A presentation on how the work of the Myers-JDC-Brookdale Institute's Smokler Center for Health Policy impacts national reform of health policy, presented by Dr. Shuli Brammli Greenberg, Senior Researcher at the Smokler Center.

1. How We Make an Impact

2. The Smokler Center's mission is to contribute to the evidence-based
development of health policy and health services in Israel
We use:
• Applied research
• Conceptual analyses
• Cross-national collaboration
• …
How We Make an Impact
2

3. Consumers' perspective
Mental health reform
Health system workforce
Private-public mix
Payment methods to providers, incentives, and equity
Current Research Areas
3

4. Israel's Healthcare System in Brief
4

5. Source: OECD 2017
Stable Inputs: Total Expenditure on Health,
as % of GDP 2000-2015
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
2000 2004 2008 2012 2016
Israel USA OECD
5

6. Source: All countries but US are from OECD Health Data 2017 and show current spending only and exclude excludes spending on
capital formation of health care providers. US data is from OECD 2016 and includes spending on capital formation.
Health Care Spending per Capita (PPP),
1980–2016
Adjusted for differences in cost of living
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
1980 1984 1988 1992 1996 2000 2004 2008 2012 2016
United States ($9,364)
Switzerland ($7,919)
Norway ($6,648)
Germany ($5,551)
Sweden ($5,489)
Netherlands ($5,385)
Denmark ($5,199)
Australia ($4,708)
Canada ($4,644)
France ($4,600)
Japan ($4,519)
United Kingdom (4,193)
New Zealand ($3,590)
Israel ($2,776)
Dollars($US)
6

7. Government
National
Insurance
Institute
Consumer
Health Plan
SI programs
Medical Care
Providers
Various payment mechanisms
(i.e., salary, capitation, FFS,
PRG)
NHI tax
General
tax
OOP payments
VHI payments
Co-payments
SI community-
rated premiums
RA capitation formula
Other payments
Financing Scheme of the Israeli Health Care System
7

8. SI
84%*
National Insurance
(uniform basket)
100%
Meuhedet
(14%)
C la lit
( 5 3 %)
M a c c a b i
( 2 5 % )
CI
57%*Supplemental
insurance (SI):
Uniform benefits
package marketed by
the health plans.
Regulated by MoH.
Commercial
insurance (CI):
Benefits package tailored
to individual needs;
marketed by for-profit
insurance companies.
Regulated by MoF.
VHI
Total expenditure in 2015:
12 Billion NIS, which is
15% of Total Health
Expenditure
Brammli-Greenberg and Waitzberg (2014) Figure 1, and Brammli-Greenberg et al., 2016
Health Insurance Market Structure
8

9. The "Integrated Reform" to Reduce
Private Health Expenditure
9

10. 10
27.3
39.1
51.8
0
10
20
30
40
50
60
OECD.stat
High Rate of Private Expenditures

11. How confident are you that if you become seriously ill
you will be able to afford the care you need?
70%
52%
58%
40%
0%
10%
20%
30%
40%
50%
60%
70%
80%
USA Israel
Very or somewhat confident that will
receive the best care if needed
Very or somewhat confident that can
afford health services
if needed
Low Rate of Public Trust
in the coverage & quality of care
Sources: Brammli-Greenberg and Medina-Artom 2015 and selected OECD countries (Schoen et al. 2010)
11

12. • The Ministries of Health and Finance and the Insurance Commissioner
independently decided on various policy steps.
• MJB helped them recognize that all of them were responding to the
same issues from different angles, and that essentially, they were
initiating a national reform.
Initial Government Responses
and the Role of MJB
12

13. 1. Regulating the practice of MDs who work both in the private and public
systems.
2. Payments for operations - including compensation for the doctor's fee -
will be made to the hospitals, with no direct payment to MDs
3. The insurers can only offer indemnity for services given by doctors with
whom they have an agreement; the insured are limited to physicians
within the network.
4. Increase in co-payment for operations in VHI.
Key Steps by the Ministries of
Health and Finance
13

