverage, and top-notch, 
technologically up-to-date care. Its outcomes in many areas are superior.
Compared to the US, Israel has more physicians per capita, a lower 
infant mortality rate, higher life expectancy, and lower rates of 
cardiovascular disease. The country has the highest number of IVF units 
in the world per population, and is near the top of the lists of 
transplant units per population and overall physicians per population.
Although not without its flaws, and always with room for improvement, 
surveys indicate remarkable general satisfaction with the health care 
system; a survey conducted every two years by the Myers-JDC-Brookdale 
Institute consistently shows 88 percent of Israelis report a high level 
of satisfaction with their health plans.
Notably, that figure is even higher among minorities: The percentage of 
respondents who were satisfied or very satisfied was highest among 
Arabic speakers, at 94 percent. “The health system in this country is in 
good shape, by any measured parameter, in both accomplishments and 
containing expenses,” says Kobi Glazer, a professor in the Tel Aviv 
University School of Management, specializing in Health Economics.
In fact, a study that the Pittsburgh Regional Health Initiative (PRHI), 
a consortium of medical, business and civic leaders in Pennsylvania, 
commissioned in the autumn of 2009, concluded that the US and other 
countries might do well to learn from the Israeli health system. 
“Israel’s healthcare system has significant relevance and important 
lessons to lend to healthcare reform efforts in the United States,” says 
Bruce Rosen, director of the Smokler Center for Health Policy Research 
at the Myers-JDC-Brookdale Institute, who participated in the PRHI study.
“US health reform debates have been about the best ways to move toward a 
more integrated model, through which payment is aligned with care 
delivery and that targets safety, efficiency, access, and quality. 
Therefore, as the US moves to strengthen primary care, contain costs, 
and require multi-provider accountability for coordinated high-quality 
care, there is much to learn from Israel, where these concepts are 
already at work.“
Despite widespread misconceptions, the country’s health care system is 
not a socialized, single-payer system. Israelis generally accept as 
almost axiomatic that there should be universal health coverage, with a 
significant acceptance of government involvement in regulating health 
care for the sake of redistribution, accountability, and preventing 
competition from leading to uncontrollable cost overruns. At the same 
time, there is also recognition of the benefits of keeping a strong 
measure of competition in the system. This has led to what Glazer 
describes as “regulated competition”: universal state-financed insurance 
coverage is provided through four competing health-maintenance 
organizations.
The HMOs are independent and non-governmental, but highly regulated. 
Although membership in one of the funds is compulsory – no permanent 
resident can voluntarily opt out of the system – residents have free 
choice of which fund they wish to belong to (a change is allowed once 
every six months), making the HMOs compete for members. HMO members are 
typically directed by their HMO to a doctor or clinic associated with 
that HMO, but it is increasingly likely that any private clinic chosen 
arbitrarily will accept insurance payments from all four HMOs.
The basic coverage that every approved HMO is required to provide every 
member, regardless of age or pre-existing condition, is called the 
“health basket,” and is determined annually by the government. Members 
of HMOs are also free to purchase additional “supplemental” 
pay-as-you-go insurance. Government hospitals provide more than half of 
all acute-care hospital beds in the country and most psychiatric facilities.
Private hospitals, clinics,  and commercial health insurance companies 
also thrive independently alongside the state-financed system, available 
to anyone who wishes to make use of them. Private insurers are regulated 
financially by the Ministry of Finance’s Insurance Commissioner, but, in 
contrast to the HMOs, they are free to reject applications on the basis 
of health status, exclude pre-existing conditions and rate premiums 
according to health status.
Between 70 to 80 percent of residents purchase supplemental insurance, 
which mostly covers private hospitalization, specialist choice, cosmetic 
surgery, and enhanced long-term care, although the percentage of 
supplemental insurance policyholders remains relatively low among the 
Arab population, low-income recipients, and the elderly. About a third 
of the population has some form of commercial comprehensive health 
insurance policy or long-term care insurance.
But satisfaction with the care provided by the standard HMOs is so high 
that supplemental and other insurance policies are rated by experts as 
underutilized relative to their potential. The Myers-JDC-Brookdale 
survey indicates that 43 percent of Israelis wait less than a week for 
appointments with specialists, and 18 percent wait between one and two 
weeks. Remarkably, only 1 percent per year take advantage of 
opportunities to switch HMO provider.
