5.3. Primary / ambulatory care

Primary care is highly accessible in Israel.[24] The cost of primary care visits is fully covered by NHI, and co-payments are limited to specialist visits. There are approximately 7000 PCPs working with the HPs throughout the country. In a 2014 national survey of the general population (Brammli-Greenberg & Medina-Artom, 2015), 91% reported being “satisfied” or “very satisfied” with the professionalism of their PCP; and 92% reported being “satisfied” or “very satisfied” with the interpersonal skills and behaviour of the PCP.

Israel has a well-developed system for monitoring the clinical quality of primary care (Rosen et al., 2011a; Jaffe et al., 2012; OECD, 2012a). The HPs have made use of the data generated by this monitoring system to make significant quality improvements rapidly (Rosen et al., 2011b). The OECD (2012a) cites the organization of physicians and other PCPs into teams as a key factor facilitating quality improvement. Others have emphasized the pivotal role of the HPs as organized systems of care and learning, as well as for the alignment of incentives between physicians and HPs (Rosen et al., 2011b). Another key factor has been the virtually universal availability of high-quality, computerized medical records. The public release, in recent years, of comparative quality data across HPs has given the plans a further, competitive, incentive to invest in quality improvement.

The HPs regularly monitor, and compare, quality performance across regions, subregions, clinics and – in some plans – also between individual physicians. They also work closely with the regions, clinics and physicians on performance improvement.

In a 2010 survey of PCPs, the vast majority of respondents (87% of 605 respondents) felt that the monitoring of quality was important and two thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent (Nissanholtz-Ganot & Rosen, 2012). Almost three quarters (71%) supported continuation of the programme in an unqualified manner. However, many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), overcompetitiveness (60%), excessive managerial pressure (48%) and distraction from other clinical issues (35%). The steps being taken to address these issues include controlling the pace with which new quality indicators are introduced and increasing the extent to which nurses are involved in improving performance as measured by the indicators.

In the 1970s and 1980s, Israel had one of the world’s highest rates of visits to physicians per 1000 population (visits to PCPs and specialists, with visits to PCPs accounting for the major share), partly because patients’ medical and psychosocial needs were not being adequately addressed, resulting in repeat visits (Shuval, 1988; Sax, 2001). However, rates have fallen since then, and in 2012 the annual number of outpatient contacts per person in Israel (6.2) was below the EU average of 7.0 (Fig5.1). At least within Clalit, Israel’s largest HP, a very high percentage of members visit their PCP at least once per year (Rosen et al., 2014) and they tend to stay with the same PCP over time (Dreiher et al., 2012).

Fig5.1

5.3.1. The employment structure for primary care physicians

The government does not make NHI funds directly available to individual physicians; all NHI funds are channelled through the HPs. Any PCP who finds employment with an HP, either as a salaried employee or as a contracted independent physician, can accept patients under the NHI framework.[25] The HPs exercise discretion regarding the PCPs with whom they want to work, in which regions they want them to work, and whether they want to work with them on a salaried or independent physician basis.

Any licensed physician can work as a PCP in the private sector. Only a very small number of patients visit private PCPs and pay for their services as OOP expenditure (generally speaking, the HPs do not allow their physicians to see HP patients privately).

The vast majority of Clalit members receive primary care from salaried physicians at clinics owned and operated by Clalit. Patients are free to choose their PCP and can switch as often as they want. Some Clalit members receive their primary care from independent physicians operating their own facilities. Most of the independent physicians in Clalit work in solo practices, although there are some group practices. Officially, any Clalit member can choose to enrol with an independent physician of his/her choice, but this opportunity is often limited by the number of independent physicians working near the member’s home, and their willingness to take on additional patients.

Leumit members also predominantly receive primary health care from salaried physicians, although the share receiving care from independent physicians is increasing. The two other HPs (Maccabi and Meuhedet) engage some PCPs in facilities owned and operated by the HPs, but a clear majority of PCPs work as independent physicians. Most of these independent physicians will accept patients from different HPs. Both group and individual practices exist (most group practices consist only of PCPs, but some contract with subspecialists to provide services within their facility). In the smaller HPs, patients are free to switch PCPs quarterly, although few patients avail themselves of this option.

In Clalit, each patient is registered with a particular PCP who acts as his/her personal physician. In Leumit, each patient is associated with a particular clinic but not a particular physician. In Maccabi and Meuhedet, there is no norm of associating patients with a particular PCP or clinic; even so, most patients receive the bulk of their care from one PCP. Moreover, in all but the largest HP, Clalit, there is a process under way of associating each patient with a particular physician for purposes of accountability for the quality of care.

