The State of the Hospital Sector in Israel and Future Trends

1
The State of the Hospital Sector in Israel and
Future Trends

• Yair C. Birnbaum, MD, MPA
• Associate Director General Director Ein
  Kerem Hospital
  Hadassah Medical Organization
  Jerusalem, Israel

December 19, 2004
2
Relevant Experience

• Hospital Experience
• Deputy Director General -
  Shaare Zedek Medical Center (1991-1995)
• Director - Ein Kerem Hospital (2001 - )
• HMO Experience
• Associate Medical Director
  Maccabi Health Care Services (1995 2001)

3
Topics to be Addressed

• Facts Figures
• Challenges facing the hospital system in Israel
• Planning for the future

4
Hospital System in Israel
5
Number of Hospitals
Source Z. Haklai et al., Ministry of Health
(2003)
6
Number of Beds Beds/1000
Source Z. Haklai et al., Ministry of Health
(2003)
7
Utilization of Acute Care Beds in Israel
unpublished data
Source Z. Haklai et al., Ministry of Health
(2003)
8
Utilization of Psychiatric Beds in Israel
Source Z. Haklai et al., Ministry of Health
(2003)
9
Utilization of Long-term Care Beds in Israel
Source Z. Haklai et al., Ministry of Health
(2003)
10
This presentation will deal mainly with the acute
care hospitals.
11
Number of Beds Beds/1000
Source Z. Haklai et al., Ministry of Health
(2003)
12
Utilization of Acute Care Beds in Israel
unpublished data
Source Z. Haklai et al., Ministry of Health
(2003)
13
Acute Beds/1000 Regional
Distribution - 2004
Source Z. Haklai et al., Ministry of Health
(2003)
14
Acute Beds Last Decade
Changes

• Two expansion plans for acute care beds in last
  decade
• Mid-1990s
• Hospitalization 2000
• Plans targeted at keeping beds at rate of
  2.4/1000 at 95 occupancy.
• Beds added at slower pace and rate declined to
  2.13/1000.

15
Acute Beds Last Decade
Changes

• Opening of beds in Hospitalization 2000 Plan
  phased out. To be completed in 2006 due to
  financial constraints.
• Only 50 of Hospitalization 2000 beds
  operational by 2003.
• 1,244 beds added in 1995-2003.

16
Comparative Data 2000
17
Comparative Data 2000 Percent
Occupancy Acute Beds
1999 data
Source OECD Health Data 2003
18
Comparative Data 2000ALOS - Days
1999 data
Source OECD Health Data 2003
19
Comparative Data 2000Acute Beds/1000
Population
Source OECD Health Data 2003
20
Challenges Facing the Israel Hospital System

• Ministry of Health conflicting roles
• Lack of external quality assessment
• Pricing system not representative
  of cost
• Hospital-community interface

21
Ownership of Acute Care Hospitals
Source Z. Haklai et al., Ministry of Health
(2003)
22
Ministry of Health Conflicting Roles

• MOH is both regulator and hospital operator
• This conflict of interest causes the Ministry
  to be viewed as a biased party.
• Insurers claim the MOH never forgets its role as
  hospital owner.
• Hospitals may feel that the MOH is trying to
  prove its regulatory role by leaning towards the
  insurers.

23
Ministry of Health Conflicting Roles

• Commissions looking into the state of the health
  care system have unanimously and repeatedly
  recommended the separation of church and state.
• This recommendation was emphasized in the last 15
  years by 3 commissions.
• National Inquiry Commission of the Health Care
  System (1989)
• Commission On The Status Of The Physician (2002)
• Leon Commission (2004)

24
Ministry of Health Conflicting Roles Proposed
Solution

• Turning government hospitals into independent,
  non-profit organizations overseen by a publicly
  appointed Board of Directors
• Hospitals to remain public hospitals serving all
  segments of the population
• Debate about the availability of private medical
  services within these hospitals
• Governments role to serve as regulator and
  overseer of quality of care

25
Issues to be Addressed in Solution

• Workers accumulated rights
• Transfer of land use rights
• Funding to cover current government support of
  its hospitals (malpractice, non-contributary
  pension, exemption of employers tax, etc.)
• Estimated yearly support to government hospitals
  - 200 million.

