Each year, about 1.1 million people are treated in the general hospitalization system in Israel. Yet despite its influence on the health of the population, the system has no measurable health outcomes.
The metrics commonly used are the basic input measures – such as the number of hospital beds nationwide – versus output measures that are general estimates of the contribution of the public healthcare system, such as the number of hospitalization days and the number of annual hospitalizations.
Therefore, the public judges the system in terms of waiting times in the emergency rooms and for hospital procedures, the quality of service, and their freedom of choice in selecting a physician. From these perspectives, it appears that the State has failed: the government is forced to institute programs to shorten waiting times for general hospital procedures and admissions.
A new study by Professor Dov Chernichovsky from the Taub Center and Roi Kfir examined the general hospitalization system in Israel. The research suggests that there are systemic failures in planning, budgeting, and regulation by the government especially in light of the increasing needs of Israel’s aging population. The result: a low number of beds per population relative to the OECD countries, inefficiencies due to the size of hospitals and their geographic dispersion, substantial gaps in accessibility to hospitals between the center and the periphery, and especially high bed occupancy rates (the average number of hospitalizations per bed per year) which make it difficult for the system to function.
Public general hospitals are those in which the major activity is supplying healthcare services in the framework of the National Health Insurance Law, regardless of the hospital’s legal ownership. Out of the 44 general hospital facilities, 19 are government-owned (hospitals in which the employees are government workers and their budgets are controlled by the State budget, such as Sheba and Rambam hospitals), and 12 are owned by health funds (such as Soroka Hospital which is owned by Clalit Health Services, although it also supplies services to other health funds). In addition, there are independent, nonprofit hospitals (such as Shaare Zedek), companies for the public benefit (such as Hadassah), or those owned by limited companies (Assuta Ashdod).
The government owns about a quarter of the hospital beds in Israel and about 47% of the curative hospital beds (not including psychiatric, long-term care, and rehabilitation beds). Clalit Health Services owns about 30% of the curative hospital beds. Thus, the State and Clalit Health Services are the two main suppliers in the Israeli market.
The State’s multiple roles in the system impairs its ability to regulate it
The “public” nature of hospitals with various ownership giving service under the National Health Insurance Law and the State’s obligation to them has never been defined.
The situation is particularly serious in light of the fact that the State, as both funder and regulator of the system, is also the largest owner and operator for general hospitalization and essentially competes with other hospitals that are dependent on it for their budgets and regulation. What is more, the State is likely to prefer short-term budgetary solutions for those hospitals under its ownership and to avoid adjustments to the budget for the basket of services and in the prices of hospitalization services that serve the entire system.
So, for example, the situation of Jerusalem residents who are dependent on hospital services from Hadassah and Shaare Zedek which are not under government ownership is, on the face of it, inferior relative to residents of Tel Aviv who receive hospital services from Ichilov and Sheba Hospitals which are owned by the government.
This reality harms managed competition as specified in the law to ensure efficiency and public satisfaction and to also ensure that the State fulfills its basic role as an independent regulator of the system. For nearly 50 years various government and public committees as well as government ministers have made recommendations but the situation has remained unchanged.
The State has failed in infrastructure planning
By law, the State is responsible for ensuring public healthcare services, and accordingly, for licensing and funding hospitalization beds and other infrastructure as well as determining the size and location of hospitals. In Israel, the number of hospital beds per 1,000 population is relatively low: 2.2 versus 3.6 in the OECD and 4.1 in European countries with healthcare systems similar to Israel’s.
Adjusting for Israel’s relatively young population, the number of beds reaches 2.5, insufficient to make up the gap between Israel and other countries. What is more, while the number of beds per 1,000 population is trending down in most countries, that trend is especially sharp in Israel – 22% (versus an OECD average of 15% and about 20% in countries with similar systems between 2002 and 2017). This is the result of the continuous growth in the population in Israel, and despite the rapid aging of the Israeli population compared to other countries.
With regard to funding, the share of expenditure on hospitalization out of the national expenditure on healthcare is declining worldwide. Nevertheless, in Israel the decline is especially sharp, and the expenditure is consistently low relative to the average in other countries. Worse, the disparity between Israel and other countries continues to widen.
