Specialized ambulatory care / inpatient care

Board-certified specialists[26]

In 2012, Israel had approximately 17 900 board-certified specialists, 13 900 of whom were below the age of 65. As in other countries, the proportion of specialists among all licensed Israeli physicians below the age of 65 years is increasing rapidly, reaching 54% by 2012. Of course, not all board-certified specialists engage in secondary care. In 2012, among board-certified specialists up to the age of 65 years, there were approximately 1650 working as family physicians (12%) – almost all of whom work in primary care – as well as approximately 2700 internists (19%) and 2050 paediatricians (15%), many of whom worked at least part-time in primary care. There are no definitive figures on the number of Israeli physicians engaged in secondary care.

The location of specialist care

While all Israeli hospitals operate outpatient clinics, most specialized ambulatory care has traditionally been provided in community-based settings, and in recent decades there has been a further shift towards the community. There are several reasons for this shift. First, the HPs felt that they often lost control of treatment plans and expenditure when their patients were cared for at hospital outpatient clinics. Second, the HPs were able to provide and/or purchase community-based specialty care at costs well below those of the hospitals. Finally, various technological innovations and cultural changes facilitated the shift from the hospital to the community setting. There has also been a shift in the location of emergency services. The HPs have developed community-based emergency centres as well as emergency home visit services as alternatives to hospital EDs (Taragin, Milman & Greenstein 2000; Greenstein & Tiaragin, 2001).

A 2012 survey found that only 10% of adults and about 33% of children who visited a specialist using public financing did so in a hospital setting (Brammli-Greenberg Waitzberg & Guberman, 2015).

In recent years, many of the hospitals have made a special effort to try to attract activity to their outpatient departments. The prices for hospital ambulatory services have been substantially reduced, and there have been cases where hospitals, in negotiating overall contracts with HPs, have proposed to provide these services free of charge as part of an overall package.

The expansion of community-based specialist care involves facilities owned and operated by both the HPs and independents, from whom they purchase services. In many cases, hospital-based specialists work part-time in community settings in order to supplement their incomes, raising both hopes and concerns. The hopes are that this will enhance hospital–community communication, continuity of care, the quality of community-based specialist care and health care system efficiency. The concern is that physicians working in both settings may not be putting enough hours into their hospital jobs and may lack a sense of institutional loyalty to either of their employers; this concern is particularly great with regard to physicians who also work privately.

The nature of community-based specialist care

All of the HPs work with a mix of employed and independent community-based specialists. In Clalit, most of the specialists are employees who work in facilities owned and operated by the HP, although Clalit also works with independent specialists. Conversely, in the other HPs the majority of the specialists are independent individuals working in their own facilities, but the HPs also use some employed and independent specialists in plan-owned facilities.

Cooperation and communication between community-based specialists and PCPs are reasonably good. In Clalit, the PCPs function as gatekeepers to the less common specialties and – to some extent – as care integrators for all types of care. In the other HPs, gatekeeping and integrating roles are less prevalent.

More cooperation and communication problems occur between the hospitals and the HPs. The hospitals are unhappy with the HPs’ efforts to shift more care to community settings and to increase monitoring and control. The HPs do not like what they perceive as the tendency of hospitals to overtreat patients, repeating tests already carried out in the community and not providing the HPs with full and up-to-date information in real time on the care of their members.

Not surprisingly, specialists tend to be concentrated in urban areas. This can result in inconvenience and access problems for people living at the periphery and in small villages, although distance does not prevent most residents from visiting specialists. Waiting times for specialists also appear to be reasonable. In 2012, among people who visited a specialist in the preceding three months, 45% reported waiting one week or less, 16% waited one to two weeks and 36% waited more than two weeks (Brammli-Greenberg & Medina-Artom, 2015).

The average waiting time for a specialist physician in the community (publicly funded) is 3.2 weeks (median of 2 weeks). Yet, there are wide differences in waiting times among the various specialties. For example, the mean waiting time for common specialties (e.g. orthopaedics, ophthalmology, dermatology, otorhinolaryngology and gynaecology) is two weeks compared with four weeks for less common specialties. The gap is even wider in the periphery and in small localities. The specialties with relatively long waiting times are rheumatology, vascular surgery, haematology, endocrinology and plastic surgery (Brammli-Greenberg, Waitzberg & Guberman, 2015).