14. 1. Setting a uniform bundled billing policy for surgical operations.
2. Allowing changes in CI coverages and premiums only once every 2 years.
3. Inclusion of a document detailing services and entitlements in every policy.
4. Unbundling of covered products.
Key Steps by the Insurance
Commissioner
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15. Is this a Reform?
• There is no official documentation defining that that is a reform
• Multiple steps by different governmental agencies aim to reach the
same objectives
• The desired effects of these steps are complementary to each other,
but their implications could conflict and bring about undesirable
changes or no change at all.
15

16. What is Our Job?
• We observe and monitor the system, we even were involved in designing
some of these policy steps
• We alerted the policymakers: this is an integrated reform
• We are conducting a study to evaluate market reaction to the reform
and the changes that are likely to occur following the integrated reform
• Research committee: all major players around the table in an objective
independent place to discuss the reform
16

17. Another Reform that MJB Defined as a "reform":
The Procedure Related Group (PRG) Reform in general
Hospitals
17

18. 18
The PRG reform
• To price procedures and create PRG codes and tariffs by medical field
• Replace Per-Diem payments with PRG
• 2010: orthopedics
• 2013: urology, general surgery, ophthalmology, head and neck
• Objectives of the reform:
1. To set consistent costing and pricing mechanisms and improve
hospitals’ financial balance sheet.
2. To refine the unit of payment
3. To improve the MoH's capacity to set policy and priorities and to
supervise and monitor.

19. 19
We Began Monitoring Developments

20. And Evaluating:
Research Objectives:
• To examine changes in volumes of activities
measured by number of discharges and ALoS in hospitals following the
PRG reform
• Unit of analysis: hospital wards as proxy for medical fields
• Hypothesis:
• Volumes shall increase and ALoS might shrink more in surgical wards
compared to internal medicine wards
• A change in volume is expected in surgical wards for which PRG codes
were created
20

21. • The MoH has requested our assistance in designing a standardization
methodology for hospital payments according to case severity and patient
characteristics
• The main objective is to diminish incentives for negative selection
• MJB researchers offer unique familiarity with the topic, international knowledge,
and access to researchers in other countries
• The MJB staff constitutes a neutral party facilitating cooperation between different
units in the MoH, and between the MoH and the Ministry of Finance
Constructing an Israeli formula for
hospital payment adjustments by case-mix
21

22. • The government and major health care providers consistently and repeatedly turn to us
for practical analytic input on some of the most complex policy issues facing them.
• They ask us to get involved both in planning policy interventions and evaluating them.
• We are able to impact the system because
• We know how to identify emerging issues on a timely basis
• We know how to work with policymakers in a respectful yet proactive manner
• We know how to combine rigorous and often complex analyses with clear
presentations of findings and conclusions
How We Make an Impact
22

23. The MJB Smokler Center Staff
Yael
Tamar
Nitza
Hadar
Bruce
Bat Sheva
Rachel
Irit
Shuli
Ruth
Elad
Ira
Rina
Jochanan
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24. 24
Chair Gary Freed, MD, MPH
Stuart Altman MA, PhD
Andrea Dubroff, JD
Marion Ein Lewin
Sherry Glied, PhD
Jonathan Javitt, MD, MPH
S. Lee Kohrman, LLB
Danny Krifcher, LLB
Stuart Kurlander, LLB
Bruce Landon, M.D, MBA, MSC
Sara Rosenbaum, JD
Fiona Sim, MD
Irv & Carol Smokler
Raphael Wittenberg, PhD
The MJB Smokler Advisory Committee

25. Thank You!
Shuli Brammli-Greenberg, PhD
Health Economist, Senior Researcher
Myers-JDC Brookdale Institute
Head of the Health Systems Management program
(MHA) School of Public Health Haifa University
shuli@jdc.org
972-508159054