The average number of curative hospital beds in Israel is low, particularly in the geographic periphery of the country. The distribution of curative hospital beds in Israel by districts shows inequalities in the number of beds per 1,000 standardized population: in the Northern and Southern periphery, the number of beds per 1,000 population is the lowest, 1.32 and 1.55 respectively, while Jerusalem hospitals have the most, 2.36. It is important to note that the number of beds per 1,000 population has declined in all districts, although in Jerusalem, Tel Aviv and the North, the decline has all but stopped, while in the Center and South, it has continued.
In addition, average distances to the nearest hospital for relatively simple medical cases are longest in the Northern district (more than 19 km), then Judea/Samaria (more than 18 km), followed by the Southern district (about 16 km). This is relative to much shorter distances in Tel Aviv and Jerusalem of about 3-4 km. Average distances to regional centers, for more complex medical treatments, are about 45 km in the Northern district, about 41 km in the Southern district, while in Jerusalem and Tel Aviv the distances remain about only 4 km.
Thus, there are differences between the Center and the periphery in terms of accessibility to healthcare services and hospitalization beds. These differences are reflected in longer waiting times for hospitalization in the periphery.
Among other reasons, this situation stems from inefficient planning of additional hospital beds – expanding hospitals beyond the optimal 800-bed range in areas which already have a high proportion of beds per population, instead of adding beds and resources to hospitals in the periphery which are in the optimal size range and building another hospital in addition to Soroka in the South (see figure below).
Due to these findings, the researchers at the Taub Center stress that it is important to consider issues of accessibility and efficiency when making decisions regarding the opening of new hospitals or the expansion of existing facilities.
Treatment and service quality are in danger
Despite the relatively low number of hospital beds, the number of hospital discharges per 100,000 population in Israel is similar to the OECD average – about 15,000 annually – although lower than the average in countries with similar systems, which is about 16,000 annually.
The average number of curative hospitalizations per bed (bed turnover rate) in Israel in 2016 was particularly high: about 66 versus an OECD average of about 41 and about 44 in countries with similar systems. Israel’s bed turnover rate reflects relatively short hospitalizations on the one hand (about 5 days per patient in contrast to an average of 6.7 days in the OECD countries and 6.2 in countries with similar systems), and particularly high bed occupancy rates on the other hand.
The average bed occupancy rate in Israeli hospitals is also exceptional at about 94%, versus and average of 75% in both the OECD countries and those countries with similar systems.
The data indicate a curative care hospitalization system that is characterized by a diminished ability to handle emergencies (not necessarily security related). This is in addition to a potentially lower level of treatment quality due to relatively short hospitalizations and additional pressures to shorten hospitalizations due to pressures of those waiting for treatment at home and in the emergency rooms, and an inability to compete with other hospitals on issues of quality of care, due to high occupancy rates.
In light of the disparities between needs and hospital infrastructure in Israel, particularly in the periphery, the addition of curative hospital beds – that are efficient and accessible – is inevitable within the next few years, even considering technological advances that allow expansion of services given in the community setting.
Before additional investments in the system are made, though, it is worthwhile to reduce the government’s involvement in the marketplace – an involvement that only exacerbates the situation as is highlighted in a second new study by the Taub Center to be published shortly.
Physicians claim that additional beds will not substantially improve the situation
Conversations with physicians have revealed that they feel additional hospital beds will not significantly change the situation, and that what needs to change are hospitalization procedures in order to reduce pressure on the hospitals and waiting times for patients.
The physicians interviewed recommend among other things: avoiding unnecessary hospitalizations by discharging patients from the emergency rooms (something that requires strengthening specialist staff in emergency rooms and opening holding units) and moving physicians to two shifts in hospital departments (in place of a single shift until 16:00 with physicians on call for critical treatment only), as well as tests in the evening hours and weekends in order to shorten overall hospitalization time.
Other suggestions included a look at the efficacy of home hospitalization and creating lines of communication between hospital departments and community physicians and physician consultations to old-age facilities and supervision of residents’ medications in order to avoid hospitalization of the elderly in curative care units in place of treatment in their residential facility.