Telemedicine in Israel
Israel’s health and care system organisation
The health and care system in Israel is predominantly a public system for health care, social care and social insurance in general (for example, pensions, welfare, child allowances, and old age allowances). One area that remains predominantly private (in terms of both insurance and care provision) is long-term care – the public support for this area is income-related. In health care, there is a growing private sector and in the provision of both health care and social care there is a public-private mix.
The main authorities are the Ministry of Health, the Ministry of Finance, the Ministry of Labour and Welfare, the National Insurance Institute, and four not-for-profit Health Plans. Their roles in the health system are discussed below.
The Ministry of Health is responsible for executing the national health insurance law, overseeing and supervising the Health Plans, overseeing and supervising the hospitals including direct operating responsibility for hospitals owned by the Ministry of Health which are the majority of acute care and psychiatric hospitals in the country as well as some of the geriatric and chronic care hospitals. The Ministry of Health, together with the Ministry of Finance, sets hospital fees for all public hospitals, and recommends approval of co-payment levels to the Parliamentary Finance Committee (which is authorised by law to approve co-payment levels for the Health Plans). The Ministry is technically responsible for prevention, although in fact most of these activities are carried out by the Health Plans. The Ministry has been responsible for acute psychiatric care in the community and hospital, but this is in the process of being transferred to the Health Plans. The Ministry is responsible for participating in the financing of long-term institutional care for functionally dependent elderly people on a means-tested income basis according to the income of the elderly person’s family.
The Ministry of Finance determines the overall allocation of the national budget for health care. This includes the health index that updates the funds allocated to the Health Plans, the Ministry of Health, and the Ministry of Health hospitals. The Ministry of Finance, as part of the bi-annual budget process, also determines the budget allocation for all social care programmes. As in most countries, the Ministry of Finance wields tremendous influence on both the health and care sectors by virtue of controlling the financing of these sectors.
The Ministry of Labour and Welfare is responsible for institutional care for the frail elderly, day care centres for the frail and dependent elderly, and numerous programmes for the low income population, including the low income elderly population.
The National Insurance Institute is the major social insurance body in Israel responsible for such areas as pensions, child allowances, and old age allowances. It is responsible for the operation of the Nursing Care Act that provides financing and oversight of personal care givers in the home of the dependent elderly living at home. The number of hours allotted to personal care in the home is based on the functional level of the elderly person as well as his/her income (although the income threshold is relatively high). This financing can be applied to the payment for an around-the-clock, live-in caregiver, although it does not cover the entire cost of this. The National Insurance Institute is also the body that collects social insurance taxes from the population (e.g. pension; the health tax). In the case of national health insurance, it pools the income from the health tax with the additional allocation from the national budget and distributes the funds among the Health Plans through a capitation formula.
There are four not-for-profit Health Plans that are responsible for the coverage and provision of the public basket of services legislated under the National Health Insurance system.
Israel’s health and care system financing
The Israeli health care system is a national compulsory statutory health insurance system based on the Bismarck model. It is financed via earmarked and general taxation. All citizens must be members of one of four Health Plans (i.e., sick funds or mutualities). Citizens pay a health tax that is 4.8 per cent of income to the National Insurance Institute. This is supplemented by funds from the national budget that are also transferred to the Institute. When pooled together, these funds must equal the “cost of the basket of services” as defined by the National Health Insurance Law. They are distributed to the four Health Plans via a capitation formula based primarily on age, sex, and region.
The Health Plans are responsible not only for covering, but also providing, the public basket of services to their members by contracting with providers and/or operating their own services. Health Plans may contract with providers selectively, including doctors, health care professionals, hospitals, and nursing homes. They can negotiate fees with the providers.
These providers may be public or private providers. In this sense they are more similar to health maintenance organisations (HMOs) such as Kaiser Permanente in the United States of America than to European Sick Funds (which are predominantly insurers and not providers of care). The Health Plans may offer supplementary health insurance to their members to cover services not included in the public basket of services (for example, drugs, dental care for adults, and alternative medicine such as homeopathy). Because there is no public insurance for Long-Term Care, each of the Health Plans has entered into a contract with a private health insurance company for a collective policy to cover long-term care services (examples include the maintenance of nursing home care and personal caregiver services in the home). Medically-oriented nursing home care and medically-oriented home care are included in the public basket of services that the Health Plans are obliged to provide under the National Health Insurance Law.
Another aspect of the Israeli health care system that is relevant to telemedicine is the level of Health ICT and electronic medical record adoption. All of the four Health Plans are completely computerised – 100 per cent of the physicians, and most of the other health care professionals, use an electronic medical record which is either connected online to or is an integral part of the Health Plan’s central medical record.
There is almost total clinical data exchange among all services in the community. These are supported by sophisticated decision support systems. This means that almost all aspects of the exchange are closed loop systems. This starts from the clinician’s computerised referral until, and including, the transmission of results back to the clinician’s computer/electronic medical record (including, for example, laboratory, imaging, and ECG records). For the prescription of medications, there is a decision support system that provides alerts to allergies and potential drug interactions and contraindications. All of the public hospitals and the large private hospitals are also computerised, including electronic medical records.
The electronic transmission of clinical data between the hospital and the Health Funds (the community healthcare system) is currently limited due to privacy legislation. However, the Ministry of Health is currently working on a national solution. In the meantime, each of the Health Funds has its own agreements with the hospitals.
All of the Health Funds have very sophisticated personal health records that give their members web access to their own medical information. This information includes doctor visits, purchased medications, laboratory results, imaging results, and other diagnostic test results. Much of this is currently accessible in at least two of the Health Plans via a smart phone as well as the Internet. In these plans, there are already proactive alerts and reminders for the funds’ members based on their medical information and protocols developed by the Health Plans. In Maccabi, the second largest Health Plan, the doctor also has access to his or her electronic medical record via a smart phone.
Israel’s telemedicine strategy and legislation
Maccabi Healthcare Services is the second largest of the health plans and covers two million people (25 per cent) of the Israeli population. Maccabi launched its strategy for telemedicine in 2008.
The organisation also has a Chronic Care Management Strategy, a Health IT strategy, and an IT/Digitisation strategy. These three were launched in 2008, 1992, and 1988 respectively.
There is no regional authority, and so there is no relevant strategy that has health-related or IT domains that includes telemedicine.
At the national level in Israel, the national authority has neither a strategy in health-related or IT domains that includes telemedicine nor does it have legislation that deals with telemedicine specifically. Israel does not have legislation that in any way hinders or obstructs the implementation of telemedicine services.