2.9. Patient empowerment

This section covers such issues as patients’ choices and rights and information on navigating the system.[8]

2.9.1. Patient information

When choosing among HPs, Israelis have available to them information on availability and accessibility of HP services, and patient satisfaction. More recently, comparative data on clinical dimensions of care have become publicly available. Additionally, a Ministry of Health website provides detailed comparative data on what health care services are covered by the various commercial, supplemental and basic insurance programmes. A Ministry of Health-operated multilingual call centre is available to answer questions about insurance coverage and other aspects of health care.

All of the HPs operate both call centres (e.g. for scheduling appointments, providing coverage details) and extensive websites (with searchable directories, coverage details, forms, etc.) to help guide their members through the health system.

Websites established by various consumer organizations also provide important health care information, as well as web-based access to medical specialists and various peer-to-peer social networking opportunities. The largest, Camoni (“like me”), has over 100 000 unique visitors per month. Israel also has a Freedom of Information Act.

There is a growing recognition in Israel of the need to make services more accessible to cultural and linguistic minorities and several initiatives have been instigated in this regard. For example, Ethiopian immigrants having access in some clinics and hospitals to employed facilitators/liaisons, and there are Arab primary care providers (PCPs) in Arab villages. However, when it comes to specialty outpatient care and hospitals, significant cultural and linguistic barriers remain. The lack of professional translators results in an overreliance on family members or hospital employees who have not been trained in translation.

2.9.2. Patient choice

All Israelis are free to choose their HP and HPs must accept all applicants. In the past, transfers were limited to specific periods of the year, but anyone who has been in a plan for at least six months may transfer at any time. In practice, each year approximately 1.0–1.5% of the population switches plans and, interestingly, switching behaviour is relatively more common among lower-income individuals. New immigrants must choose a plan for the first time.

Interestingly, in a 2014 MJB Institute survey with 1540 participants (Brammli-Greenberg & Medina-Artom, 2015), 20% of adult respondents indicated that they had considered switching plans in the past year. Reasons for ultimately remaining in the plan were personal reasons (laziness/lack of time), 38%; realization that they were satisfied with their own plan, 32%; concerns regarding whether it was worthwhile to switch, 20%; and bureaucratic reasons, 18% (respondents were allowed to cite more than one reason). Another category included concerns about continuity of benefits/eligibilities and the price of supplemental insurance in the new plan. It is also important to keep in mind that the survey shows that the vast majority of the population (over 85%) are either satisfied or very satisfied with their plan.

Within plans, patients have a great deal of freedom in choosing their community-based physicians – both primary and specialist – from among those physicians affiliated with the plan. In most specialties, and in most areas of the country, each plan is affiliated with numerous physicians so that there is real choice in practice. Nevertheless, there are some specialties (e.g. child psychiatry) and regions (e.g. the Negev) where choice is more limited. If a member wants to see a physician not affiliated with the plan, access is not guaranteed through the basic benefits package, but in many circumstances partial coverage is available for those who have enrolled in supplemental insurance programmes.

HPs have the right to direct their patients to particular hospitals. With the growth of selective contracting between HPs and hospitals, the plans have become much more active in directing patients. This has led to strong objections from many patients, and even more so from certain hospitals. The German Commission (see section 6.2) has recently recommended that HPs be required to provide their members in need of hospitalization with a choice of at least three hospitals.

In general, patients in non-profit-making hospitals are not free to choose which hospital-based physician will treat them.[9] Instead, department heads assign physicians to particular rotations and/or patients. However, in Jerusalem’s non-profit-making hospitals, there is a private medical service option (SHARAP), in which the patient can choose their physician for an additional fee (i.e. beyond the fee paid by the HP for the basic hospitalization). All of the supplemental and commercial insurance packages offer partial or total coverage for this additional fee and the private medical service programme has grown markedly since the mid-2000s. Similarly, in Israel’s rapidly growing profit-making hospital sector, patients can choose their doctor, and with most of these fees being covered by supplemental and commercial insurers, more and more patients are electing to do so.