Sometimes, when a patient realizes that the waiting time to see a specialist within the NHI basic insurance framework would be what he or she perceives to be too long, the patient will obtain specialist care via the “second opinion” clause of his/her supplementary insurance package. This happens despite the fact that this is not really a second opinion.

Rates of visits to specialist physicians are substantially lower among Israeli Arabs than among Israeli Jews. This finding is particularly significant in light of the fact that visit rates to PCPs and hospitalization rates are higher among Arabs than Jews. The reasons for the large gap in specialist visit rates are not fully understood. A key factor appears to be the time and inconvenience involved in travelling from many Arab villages to urban centres, particularly for mothers of large families and people who do not own cars. Another factor may be the shortage of Arabic-speaking specialists. A third factor may be a greater tendency among Jews than Arabs to insist on being seen by a specialist rather than a PCP, a factor which may, in turn, be linked to differences in educational and socioeconomic levels, as well as urban–rural differences.

Nirel et al. (2008) found that community-based specialists saw an average of 34 patients per working day. The number of patients whom specialists saw in a day raises the issue of how much time and attention they are able to devote to their patients. In this context, the time that physicians allocate to their patient appointments was examined. According to the results of the study, specialists allocated an average of 13 minutes to an appointment.

In that same study, 80% of specialists reported that their patients exercised freedom of choice in selecting a specialist physician, and that the physicians were chosen by their patients and not referred by the HP.

Specialist care in hospitals

Almost all the specialists working in Israeli hospitals are salaried employees of those hospitals. This is similar to the situation that prevails in most European countries, in contrast to the North American system of independent attending physicians. Only the few private hospitals have implemented the independent attending physician model.

Department heads play a dominant role in Israeli hospitals. They have a major say in the selection of the specialists who will work with them and the tasks they will be assigned.

Generally speaking, patients in Israeli hospitals cannot select which specialist will care for them. They are assigned a physician according to the rotation schedule determined by department heads and their assistants. The exception is the private medical service in Jerusalem’s non-profit-making hospitals where, in return for an additional fee, the patient can choose her/his physician.

As indicated in Chapter 4, Israel is projecting an overall physician shortage and, according to the Director-General of the Ministry of Health, there are already shortages in certain hospital-based specialties such as anaesthesiology, intensive care and neonatology. The shortages are particularly acute in hospitals in peripheral regions.

The 2011 collective bargaining agreement between the IMA and the major employers introduced major financial incentives for physicians to pursue residencies in a range of distressed specialties. The initial indications are that these incentives are proving effective.

Day care

The data summarized here on inpatient institutions and day-care units in Israel are derived from Haklai (2014). At the end of 2013, Israel had approximately 1600 registered day hospitalization beds. About two thirds of them were in general hospitals, one fifth were in psychiatric hospitals, and one tenth were in hospitals for chronic diseases. In recent years, the number of such beds in general hospitals has been increasing slowly, while it has been stable in the other settings. The day hospitalization beds are highly concentrated in the centre of the country.

Day hospitalization is defined as “a diagnostic and/or therapeutic framework without overnight stays which includes admissions, discharge, as well as diagnostic, therapeutic and hotel capacities”. General day hospitalization handles internal medicine, paediatrics and gynaecology. There are also specialized units for surgical oncology, psychiatric care and geriatric day care.

The HPs also operate various community-based care centres that provide some, but not all, of the services provided in a day hospitalization framework (e.g. provision of intravenous fluids and medications).[27] In 2013, there were also 444 day-care beds for mental health care, with two thirds of them in psychiatric hospitals and a third in general hospitals. There were also five community-based mental health day-care units.

The psychiatric day-care units provide crisis care for patients referred directly from the community. In contrast, psychiatric hospitalization units are for patients who have been recently discharged from a psychiatric hospital and are intended to help the patient to transition gradually to functioning within the community.

Israel also has a network of day-care centres for the elderly, which have a social rather than a medical orientation (see section 5.8). There are also various community-based day-care services with a rehabilitation focus (see section 5.7).