S., a mother of three, tells of a routine situation with one of her 
children. “On a Thursday night it dawned on me that the sore throat my 
13-year-old had been complaining about was getting worse and might need 
medical attention. But it was already after hours and our neighborhood 
HMO branch wouldn’t be open until Sunday. I called the main office, and 
they directed me to their night-time pediatric walk-in clinic.
“We went in at 10:30 p.m. with no appointment and no wait. The doctor 
took one look, diagnosed strep throat without lab tests and prescribed 
antibiotics, which we proceeded to buy in the same building for 32 
shekels ($8). When, a few days later, he didn’t seem to be getting 
better, I took him to his pediatrician at our local clinic, who ordered 
blood tests for a viral infection. There was another follow-up visit and 
finally a throat culture was taken after all. All the tests came back 
negative so we never knew what he had, but he recovered. There was never 
a question about getting same-day appointments, no paperwork, and the 
only expense was the medicine.”
Avigdor, a middle-aged media person, had a bout of pneumonia a few years 
ago. A follow-up X-ray revealed a growth on his lung. After looking at 
the CAT scan the lung specialist pronounced cancer. “That was somewhat 
scary,” Avigdor tells The Report.
He was rushed to surgery for the removal of part of his lung and then it 
turned out the the growth was a carcinoid – cancerlike, but 
non-malignant. Apart from the trauma of the diagnosis and the surgery, 
Avigdor was spared the worry of arranging and paying for the costly 
procedures. His health fund took care of it all.
“I paid less for a chest operation and a stay in intensive care, than it 
costs me to get a tooth fixed,” he remarks.
By law, there are only four approved HMOs. The 1995 law left open the 
possibility of adding a fifth HMO, but that will require a government 
vote of approval – a significant limitation of competition in public 
health insurance.
“But competition in health provision is not necessarily good, and under 
certain conditions it can be harmful,” says Glazer. “This is not like 
the market of, say, restaurants, or computer chips, and the difference 
is due to information asymmetry. Patients have far less information 
about which treatments are necessary and which are not than the 
providers. In unlimited competition, as we have seen in the US, 
providers have an incentive to exploit the information they have to push 
patients to undertake expensive treatments that may not be needed, in 
order to profit. The solution to this is regulated competition.”
The Israeli health system was largely shaped by historical 
circumstances. The first health plan was established back in 1911 by a 
workers’ association, espousing the idea that society as a whole is 
responsible for the health of its citizens. All four of the existing 
HMOs were established in the period between 1920 and the early 1940s, 
prior to the creation of the state. Reflective of the spirit of the 
times, when one’s political association determined membership in 
everything from sports clubs to youth movements, two of the four HMOs 
were associated in the past with political parties and labor organizations.
By the late 1980s, approximately 95 percent of the population was 
insured in one of the four HMOs – with more than 80 percent at Clalit, 
which was affiliated with the Histadrut (the General Federation of 
Labor). There was also a sense of general dissatisfaction with health 
care, and there were frequent doctor and nurse strikes. About 5 percent 
of the population was uninsured, and HMOs had a financial incentive to 
accept only younger and healthier people. Clalit, which had a 
disproportionate share of elderly and poorer members, ran increasingly 
large deficits that were covered by the public purse. There was also 
public unease with the fact that membership dues to Clalit went through 
the Histadrut, which took some of that money for its labor activities.
The National Health Law of 1995 ended the connection of health coverage 
with political parties, guaranteed universal health insurance, and made 
the specification of basic health benefits an explicit function of 
government. Clalit’s relative market share has shrunk to about half of 
the population.
The following year, an innovative Patients’ Rights Act was adopted, 
intended to shift medical care to a model that increases patient 
autonomy. The law defined basic rights and established bodies for 
handling complaints, along with ethics committees.
Public health, of course, needs to be financed. The financing sources of 
national health are about evenly divided between a health tax, which is 
a payroll tax earmarked for health spending, and the general state 
budget. Failure to pay health tax is a form of tax evasion and punished 
as such, but it cannot be used as a reason to deny an individual 
national health benefits. In return for providing state-mandated health 
benefits, the government gives the HMOs a capitation payment, with the 
total amount of public support each HMO receives determined by the 
number of members it has enrolled. The per-capita payments are higher 
for elderly members than for younger members, to avoid situations in 
which HMOs try to drive away the elderly from their rolls.