26
Will This Recommendation Be Achieved? When?
?
27
Quality Assessment in the Hospital System

• All hospitals address quality issues in varying
  ways
• No system-wide centralized and comparative data
  gathered

28
Ministry of Health and QABackground 1994

• National survey of all CABG surgery
• Steering committee comprised of all heads of
  service
• Survey done by undisputed team

29
Ministry of Health and QABackground 1996-7

• Hospitals received results with comparison to
  national average and rank within all hospitals
• Results not made public but leaked to press
• Main finding - two hospitals had above average
  30-day mortality

30
Ministry of Health and QABackground

• As a result, Israel Medical Association and the
  Ministry of Health reached an agreement.
• Since then, no other medical outcome surveys
  done.
• Ministry of Health surveys restricted entirely to
  structure and process issues.

31
May 12, 2003
32
Coronary Artery Bypass SurgeryHadassah Results -
1994
33
Coronary Artery Bypass SurgeryHadassah Patients
Clinical Data
34
Coronary Artery Bypass SurgeryHadassah Results
2001

• At managements initiative, a repeat survey was
  done at Hadassah by the staff of the School of
  Public Health.
• Patients were found at higher risk than in 1994.
• 30-day mortality was down to 1.7
  as compared to 2.5 in 1994.

35
Ministry of HealthStructure and Process Surveys

• Started after outcome surveys were stopped
• Dealt with a variety of issues linked to the
  health care system
• Results given only in comparison to national
  average and same-size hospital average
• Results not made public and until now not leaked
  to the press
• Most questions answered by yes or no - some
  with intermediate answer

36
Ministry of HealthStructure and Process Surveys
Recent surveys dealt with the following
issues

• Infection control
• Waste management
• Physiotherapy services
• Institutional review board
• Nursing service issues (2.5 years ago)

37
Infection ControlIssues Addressed

• Structure of unit
• Staff ratio to beds
• Regulations for antibiotic use
• Regulations for isolation
• Training of hospital staff
• Safety and equipment issues
• Workers health
• Relation of sterile supplies, kitchen pharmacy

38
Infection ControlIssues Not Addressed

• Rate of infection (in-hospital, post-surgery)
• Interventions and their outcome
• Resistant strains
• Implementation of regulations

39
Infection Control

• All hospitals do various surveys relevant to
  issues of infection control
• Complete list of surveys done provided
• Top secret
• Who did which survey
• Local survey results

40
Waste ManagementResults
41
Waste ManagementResults
42
Physiotherapy ResultsEin Kerem
43
Physiotherapy ResultsMt. Scopus
44
Institutional Review Board
45
Proposed Solution

• Creation of external quality system which will
  evaluate in a systemic and ongoing fashion the
  quality of care in the hospital system
• Significant findings to be made public
• Could start as a voluntary program if
  politically impossible to impose make
  compulsory.

46

• In the last decade, leading organizations have
  launched major initiatives to promote
  professionalism within medical training
• Primacy of patient welfare
• Patient autonomy
• Social justice

American Board of Internal Medicine,
Association of American Medical Colleges,
Accreditation Council on Graduate Medical
Education
47
Physicians should engage in internal assessment
and accept external scrutiny of all aspects of
their professional performance.

• Charter on Medical Professionalism Annals of
  Internal Medicine 2002 136243-6.

48
Pricing System

• Cost information is fragmentary and in dispute
  between hospitals and insurers
• The government has a plan to calculate costs of
  the hospital system
• No direct correlation between cost and pricing

49
Pricing System Inpatients

• Inpatient services compensated in two ways
• Per diem
• DRG surgical procedures
• All fees based on averages which
  have been in place for years
• Annual yearly adjustments in prices made taking
  in account mainly economic indexes (cost of
  living, wage changes, etc.) and not technological
  or service issues

50
Pricing System Inpatients

• ALL inpatients charged per diem are billed the
  same sum.
• A day in Dermatology and a day in an Intensive
  Care Unit (ICU) are priced similarly, although
  costs are far apart.
• A per diem fee of 350 (1600 NIS) is all
  inclusive and system-wide.
• The per diem system has been in place since 1977
  and has not undergone a major revision since.