Although informed consent and a patient’s right to information are regulated by Israeli law, little provision is made for shared decision-making and few organizations formally promote it; as a result, there are those who see potential for increased shared decision-making because of Israel’s universal coverage and limited number of HPs (Miron-Shatz et al., 2012). However, others note that, when choosing among treatment options, responsibility for the final decision typically lies with patients, with doctors being responsible for providing information to inform patient choice; some doctors find fault with this policy since not all patients may be fully capable of making such choices.

2.9.3. Patient rights

The Patients’ Rights Law, enacted in 1996, emphasizes that patients have rights above and beyond the right to health care alone. Also enshrined in the Law is the patient’s right to review and transfer the information in her/his medical record.

The Law was the product of cooperation between Knesset members, government offices, the Association for Civil Rights, religious and legal representatives, women’s organizations and patient and professional associations. It defined the rights and obligations of patient–provider relationships, moving from a paternalistic model of care to a patient-centred model emphasizing patient autonomy. The main goals of the Law were to ensure caregiver professionalism and quality and to protect the dignity and privacy of patients. In addition, the Law included rights that were previously granted in lawsuit verdicts within the realm of medical ethics and social norms, for example prohibition against discrimination and promotion of informed consent.

In 2008, the Law on Equal Rights for People with Disabilities (2005) was amended to require that, within 12 years, all public buildings will be accessible to the disabled and that all new buildings must provide such access from their inception. Although no comprehensive data regarding accessibility in health care facilities exist, a study finding that the vast majority of gynaecological clinics were not accessible for the disabled sparked an awareness campaign by several voluntary organizations. There are some preliminary indications that these efforts have worked to increase awareness of needs and to persuade the HPs to increase access.

2.9.4. Complaints procedures

All major Israeli health care institutions (such as HPs and hospitals) are required to assign a designated person as responsible for handling patient complaints. In addition, the Ministry of Health itself operates several units to which patients can send complaints regarding problems they encounter anywhere in the health system, both clinical and administrative. Both the Ministry and the providers try to respond to the complaints at two levels: by trying to better meet the specific needs of the individual who submitted the complaint, and by analysing aggregate complaint data to identify and then address problems that are prevalent and systemic in nature. The Ministry of Health also publishes an annual report that includes detailed information on the prevalence of complaints by provider and type of problem, as well as documenting the types of action carried out to address those complaints.

While all health care organizations have staff to handle complaints, people can still get lost in the system. Consequently, a national ombudsman has been appointed to address this issue and serve as a liaison between the individual and the system. The ombudsman can address both clinical/malpractice issues and patient financial rights/administrative issues; the ombudsman can enforce the withholding of funds from noncompliant HPs.

The Director-General of the Ministry of Health has recently encouraged the public to file complaints for any service that does not meet the standards of the NHI Law. In 2012, almost 4000 complaints were filed, of which approximately 25% were found to be justified (Ministry of Health, 2013b). It is unclear to what extent complaints are not filed even when patients have a right to do so. For example, advocates for those with mental health issues say that, as a practical matter, patients cannot complain while in psychiatric hospitals because the staff has de facto power over them.

With specific regard to hospital care, all Israeli hospitals are authorized by law to maintain two types of quality committee: a quality control committee to monitor and promote quality on an ongoing basis and a quality examination committee charged with examining specific untoward events. A 1995 Supreme Court ruling (Civil Appeal Request 1412/94) determined that patients and their families should be guaranteed access to the findings of the quality examination committees regarding their specific cases, but the IMA objected strongly to this and encouraged physicians to not cooperate. Over time, the extent of the IMA opposition has abated and the extent of physician cooperation has increased. The IMA continues to encourage physicians appearing before quality examination committees to bring a lawyer with them.

Hospitals are required to send reports to the Ministry of Health concerning all hospital deaths and unusual events in hospitals. The Unit for the Assessment of Reportable Deaths and Events reviews these reports and determines which cases require more in-depth investigation (which, in turn, could lead to disciplinary measures) and maintains a database encompassing all reports to identify systemic problems as a basis for system-wide interventions.

With regard to adverse drug reactions, the public is encouraged to report these directly to the Ministry of Health, although usually they discuss these with their physician, who then reports the event to the Ministry.

Direct-to-consumer advertising of pharmaceuticals is illegal, while the situation with regard to medical devices is ambiguous. Advertisements by doctors are strictly regulated.