The health tax is not entirely progressive – income above five times the 
average salary is not taxed for health purposes. This has drawn some 
criticism, with some voices claiming that health spending should come 
entirely out of the general budget. Glazer, however, recommends against 
making any major changes to the way national health is funded. “The 
current hybrid tax system works,” he says. “There is no pressing need to 
change it. There are advantages to having tax collected specifically for 
the purpose of health care, and not leaving health spending entirely in 
the hands of Finance Ministry officials.”
The Ministry of Health targets a 2 percent yearly increase for 
technology and 2.5 percent for demographic shifts, but the Finance 
Ministry often approves appropriations increases that fall short of this 
goal. Given that hospitals are already operating at 92 percent bed 
utilization – and in some cases running over 100 percent – Ministry of 
Health officials have expressed concern that there has been insufficient 
capital budgeting over the past several years.
The standard national health benefits package does not include long-term 
care, mental health care, preventive health care, public health services 
and dental care. Nor is medical research covered. Households generally 
pay out-of-pocket for private laboratory tests, complementary medicine, 
private nurses and ambulances, psychological visits, optometry, and 
dental care, with dental care alone accounting for about 9 percent of 
total health expenditure.
In fact, taking this into account, over a third of Israel’s national 
health expenditures are covered by households. Adding private insurance 
payments to these figures, it turns out that public sources account for 
only 56 percent of Israel’s national health, according to OECD 
accounting estimates, and that share has been declining. This makes for 
an interesting comparison with the US, where public sources account for 
approximately 48 percent of health care expenses, paid through Medicare, 
Medicaid and the Department of Veterans’ Affairs – a challenge to the 
stereotypes of “socialized” medicine in Israel versus “private” medicine 
in the US.
“There isn’t one system here, and private and public health care gets 
mixed together,” says Dr Michael Bayme, a surgeon at Soroka Hospital in 
Beersheba, who studied medicine at NYU and worked as a physician for 
nearly ten years in the US before immigrating to Israel. “Patients will 
have surgery at a private hospital, and then go to follow-ups at public 
clinics, or the other way around, just as easily. All the possibilities 
are available, and people choose whichever works for them.”
Despite the praise that  Israel’s national health law has drawn, for 
providing high standards and reliable medical care, there are also 
criticisms.
The annual determination of the basket of coverage is guaranteed to 
spark controversy and headlines. The Ministry of Health determines the 
basket of benefits based on the recommendations of a public committee 
composed of experts in health provision, financing, and public policy, 
and an appeals process exists for individuals who face rejection of 
treatments. But inevitably, some highly expensive treatments and 
medications are left out of the basket. Media articles highlight the 
plight of individuals dependent on treatments that have not made the cut 
of inclusion in the basket.
This priority-setting process, however, has also been praised by 
professionals for transparently dealing with the difficult question of 
the limits of public allocations for health, in an openly-debated manner 
that is rare through most of the world. “The state is committed to 
supporting health, but ultimately there is a limited amount of resources 
that can be given to health coverage,” points out Glazer. “That is also 
true of any health provider, private or public. And just like the 
government needs to balance its resource allocation, and determine how 
many tanks to purchase, and how many classrooms to have in schools, it 
needs to determine what medical treatments are covered, and at what cost.
“This is a decision that has to be taken at the national level, and then 
applied uniformly at every HMO – if each HMO were given the right to 
determine its own basket of coverage, they would tailor their coverage 
to the benefit of the young and healthy, to reduce as much as possible 
the old and sick on their rolls.”
The existence of supplemental insurance is also sometimes criticized, 
with some claiming that for-fee services provided by the registered HMO 
contradict the spirit in which the national health law was passed, to 
provide equal care for all, regardless of income. But Glazer defends the 
current system. “The main benefit of supplemental insurance is that it 
gives patients a choice of which doctor will treat them, and access to 
doctors at private hospitals,” he says. “The positive aspect of it is 
that the state requires the HMOs to offer supplemental insurance to 
everyone, regardless of health condition, and at an equal price, so that 
there is a measure of equity here.”
Other flaws in the health system that have been pointed to include the 
law’s failure to include psychological care and dental treatments in the 
list of basic public health benefits, despite persistent indications of 
correlations between both mental and dental health and overall health. 
End-of-life and palliative care are also generally regarded as 
under-funded, and there is no independent system for regulating hospital 
quality measurement and maintenance.