51
Pricing System Inpatients

• Until 1991, all inpatient services were priced on
  a per diem system with long waiting time for
  procedures, from open heart surgery to cataract
  extraction.
• 50 surgical and interventional procedures are
  priced based upon a DRG system.

52
Pricing System Inpatients

• DRG-based prices are also average prices per
  procedure
• Neurosurgery VP shunt Base Skull Surgery
• Hernia
• Open laparoscopic
• First redo
• Regular mesh
• Young old

53
Pricing System Outpatients

• Based on a fee-for-service system and day
  hospital fees (which are all inclusive)
• Only a minority of the fees based on accurate
  costing
• Relatively high pricing of high volume ambulatory
  services
• CBC - 20
• Clinic Visit - 45
• Biochemistry profile - 50

54
Pricing System Outpatients

• Due to price and service issues insurers
  developed extensive outpatient services with
  duplication and minimal interaction with
  the hospital system.
• Hospitals continue to develop ambulatory services
  with special emphasis on sub-specialty niches.

55
Costing/Pricing System

• Two lines of thought are active in the
  costing/pricing debate
• Bring economic sense to system
• Dont rock the (stable?) boat.

OR
56
Costing/Pricing System

• Economic sense only cost-based pricing viable
  in the long-term without external support.
• Dont rock the boat the system is funded by a
  National Health Insurance Bill. Services are
  provided directly or by outsourcing through HMOs.
  HMOs funded by government. The system is
  somehow in a delicate balance. Any
  change will be for the worse.

57
Hospital-Community Interface

• The hospital system and community-based services
  are basically two separate entities with minimal
  information sharing on a real-time basis.
• The concept of a community-based attending
  physician is non-existent.

58
Hospital-Community Interface

• Most hospitalizations occur with no involvement
  of primary care physicians.
• Most hospitalizations occur without knowledge of
  relevant workup done in the community.
• Most hospitalizations end without communication
  between treating physicians in the two systems.

59
Initiatives to Improve
Hospital-Community
Interface

• The biggest HMO in Israel has created a
  information system so hospitals (belonging to the
  system) and community-based services have online
  access to all information relevant to a specific
  patient.
• The second largest HMO is experimenting with
  having their inpatients concentrated in only one
  of a similar set of departments with liaison
  staff in charge of bi-directional flow of
  information.

60
Initiatives to Improve
Hospital-Community
Interface

• A large NGO is trying to look into a pilot
  project to enlist and train volunteers to help in
  bridging the gap between the two systems.
• The Ministry of Health has taken steps towards
  the creation of a basic computerized medical
  record for every citizen.

61
Planning for the Future
62
Academic Basis of Hospital Planning

• Hospital planning is done on the basis of limited
  research.
• There is little evaluation of completed plans.
• Planning needs to take into account the limited
  state of knowledge.

63

• The reduction in ALOS and utilization can be
  attributed to a few factors
• Medical issues
• Improved care new technologies
• Increased efficiency
• Decreased efficiency
• Shortage of beds
• Financial incentives
• DRG-based reimbursement
• Daycare incentives
• Utilization review
• Capping system

64
The health care industry lacks a centralized
resource that tracks medical developments and
assesses the impact on hospital service demands
and capacity requirements.
Health Care Financial Management, March 2002
65

• There is no agreed method for calculating even
  such basic building blocks as the demand for
  hospital care, the impact of aging, the LOS or
  the day case rate.

Edwards N. Harison A.
BMJ 319 1262-4, 1997
66
Hospital Planning Does Not Have Control Over
Various Constraints
For example

• Medical issues the speed of scientific progress
  and the ability to keep up with such progress.
• Health policy
• Financial constraints
• .. and others

67
Hospital planning must be adapted to ....limiting
factors which means planning without rigidity..
The Hospital of Tomorrow, WHO, 1990s
68
Planning for the Future

• By 2010-12, the population of Israel is going to
  increase by 1.0 million.
• Just to keep the current rate of 2.16 beds/1000
  in the acute care system, an additional 2160 beds
  will be needed.

