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ISRAEL Together, these two types of private VHI financed 14 percent of national health expenditures in 2012, a figure that has been increasing steadily. The Ministry of Health regulates HP-VHI programs, while the Commissioner of Insurance, who is part of the Ministry of Finance, regulates C-VHI programs. The focus of C-VHI regulation is actuarial solvency, with secondary attention to consumer protection more generally; in HP-VHI regulation, there is more attention to equity considerations and potential impacts on the health care system (Brammli-Greenberg, Waitzberg and Gross, 2015). Reasons for purchasing VHI include securing coverage of services not covered by NHI (e.g. dental care, certain life-saving medications, institutional long-term care, and treatments abroad), care in private hospitals, or a premium level of service for services covered by NHI (e.g., choice of surgeon and reduction of waiting times). VHI coverage is also purchased as a result of a general lack of confidence in the NHI system’s capacity to fully fund and deliver all services needed in cases of severe illnesses. What is covered? The mandated benefits package includes hospital, primary, and specialty care, prescription drugs, certain preventive services, mental health care, dental care for children, and other services. Dental care for adults, optometry, and home care are generally excluded, although the National Insurance Institute does provide some funding for home care, dependent on need. Limited palliative and hospice services are included in the NHI benefits package as well (Bentur et al., 2012). Israel has a well-developed system for prioritizing coverage of new technologies within an annual overall budget set by the Cabinet (which includes Parliament members from the ruling parties) (Greenberg et al., 2009). Proposals for additions are solicited and received from pharmaceutical companies, medical specialty societies, and others. The Ministry of Health then assesses costs and benefits of the proposed additions, and a public commission combines the technical input with broader considerations to prepare a set of recommendations. These are usually adopted by the Minister of Health and subsequently by the Cabinet. Cost-sharing and out-of-pocket spending: In 2012, out-of-pocket spending accounted for 26 percent of national health expenditures. Some of this was for services not included in the NHI benefits package, including dental care for adults, optical care, institutional long-term care (for those not eligible for means-tested assistance), certain medications, and medical equipment. The other major component was copayments for NHI services, such as pharmaceuticals, visits to specialists, and certain diagnostic tests. Dental care and pharmaceuticals are the two largest out-of-pocket components. There are no copayments for primary care visits or for hospital admissions. There are also no quarterly or annual deductibles with NHI coverage. Within the NHI system, physicians are not allowed to balance-bill. Safety net: There are a variety of safety-net mechanisms in place. For pharmaceuticals there is a quarterly ceiling for the chronically ill, and discounts for the elderly based on age, income, and health status. Holocaust survivors are exempt from copayments for pharmaceuticals. With regard to specialist visits, there are exemptions for elderly welfare recipients, children receiving disability payments, and people afflicted with certain severe diseases. There is a quarterly ceiling on total copayments for these visits at the household level, which is 50 percent lower for elderly people. In addition, people earning less than 60 percent of average wages pay a reduced health tax of 3 percent of income, instead of 5 percent. How is the delivery system organized and financed? Primary care: Nearly all Israeli primary care physicians (referred to as general practitioners (GPs) in this profile, although they also include board-certified family physicians) provide care through only one of the four competing nonprofit health plans, which vary markedly in how they organize care. 88 The Commonwealth Fund
ISRAEL In Clalit, the largest health plan, most primary care is provided in clinics owned and operated by the plan, and GPs are salaried employees. The typical clinic has three to six GPs, several nurses, pharmacists, and other professionals. Clalit also contracts with independent physicians; although these doctors tend to work in solo practices with limited on-site support from nonphysicians, they have access to various administrative and nursing services at Clalit district clinics. The other three health plans also use of a mix of clinics and independent physicians in primary care, with the mix varying across plans. In Maccabi (the second-largest plan) and Meuhedet, almost all of the primary care is provided by independent physicians, while in Leumit the clinic model predominates (though not to the same extent as in Clalit). Members of all plans can generally choose their GP from among those on the plan’s list and can switch freely. In practice, nearly all patients remain with the same GP for extended periods. In Clalit, each patient is registered with a GP who has responsibility for coordinating care and acts as gatekeeper, except for access to five common specialties. In Leumit, patients are registered with a clinic rather than a GP, while there is no registration in the other two plans. However, in all plans there is movement under way to associate each member with a physician for purposes of quality assurance and accountability. Clalit is the