Glazer also criticizes strict policies forbidding the provision of 
private health treatment in public hospitals, a policy that was adopted 
to prevent a situation in which private care slowly crowds out public 
care. “But this has led doctors working in public hospitals to leave en 
masse in the early afternoon, to rush to their other jobs at private 
hospitals and clinics,” says Glazer. “This is a redundancy in the system 
that leads to unnecessary costs and waste, not to mention causing the 
doctors stress and exhaustion. There is no reason not to allow public 
hospitals to permit doctors to treat patients on their grounds under 
private arrangements, at agreed-upon hours, as long as it is regulated, 
and does not come at the expense of public health provision.”
Dr. Bayme agrees that physicians have to scramble to make a living. “I 
know of no doctor who works only at his day job,” he says. “The base 
salary for work at a public hospital is simply too low. Everyone either 
works many extra hours at private clinics and hospitals, or signs up for 
endless evening, weekend and holiday shifts at public hospitals. But 
when I worked in the US, I was also dividing my time between about eight 
hospitals, and a private clinic, and I was always on call. The only 
difference is that doctors in America make ten times as much, and are in 
the top three percent of the income ladder just by virtue of their 
 profession.”
Both Glazer and Myers-JDC-Brookdale’s studies indicate that a potential 
shortage of nurses and doctors also looms as a near-future threat. Given 
the density of physicians in Israel – 3.6 per thousand, compared with 
only 2.4 per thousand in the US – this might seem a surprising concern. 
But Israel has relied heavily on immigration as a source of new 
physicians, especially the large immigration from the former Soviet 
Union in the 1990s; it is estimated that fewer than 40 percent of all 
licensed physicians in the country up to age 65 have studied in local 
medical schools. The sources of immigration are drying up, however, and 
greater reliance on homegrown physicians will be inevitable. The country 
currently has four medical schools and is planning to open a fifth.
“There is going to be a shortage of doctors in the near future,” says 
Glazer matter-of- factly. “This is a global phenomenon, but that means 
there will be competition between countries in attracting physicians. We 
need to prepare for this now, whether that means increasing the number 
of medical students, or improving the conditions of doctors in order to 
attract more talented young people to the field, and keeping them here.”
Ran Melamed, deputy director of Yedid, an association for community 
empowerment, tells The Report that gaps in medical care have left the 
population living in outlying parts of the country behind. Soroka 
Hospital is the only major public hospital serving most of the south, 
while there are seven major hospitals in relatively close geographic 
proximity in the densely populated core of the country.
“People living on the periphery have less access to basic information,” 
says Melamed, “both regarding their rights, and medical facts. They 
express fear of doctors, who intimidate them with attitudes of 
superiority. And they are poorer. With important health elements 
available only to those who can pay for supplemental insurance, the 
basic basket is disappearing for the poor. Many avoid seeing doctors out 
of concern that if a doctor diagnoses them as suffering from a major 
disease, they will not be able to afford out-of-pocket payments.”
What can be done to correct this situation? Melamed recommends requiring 
the HMOs to publish figures on the profits they are making on 
pharmaceutical sales. “They claim that profits from pharmaceuticals 
subsidize other activities, but they never present proof,” he says. 
“They should be required to lower the prices they charge for medications 
to lower-income members.”
Ran Shorrer, who has been studying the health system for his master’s 
thesis in economics at Hebrew University, even asks whether the 
competitiveness said to be inherent between the HMOs is overrated. “It 
is unclear where exactly the competition is expressed,” says Shorrer. 
“There is very little movement of insured members from one HMO to 
another, because they are perceived as indistinguishable. At this point, 
virtually every private clinic and doctor accepts insurance payments 
from all four HMOs, reducing a lot of the role of the HMO, from the 
perspective of much of the population, to a grand system for setting 
appointments with doctors, and then handling the insurance paperwork.”
Shorrer says that there is, in fact, competition between the HMOs, but 
what they are competing over is the ratio of the number of young insured 
members to elderly members, precisely what the health law was intended 
to prevent. “The extra payment from the government per capita for 
elderly members is supposed to make every insured citizen equally 
valuable for the HMOs, but obviously the HMOs themselves don’t believe 
this,” says Shorrer. “If you track carefully both their advertisements, 
and the services they voluntarily offer members beyond what they are 
required by law, you can see the bias towards the young. The extra 
benefits are concentrated in ante-natal care and child care, precisely 
because every HMO wants to increase the number of insured on its rolls 
in the young adult age group.”