69
Issues to be Addressed in Planning

• Ageing of population
• Occupancy rate
• Past trends and future projections
• Day care vs. hospitalization
• Medical Issues
• Responsibility for LTC
• Sub-acute Clinical Department
• Strengthening Community Services
• Emergency Medicine
• Preventive Medicine
• Pricing changes
• and many others (know and unknown)

70
Aging of Population

• The percent of population aged 65 in 2003 was
  9.8 with those 75 only 4.4
• 35 of all the acute care hospitalizations were
  in the 65 age group
• 57 in Medical Wards (66 of days)
• 50 in ICU
• 27 in Surgical Wards
• Within a decade, this segment of the population
  is expected to reach up to 12.1.

71
Occupancy Rate

• Which average occupancy rate should be the basis
  for future planning?
• Ministry of Finance (funding) 95
• Ministry of Health (regulator) 90
• Adopting a 90 occupancy rate means that the
  current acute care system is in need of an
  additional 750 beds even before future planning.

72
Past Trends and Future Projection

• ALOS has decreased from 8.0 days in 1975 to 4.1
  in 2002. what is the minimum ALOS to plan for?
• Looking at the trend of utilization of hospital
  beds in 1996-2002 as compared to 2002 alone will
  lead to different results.
• This difference is estimated to be in the range
  of 700 beds in the next 10 years.

73
Day Care vs. Hospitalization

• Hospitalizations of up to one day make up
• 30 of all hospitalizations
• 25 in Medical wards
• 30 in Pediatric wards
• 40 in Surgical wards
• 50 in General Surgery
• There is widespread agreement that these
  hospitalizations can be drastically
  (50-70) reduced by utilization of daycare and
  strengthening community medicine.

74
Increased Daycare Utilization
Changes that will increase Daycare utilization

• Financial incentives
• To cover real costs
• To make alternative unattractive
• Expansion of scope of services that can be done
  in daycare

75
Medical Issues Long-term Care

• LTC is currently the responsibility of the
  government and one of the few issues not covered
  by the National Health Insurance Law.
• Due to budgetary constraints, patients have to
  wait for placement in LTC facilities.
• Some of these waiting patients are an
  additional burden on the acute care system.

76
The Elderly Dont Die According to The Plans of
the Finance Ministry
1200 Senior Citizens Waiting For Placement
77
Medical Issues Sub-acute Care

• Between 1995-2003, the acute care system was
  enlarged by 1244 beds. 50 of these beds were in
  Internal Medicine and Geriatrics.
• Some of the patients could utilize alternative
  and cheaper inpatient care
• Direct admission to sub-acute care beds
• Transfer after stabilization to sub-acute beds

78
Medical Issues Sub-acute Care

• In order to facilitate such a change
• Create alliances between acute care and LTC
  system
• Enlarge availability of sub-acute beds
• Convince insurers that these beds arent
  additional beds and their licensure is in lieu
  of additional acute care beds.

79
Emergency Medicine

• Only recently recognized as independent specialty
• ER usually staffed by residents in second part of
  their training
• An average of 30 of all ER visits end in
  hospitalization. The range is 22 - 38.
• A certain percent of these hospitalizations
  deemed inappropriate.

80
Emergency Medicine

• The thought is that staffing the ER with
  permanent board certified specialists in
  Emergency Medicine could (in combination with
  strengthening the communityhospital interface
  and other steps) reduce some of the need for
  additional acute care beds.

81
Financial Incentives

• Financial incentives can change clinical
  practice.
• DRG-based reimbursement
• Daycare incentives
• Utilization review
• Capping system

82
A Final Thought

• Should socio-economic status and morbidity be
  part of the consideration in allocation
  additional inpatient beds?

83
What is the Problem?
Although on average there is a marked improvement
in health status there is large variability and
there are substantial inequalities in health
among segments of the population.
84
(No Transcript)
85
The Inverse Care Law
People with the greatest need tend to have poorer
access to quality services.
86
Factors Affecting Health
Morbidity
Genetic
Biological
87
Jerusalem LRC Study (Lipid Research
Clinic)