2.9.5. Public participation/involvement

In addition to their influence via political parties, citizens also influence the health care system through their involvement in the boards of directors of key organizations, such as Hadassah, the HPs, and Magen David Adom, and through participation on various government advisory bodies, such as the National Health Council.

Citizens, as consumers, also have influence over the system through the mechanisms of “voice” and “exit”. Increasingly, researchers are using surveys and in-depth interviews to help consumers to articulate their needs and wants with regard to an ever-widening set of health care services and issues. Moreover, in those areas of health care characterized by competition, such as the HP sector, shifts and potential shifts in market shares have led providers to be much more responsive to consumer demands and wants than they were in the past.

The MJB carries out a biannual survey of the general population regarding health system performance. In the 2007 survey, 88% of respondents indicated that they were “satisfied” or “very satisfied” with their HPs. In the first round of the survey, the comparable figure was 83% (1995); by the second round, it had risen to 91% (1997) (probably as a result of the introduction of NHI), and has remained high since then (89% in 2014). The survey also enquires about satisfaction with the health system as a whole, and here the percentage of “satisfied” or “very satisfied” individuals was 62% in 2014, which was down from 70% in 2012, but still slightly higher than the 58% level found in the 2003 survey.

In 2003, a unique initiative was launched – the Health Parliament. Groups of ordinary citizens from around the country were given an opportunity to voice their views on pressing health policy issues after being given extensive background information on those issues in a series of regional meetings with leading health policy experts (Guttman et al., 2008). The initiative succeeded in providing policy-makers with valuable input on citizens’ preferences but was discontinued the following year because of funding problems.

A variety of entities have undertaken initiatives to improve the patient experience. The government is working specifically to improve communication between geriatric patients and providers, with future projects directed at including patient experience in medical school curricula as well as at further surveys on patient satisfaction in hospitals and the community. An emphasis has also been placed on collecting data for measures that other OECD countries collect, such as readmission rates, in order to facilitate cross-country comparisons.

Innovative nongovernmental initiatives include, for example, the Askme3 programme – an American patient education programme that has been implemented in Israel and encourages patients to ask doctors what is the medical problem, what do they need to do and why is it important.

Advanced technology call centres have also been developed for specific purposes such as patients with complex needs. For example, one HP and research institute have together created the first call centre in Israel for people with chronic diseases (and their caregivers), coordinating clinical and community support.

2.9.6. Patients and cross-border health care

The detection and control of infectious diseases is a major focus of cross-border cooperation and is pursued through the Middle East Consortium for Infectious Disease Surveillance. Established in 2003, it was set up to improve detection and control of foodborne infectious diseases and facilitating data sharing and cross-border communication, but this infrastructure has proved invaluable for broadening surveillance of other serious emerging infections, such as avian influenza.

Hospital care is another focus of cross-border cooperation. Israel’s tertiary hospitals attract patients in need of highly specialized care from various Mediterranean and Middle Eastern countries. Israeli hospitals also treat patients from the Palestinian Authority in the West Bank and the Gaza strip. The vagaries of the security and diplomatic situation influence the number of these types of patient.

In recent years, Israel has emerged as a major medical tourism destination for patients from beyond the region. This is because Israel can offer many advantages, including first-rate quality of care at reasonable prices. Israel’s facilities are recognized throughout the world, with regular contacts maintained on a reciprocal basis with major medical and scientific research centres abroad. Israel is frequently the host venue for international conferences on a wide variety of medical topics. Patients come to Israel for procedures such as in vitro fertilization, bone marrow transplants, heart surgery and catheterization, oncological and neurological treatments, car accident rehabilitation and more. A growing number of private companies are engaged in marketing Israeli hospital care abroad. The growth in medical tourism to Israel has sparked a major debate about its appropriate scope and how it should be regulated.

In parallel, a number of Israeli patients go to other countries voluntarily to seek care. This is especially true in the area of reproductive care.

Many migrant workers, who make up to 14% of the Israeli workforce, are not eligible to receive NHI, but employers are obliged by law to purchase private health coverage for non-resident workers. Undocumented migrants in particular may face individual, social and structural obstacles, leading them to avoid seeking medical care.