Even with its shortcomings, the Israeli health system has been 
successful from the perspective of the economic bottom line: per capita 
spending on health in Israel is $2,069, compared with $6,401 in the 
United States. Expenditure on health as a percent of GDP is only 8 
percent in Israel, versus 15 percent in the US, even though insurance 
coverage in Israel is universal, while 15 percent of the population in 
the US is  uninsured.
A major part of the PRHI study is devoted to asking what factors 
contribute to these differences, and it suggests several. The Israeli 
emphasis on out-of-hospital primary care, rather than in-hospital 
medical care and short-term follow-up, is one of them. Ninety percent of 
the population regularly has contact with a primary care physician, who 
serves as a gatekeeper to direct them to specialists, as needed. This 
tends to reduce unnecessary diagnostic procedures and over-reliance on 
complex  technology.
The pay incentives for physicians also make a difference; most Israeli 
physicians are contracted employees, and their work is generally 
assessed by overall results, not the number of tests or operations they 
order. In contrast, several studies indicate that fee-per-service 
incentives in the US have led to wasted spending on clinically 
irrelevant procedures.
Another factor is the relatively small differentiation in salaries paid 
to Israeli physicians in different specialties, from internal medicine, 
to radiology, to surgery and so on. In the US, differential salaries 
between specialties are a factor in the cost and structure of the health 
care system. The immense gulf between medical school tuitions in the two 
countries is another driver of macro distinctions between the health 
systems. In Israel, where medical schools are state subsidized, students 
pay less than $3,000 per year in tuition. In the US, students typically 
pay 10 to 20 times as much. The need to repay medical school loans then 
pushes top students to the sub-specialties that generate the most income.
Rosen adds to that list fewer malpractice suits in Israel, and hence 
less defensive medicine, a culture that recognizes that you can’t have 
everything and need to prioritize, and even constraints on hospital bed 
supply in Israel, resulting in less hospitalization. He cautions, 
however, against over-comparison to the US. “It is important to keep in 
mind that when you look at OECD countries as a whole, the US is the 
outlier, not Israel,” he says.
Glazer agrees. “National health works in every advanced country in the 
world,” he says emphatically, “and it can work in the US just as well.” 
Given the widely held assumption in Israel that universal health 
coverage should be guaranteed by society, and the success of 15 years of 
national health, many Israelis find the fierceness of opposition to 
health reform expressed in the US bewildering. “Americans are paranoid 
about changing their health system, to their detriment,” opines Glazer. 
“Of course, under the Israeli system there is rationing – you don’t have 
complete freedom to be treated by any doctor you want, and sometimes you 
might need to wait a couple of weeks for an appointment.
“But any health system will include some aspect of rationing. There is 
health care rationing in the US right now, in various ways, such as the 
number of people who are entirely uninsured, and people who have paid 
for health insurance for years and then discover their coverage 
disappears as soon as they get seriously ill,”Glazer notes.

 un modello per tutte le democrazie
ROTFL. Puoi rivelare al caro pubblico quanto si campa col "modello"
israeliano e quanto nei paesi che dovrebbero seguire quel modello?

 un modello per tutte le democrazie
ah beh s� beh
Secondo i dati dell'OMS del 2000 (vabb� risalgono a dieci anni fa) il 
miglior sistema sanitario del mondo � quello francese, seguito al secondo 
posto da quello italiano.
Pertanto � abbastanza ridicolo promuovere altri sistemi sanitari su un 
gruppo francese o italiano, perch� ti fai ridere dietro...

 Pertanto è abbastanza ridicolo promuovere altri sistemi sanitari 
l'articolo di cui sopra si rivolge al pubblico americano. E si', credo 
che gli americani dovrebbero imparare da Israele.

 ha scritto nel messaggio

gli americani sulla sanità dovrebbero imparare da mezzo mondo, Cuba
inclusa, addirittura. Ma tra "gli americani" e "tutte le democrazie"
c'è la stessa differenza che c'è tra biasimare il vescovo emerito
antisemita di Grosseto e scrivere che i cattolici sono
consustanzialmente antisemiti

 gli americani dovrebbero imparare da Israele.
Guarda, imho gli americani dovrebbero imparare da molti, non solo da IL:
Hanno un sistema sanitario da paura.