Health & Healthcare–Who’s Responsible?

In November, the Taub Center convened its annual international conference. This year, the subject was “Health and Healthcare – Who’s Responsible? The Role of Individuals, Providers and the State.”  Participants included international experts in the field of health policy and senior professionals in the health system in Israel

Date: November 03, 2015

Individual Responsibility: “The patient must be responsible for his actions, and it is moral to demand personal responsibility”

Professor Yonatan Halevy praised the National Health Insurance Act of 1995, claiming that “the Israeli patient enjoys a long lifespan, and the data shows improvements over time. The treatment of diseases, such as diabetes and certain types of cancer, has also improved.” Regarding changes to the nature of a patient’s visit, he said “Patients now have much higher expectations due to the development of new diagnostic methods and the digital era. It won’t be long until patients are able to self-diagnose via smartphones and also compare themselves to other patients in similar situations.” Halevy noted that technological advances carry with them the good along with the bad: “We have before us innovative medications, digital accuracy, and digital tools. HMOs have also become quite advanced in the field of electronic records. However, when it comes to physician-patient relationships, we’ve seen negative developments. Doctors concentrate more on typing on their computers than on their patient.

Professor Chaim Bitterman raised two contradictory approaches to patient responsibility. The first holds that all citizens must take personal responsibility for their own wellbeing and take actions such as avoiding smoking, engaging in physical activity, and maintaining a healthy diet. On the other hand, there is the approach which suggests that citizens have almost no responsibility for their health. In Bitterman’s words, “Even with the best intentions coming from leaders in the health system, a substantial part of health is influenced by personal or environmental factors. The impact of the health system and of behavioral factors is at most 40% – the remainder is determined by one’s unique personal environment.” Bitterman also discussed the nature of Israel’s health consumer in 2015: “Healthcare consumers’ expectations of support and treatment are quite different today from what they once were. Knowledge is not only the property of the provider, but also of the patient. Patients participate in healthcare seminars and associations, and they set up tools for sharing information. Providers, then, must refresh and update their training methods to respond to the public’s thirst for information.”

The ensuing panel discussion dealt with the question of whether demands should be made on the citizen to take responsibility for his medical situation even when it involves weaker population groups. Dr. Orit Jacobson, Deputy Director General of Clalit Health Services, referred to the elderly population and said: “I was looking for a program to lower costs for treatment of the elderly but I could not find a community model. In the end, I asked the elderly how they would like to be treated. Through a parliament of the elderly in Tel Aviv, we built an intervention plan and we saw a lowering of hospitalizations and a rise in quality indicators – that is, the model worked. The Clalit Health Services later adopted the model countrywide.”

Prof. Nachman Ash raised a delicate issue: “Can we give bonuses to responsible patients and punish the others?” In his words, “We don’t like to punish victims, but sometimes there is no choice. We have already tried putting a tax on cigarettes and it is clear that this doesn’t work. Twenty percent of the population smokes, half of the citizens suffer from being overweight, and the most absurd thing is that some 50 percent of the healthcare system’s workers don’t even get the flu vaccine. The patient needs to be responsible for his actions, and it is moral to demand personal responsibility. We don’t need to be extreme and withhold treatment or humiliate the patient, but the patient needs to feel personal responsibility – particularly the weaker populations.”

Liora Bowers, Director of Policy at the Taub Center, added an international perspective to the question of personal responsibility: “As the trend in healthcare is towards growing individual responsibility, there are lessons that can be drawn from the United States, where Obama’s health reform was based on individual’s taking responsibility for their own health.”  Bowers discussed the importance of balancing the desire to place responsibility on the individual while at the same time considering the larger policy objectives.  She used the example that the government of California chose not to go forward with a popular proposal to charge smokers higher health insurance premiums than non-smokers. “Many of California’s smokers are from low socioeconomic populations, which would be further marginalized and left out of the healthcare system if they were charged higher prices for insurance; this would be counterproductive to the government’s goals to improve health and reduce disparities.”

The Responsibility of Service Providers: “The patient no longer trusts the doctor or the system”

At the beginning of the second session, Prof. Larry Brown spoke about the changes in the social contract over the past 20 years between the service provider and the patient and on the new challenges that we face: “When we stand before a patient in the system, we need to take into consideration several things beyond his health status: income, status, personal stress, and more.” Brown noted that service providers need to know that they cannot change their patients’ socioeconomic status, “but they need to understand the home and environment the patient returns to after the visit, in order to give them a comprehensive consultation.”