• Initiated by
• Prof. Y. Stein the late Prof. S. Eisenberg
• 1976-8

88
Jerusalem LRC
25-year Incidence of CHD (preliminary data)
Kark et al, ongoing 2004
89
Strong Inverse Association of CHD Incidence With
Years of Education in Women, but Not in Men (Odds
Ratios)
Age adjusted (preliminary data, Kark et al,
ongoing 2004)
90
Infant Mortality in Israel 1955 -
2001
NJ / J
IM / 1000 Live Births
8.8 4.4
Non-Jews
Jews
91
Infant Mortality in Israel 1955 -
2001
NJ / J
IM / 1000 Live Births
Ratio
8.8 4.4
Non-Jews
Jews
92
Mothers Education as a Determinant of Infant
Mortality (1993-1996)
Yrs education
Mortality rate per 1000 live births
?????? ??????, 2001 ?????? ??????. ???? ???????
93
Israel Longitudinal Mortality Study (ILMS I)

• The study is based on a record linkage between a
  20 sample of the Israeli population taken at the
  1983 census and

death certificates 1983-1992.
Results are based on 115,000 Jewish Israeli
citizens aged 45-69.
94
Inequalities in the 80s
Mortality Odds Ratios
Men Women
Education 13 years 1.0 1.0 0-8
years 1.6 1.4
Car possession Yes 1.0 1.0 No 1.5 1.4
Number of rooms 3 1.0 1.0 lt3 1.4 1.4
Ages 45-69 years
Manor et al, 1999, AJPH.
age-adjusted
95
Mortality Inequalities in the 80s by Income and
Employment Men
96
Mortality Inequalities by Origin
Mortality Odds Ratios
Men Women
Origin Europe/USA 1.0 1.0 North
Africa 1.2 1.2
After adjusting for SES, all the excess mortality
among North Africans disappeared.
age-adjusted ages 45-69 years
97
Israel Longitudinal Mortality Study (ILMS II)

• The study is based on a record linkage between
  20 sample of the Israeli population taken at the
  1995 census and
• death certificates 1995-2001.

Results are based on 155,000 Jewish Israeli
citizens aged 45-69.
98
Changes Over Time in Age-adjusted
Odds-ratios for Mortality by Education
0-8 vs. 13 Years
2.3 2.0
99
Changes Over Time In Age-adjusted
Odds-ratios For CVD Mortality
by Education 0-8 vs. 13 Years
Men Women
100
Conclusions Mortality

• Infant mortality is higher among the more
  disadvantaged segments of the society.
• Less educated men and women suffer higher risk of
  overall CVD mortality.
• Mortality differentials by education have widened
  among Israelis from the 1980s ? 1990s.

101
JPS - Jerusalem Perinatal Study

• Research cohort established in 1964-76
• All births to residents of West Jerusalem
• 92,408 children
• gt40,000 mothers

102
Breast Cancer Risk Is HIGHER In the Higher
Socio-economic Groups
High SES
Jerusalem Perinatal Study Cohort Breast Cancer
Risk by SES
Low SES
Follow-up Years
103
.But Survival is BETTER in the High SES Groups
Jerusalem Perinatal Study, Breast cancer survival
by SES (Kaplan-Meier(
High SES
Low SES
Follow-up Years
104
Age-adjusted Prevalence of Obesity ()
Increases With Lower Socio-economic Status
Men

Women
Socio-Economic Status (Mabat)
105
Exercise in The Over 60s Increases With Income
Education

55
49
40
45
44
39
29
28
20
21
11
0
13
lt1,400
0
gt7,000
Years of education
Monthly Income, Shekels
Shemesh Rasooli , 1999
106
Diabetes () Among BOTH Jews Arabs Increases
With Lack of Education (FgtM)
JEWS
ARABS
107
Summary of Socio-Economic Influences on Health
Inequalities in Health Behavior, Access to Health
Care Health Outcomes
108
The Limits of Planning

• Predicting the future of hospital design is
  hardly a consensus forming art. Crystal ball
  visions of the 21st century hospital vary from
  expert to expert. Perhaps thats simply a sign
  of the diversity of health care systems. Or
  perhaps its a problem inherent in reading the
  future.

California Hospitals, 1992
109
The Limits of Planning

• Looking into the future predictions dont
  always come true, but hospitals still must look
  ahead on the aging population and new
  technologies which require new solutions.

Modern Health Care, 2003
110
The Limits of Planning
111
The Economist