only plan with referral requirements to secondary care. Independent physicians in all plans are paid on a capitation basis, with Clalit and Leumit using “passive capitation” (a quarterly, per member payment made irrespective of whether the member visited the GP in the relevant quarter) and Maccabi and Meuhedet using “active capitation” (where the payment is made only for members who visited their GP at least once during the quarter). Independent physicians also receive limited fee-for-service payments for certain procedures. Plans monitor the care provided by their GPs and work closely with them to improve quality (Rosen et al., 2011). However, quality-related financial incentives are generally not used. The salaries of Clalit clinic physicians are set via a collective bargaining agreement with the Israel Medical Association. The capitation rates of independent physicians, in all the health plans, are set by the plans in consultation with their physicians’ associations. It is estimated that of Israel’s 24,000 physicians employed in 2011, approximately 7,000 worked with or for the health plans as GPs. Outpatient specialty care: Outpatient specialty care is provided predominantly in community settings, either health plan clinics (the dominant mode in Clalit) or physician’s offices (the dominant mode in the other health plans). The former tend to be integrated multispecialty clinics, while the latter tend to be single-specialty. Most specialists are paid on an active capitation basis, plus fee-for-service for certain procedures. Rates are set by the health plans and, within the NHI system, specialists may not balance-bill; patients pay the quarterly copayment only. Patients can choose from a list of specialists provided by their health plans. Specialists who work for the plans may also see private patients. Administrative mechanisms for direct patient payments to providers: As noted above, the only direct payments to NHI providers are copayments. Patients can usually use their health plan membership cards instead of making cash payments; the provider receives the full fee from the health plans, which then collect the copayments from enrollees. After-hours care: After-hours care is available via hospital emergency departments (EDs), freestanding walk-in “emergi-centers,” and companies that provide physician home visits. Physicians providing care in EDs and emergi-centers come from a range of disciplines, including primary care, internal medicine, general surgery, orthopedics and, increasingly, emergency medicine. Nurses play a significant role in triage. They are typically salaried, while physicians working for home-visit companies are typically paid per visit. International Profiles of Health Care Systems, 2015 89
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
Page 38 and 39: CHINA References Chen, X. (2014).
Page 40 and 41: DENMARK In addition, nearly 1.5 mil
Page 42 and 43: DENMARK Social psychiatry and care
Page 44 and 45: DENMARK Quality data for a number o
Page 46 and 47: DENMARK portion is small, it makes
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Page 50 and 51: ENGLAND immunization, and vaccinati
Page 52 and 53: ENGLAND Hospitals: Publicly owned h
Page 54 and 55: ENGLAND Organization of the Health
Page 56 and 57: ENGLAND How are costs contained? Ra
Page 58 and 59: ENGLAND Organisation for Economic C
Page 60 and 61: FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 64 and 65: FRANCE What are the key entities fo
Page 66 and 67: FRANCE inequities in prevention rel
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 74 and 75: GERMANY management system, by the s
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
Page 84 and 85: INDIA How are costs contained? Ther
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Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
Page 114 and 115: JAPAN The author would like to ackn
Page 116 and 117: THE NETHERLANDS receive faster acce
Page 118 and 119: THE NETHERLANDS Hospital payment ra
Page 120 and 121: THE NETHERLANDS Organization of the
Page 122 and 123: THE NETHERLANDS References Organisa
Page 124 and 125: NEW ZEALAND provided in GP clinics.
Page 126 and 127: NEW ZEALAND management (e.g., clean
Page 128 and 129: NEW ZEALAND including such informat
Page 130 and 131: NEW ZEALAND largely through efficie
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Page 134 and 135: NORWAY Primary, preventive, and nur
Page 136 and 137: NORWAY Patients are free to choose
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NORWAY What are the major strategie
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NORWAY The National System for the
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SINGAPORE Medifund is the governmen
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SINGAPORE Public hospital funding i
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SINGAPORE Public consultation: The
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SINGAPORE To keep demand for servic
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152
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SWEDEN What is covered? Services: T
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SWEDEN Hospitals: There are seven u
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SWEDEN Care, which promotes use of
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SWEDEN What major innovations and r
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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170
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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