Prof. David Chinitz from the Hebrew University noted the historic evolution of responsibilities of the provider, from the Hippocratic Oath of “Do no harm” to the explosion of expectations today.  “Physicians today are expected to do their best to patients, to health plans, to patient populations, to global health and more.  The responsibilities are huge.”

Attorney Leah Vefner, Secretary General of the Israel Medical Association, added: “Should we just be saving money? Let’s invest it where it is most needed.” She related to the relationship between factions in the health system, and noted that “policy makers do not trust the doctors and say that they need to be supervised. This isn’t something new, but what is new is that the patient no longer trusts the doctor – or the system as a whole.”

Prof. Ran Balicer, Director of Clalit Research Institute, offered a solution to the situation: “We should only offer treatments that give results. The worst thing is overtreatment – it not only wastes money but it harms the patient. Not everything that matters can be measured, but some very important things can (and should) be measured. It is possible to use the information that the patient gives more wisely.” Balicer determined that “the system must change because it is built on ex post facto treatment. In Israel the situation is better, but there is a need to change from our current working propositions.”

Dr. Bishara Bisharat, Director, English Hospital of Nazareth and Chair of the Society for Health Promotion in the Arab Community in the Israel Medical Association, related to the role of the hospital: “The hospital should lead and influence the area like creating walking paths and serving healthy food in public places.”

The State’s Responsibility: “Just like we raise the defense budget in times of war, we should also raise the health basket as a result of increasing needs”

The third session raised a number of issues among participants. Prof. Mark Stabile suggested a new perspective to looking at the way the government should design healthcare services provided to its public. “The types of illnesses that people suffer from haven’t changes much in the past 20-30 years.” Stabile added and said “Despite its defects, ‘Obamacare’ recognizes that the healthcare system of services has changed significantly. The system relates to the fact that the population’s wishes have changed. We know that the population is aging and suffering from new diseases, and what has changed rapidly is the way of treating these problems. At the center of healthcare services should be creating solutions for the good of the public and not the needs or desires of the service providers or the government.”

Following this, MK Meir Cohen, past Minister of Welfare, related to the healthcare system in the periphery. In his words, “The true difficulty is to strengthen the periphery in order to create true equality with the cities of the central region. It is not reasonable that hospitals in the periphery rely on philanthropy; this is the role of the state.” Cohen determined that “there is money in the ministry; it is simply a question of priorities.”

Moshe Bar Siman Tov said that the ministry is using a strategy that includes strengthening the foundations and the status of doctors in Israel, budgeting the system, strengthening public medicine, encouraging healthy life styles, transparency, and dealing with future challenges. In this context, Bar Siman Tov noted that “changes are very rapid, especially demographic. Israel is one of the youngest countries in the world, and is also aging quickly, and that requires preparation in terms of hospital beds, long-term hospitalization and geriatric beds.” In his words, “we want to put the patient at the center and strengthen the socio-cultural connection.”

Prof. Shlomo Mor-Yosef tried to sharpen the definition of the healthcare that Israeli’s are entitled to: “It’s important that the state defines what healthcare services citizens should get, and that everyone – rich and poor – receives those benefits.  Because if you only give the poor certain benefits, than no one is there to defend the poor when someone tries to take those away.” With regard to personal responsibility Mor-Yosef added: “I am against punishment. I believe in creating incentives in terms of regulation and prices. If you want people to eat healthy, then it can’t be that healthy food costs the most. By the way, this is also the state’s responsibility.”

Prof. Dov Chernichovsky, senior researcher and Chair of the Taub Center Health Policy Program, raised some controversial ideas in his presentation, suggesting that the argument in favor of universal healthcare provided by the state is eroding with the increasing shift towards chronic diseases which depend on lifestyle.  He predicted that states will move away from providing a guaranteed basket of full health services, to a basket that meets only the minimum needs and is focused on catastrophic coverage.  In general, Chernichovsky explained that “inevitably, we will see a decrease in involvement and funding of healthcare by the state over time.  Nonetheless, the state must continue to protect the interests of certain groups – such as the young and those in the periphery, ensure oversight of medical technology prices, and be more involved in old-age and nursing care.”

Iris Ginsburg, an economist and member of the Health Basket Committee, summarized the discussion, and said: “Without some forethought about a new direction, the coverage of the state in the area of health is likely to change to resemble that of the area of welfare. The National Health Insurance Law provides a decent basket of services, and it apparently does not justify the private expenditure on health that amounts to 40% of the funding. When the individual continues to increase his expenditure in parallel with technological developments, this will create inequality in life expectancies and a split between two groups of the population.”