As the independent physicians (in all the plans) are paid on a capitation basis (either active or passive), they have an incentive to increase the size of their patient rosters. There is a concern among government regulators that, in some cases, this has led to overly large rosters, which jeopardize the quality of care.

The salaried PCPs tend to work with only one HP, while many of the independent physicians work with several plans.

5.3.2. The role of nurses in primary care

Nurses play an extensive role in the primary care provided via the HPs in such areas as preventive health care, counselling, triaging of urgent cases, home care, chronic disease management and the handling of clinical paperwork related to the patients’ eligibility for various social benefits.

Another mechanism through which nurses are playing an increasingly important role is the call centres operated by each of the four HPs. These are staffed primarily by specially trained nurses who provide members/patients with 24-hour guidance on how to respond to various illnesses and symptoms.

5.3.3. The primary care practitioner specialty mix

As of the end of 2012, approximately 38% of PCPs who worked with adults were general practitioners – that is, non-specialist graduates of medical schools – and 43% were board-certified specialists in family medicine. Other specialties, such as internal medicine, accounted for the other 19% (Nissanholtz-Ganot & Rosen, 2012).

During the 1980s and 1990s, there was considerable dispute among primary care leaders in Israel over whether family medicine or paediatrics and internal medicine training was the best basis for high-quality primary care. While differences of opinion on this issue remain, the debate is not nearly as heated as it was at that time. The general – but by no means unanimous – consensus is that paediatrics and internal medicine training (and not just family practice training) can provide a good base for primary care but only if those training programmes are modified to provide more exposure to primary care settings. Today, most children are cared for by paediatricians rather than family physicians and most of the paediatric PCPs work in group practices.

5.3.4. Primary care practitioners and gatekeeping

In all the HPs, visits to hospital-based specialists require prior authorization, either from a PCP or a community-based specialist. In the smaller HPs, members have unrestricted access to all plan-affiliated community-based (as opposed to hospital-based) specialists, without prior authorization from a PCP. In Clalit, the PCP plays more of a gatekeeper role; members have free access to specialists in five areas – ear, nose and throat; dermatology; orthopaedics; ophthalmology; and gynaecology – but access to other specialists is contingent upon referral from a PCP.

5.3.5. Recent developments in primary care and key challenges

Technological developments are having a major impact on primary care. HP members are increasingly making use of online consultations on such topics as chronic disease self-care, after-hours primary care and how to respond to troubling symptoms in children. Many members maintain an online personal health record, which includes automatic reminders for health care. These are accessed by members either via their personal computers or, increasingly, via their smart phones. Prescriptions are increasingly being renewed digitally by physicians and sent directly to the relevant pharmacy (thus removing both the face-to-face meeting with the physician and attendance at the clinic). Progress is being made in facilitating asynchronous, distal communication between PCPs and patients, particularly through the use of e-mail. Health information exchanges are increasingly alerting PCPs when their patients are admitted to, or discharged from, hospitals and providing information about the care in the hospital that is vital for after-care in the community.

The HPs are continuing to shape primary care provision in their ongoing search for efficiency. They are merging smaller clinics and encouraging teamwork between PCPs and other health care professionals. Some HPs are setting limits (or at least guidelines) on how much time PCPs can spend with each patient, and focusing the PCPs’ time on direct patient care in the clinics (as opposed to activities such as staff meetings or home visits). They are also providing PCPs with after-hours back-up by specialized units.

Broader forces are also affecting primary care. Societal changes, backed by various legislative initiatives, are empowering patients and making care more patient-centred. In addition, the government has added various health promotion and disease prevention services to the NHI benefits package, and PCPs are being called upon to play a role in such areas as smoking cessation and weight reduction. Moreover, increased attention to chronic conditions and their management has put the PCPs in a position where they are increasingly expected to manage (or at least be mindful of) their patients’ use of secondary and tertiary services.

Key challenges currently facing primary care, as discussed in the recent German Committee report (see section 6.2), include:

• a projected shortage of PCPs as growing numbers reach retirement age and relatively few young physicians are entering the field (OECD, 2012b);
• insufficient time to spend with each patient, which limits the PCP’s ability to coordinate care and go beyond the most pressing health issues; and
• the need to expand the PCPs’ capacities to engage in health promotion, deal with an ageing population and address mental health needs.