PRESS RELEASE: Your Place in Line: Waiting Times in Israel’s Public Hospitals

A new study by the Taub Center for Social Policy Studies in Israel has found that patients in the large metropolitan area hospitals (Tel Aviv, Haifa and Jerusalem) have shorter waiting times for medical procedures than those at hospitals in the Northern and Southern districts. According to the study, steps such as improving collection and accessibility of waiting times data, setting targets for hospitals and enforcing them, and creating appropriate incentives are likely to shorten waiting times for procedures in public hospitals.

Click here to read the full policy brief on Waiting Times in Israel’s Public Hospitals. 

Main findings:

• There is a negative correlation between the supply of hospital beds and waiting times for elective surgery. In Jerusalem, Tel Aviv and Haifa, the supply of beds is the highest in the country (2.2-2.5 beds per 1,000 population), and the waiting times are 15%-30% shorter than the national average. In contrast, in the Southern district, there are only 1.3 beds per 1,000 population, and waiting times are about 44% longer than the average.
• Between 1999 and 2012, the share of Israelis holding both types of private health insurance (supplementary and commercial) nearly quadrupled, and stood at about 40% in 2012. This phenomenon may come from the feeling among Israelis that they do not receive effective care in the public healthcare system. Since the public and private system rely on the same healthcare workforce, the existence of supplementary insurance leads to longer lines in the public system and thus further proliferation of private care.
• When measuring waiting times in 27 public hospitals in Israel, it was found that there is large variation between institutions. For example, there is a difference of nearly a year in waiting times for knee replacement, tonsillectomy and deviated septum procedures between the hospitals with the longest and shortest waiting times.
• At hospitals owned by Clalit Health Services, the median wait time is the longest – about 15% higher than the national average. In hospitals that function as non-profits, wait times are the shortest – 32% less than the national average.
• 23 OECD countries have stated that waiting times are an important policy issue (including Israel), 15 of which have strategic plans to deal with the challenge. In contrast, there is still no such plan in Israel.

The National Health Insurance Law established that every resident is entitled to receive healthcare within a reasonable time and at a reasonable distance from his/her place of residence. To date, no guidelines have been set regarding “reasonable time or distance,” and this remains one of the main challenges facing policy makers in the field of healthcare in Israel. A new study by Liora Bowers, Taub Center Director of Policy, and Prof. Dov Chernichovsky, Taub Center Health Policy Program Chair, examines the issue of waiting times for medical care in Israel, differentiating between hospitals in the periphery and center, individuals who do and do not hold private insurance, and hospitals owned by various parties. This is one of the first studies in Israel that looks at waiting times for elective surgeries from an international comparison perspective.

Lack of trust in the public system?

According to the Taub Center study, private payment for medical care is becoming more and more common among the Israeli public. The share of those with supplementary insurance (offered by the country’s health funds) increased by about 60% between 1999 and 2012. It has reached the point where almost four out of five Israelis (80%) hold this type of insurance. In parallel, the share of those with commercial health insurance has risen by about 80%, with about 40% of the population holding private commercial health insurance in 2012. It may be that people are concerned that they will not get satisfactory healthcare through the public system, fears which are intensified by the fact that patients at public hospitals cannot choose their treating doctor, as well as due to the lack of transparency and the lack of information regarding expected waiting times.  Patients are also encouraged by the system to shorten waiting times by choosing to activate their private insurance.

It is important to understand that waiting times are a mechanism for rationing care in a system where patients are not deterred by the cost of care because they do not pay a significant portion of the cost. Nonetheless, there is evidence that lengthy wait times are a burden on society since they increase the likelihood of more complex hospitalizations and poorer outcomes, potentially leading to increased healthcare costs. In addition, long waits are likely to influence the patient’s ability to work and the quality of their leisure time and increase dissatisfaction levels with the overall healthcare system.

Waiting for surgery? That depends on where you live

Among the leaders of the healthcare system, there is a widespread feeling that the average waiting times represent a mix of two different population groups: on the one hand, the “haves” – Israelis who are well-off, have personal connections, the ability to stand up for their rights and who thus have access to quick medical care; and on the other hand, the “have-nots” – patients from weaker population groups who lack financial means, who often have to wait a long time for their medical treatment.

The Taub Center study also looked at waiting times for elective medical procedures by location of residence and found that the median waiting time for surgery in the large metropolitan areas (Jerusalem, Tel Aviv and Haifa) are substantially shorter than waiting times in hospitals in the North and South of the country. In Jerusalem, waiting times are about 28% shorter than the national average, while in the South, waiting times are the longest in the country – about 44% longer than the national average. The long waiting times in the periphery parallel the limited healthcare resources allocated to these areas, and particularly the number of inpatient beds. In Jerusalem, Tel Aviv and Haifa, the supply of beds is between 2.2 and 2.5 beds per 1,000 people, while in the Southern district, the supply is only 1.3 beds per 1,000 people. In 2013, the supply of doctors per 1,000 people in the North was only two-thirds as high as in other parts of the country (2.2 versus 3.2 or more, respectively), while the supply of other healthcare professionals (such as pharmacists, physiotherapists, occupational therapists, etc.) in the North and South was half that of other regions (2.1 and 2.2 versus 4.0 or more, respectively). It should be noted that there are efforts underway to narrow these gaps, including the opening of a medical school in Safed and additional pay for doctors who work in the periphery. It is still too early to assess the result of these actions.

The study by Bowers and Chernichovsky also found substantial disparities among public hospitals in waiting times for elective surgeries. For example, a patient waiting for knee replacement surgery in one hospital in Haifa has an average wait of three weeks, while a patient waiting for the same surgery in the South has a wait of over a year.  Among other things, long waiting times for elective procedures in hospitals are likely due to overcrowding: the supply of hospital beds in Israel is among the lowest in the OECD, and due to this, occupancy rates are also among the highest of the developed countries – at about 96%.

An additional finding is that waiting times relate to the ownership of the hospital. In hospitals owned by Clalit Health Services, the median waiting times are the longest – about 15% longer than the national average – while at hospitals that are non-profits, waiting times are the shortest – 32% less than the national average. Waiting times in government hospitals are about 23% less than the national average. The long wait times at Clalit hospitals may be explained by two factors. First, Clalit also runs hospitals, in contrast to the other health funds, and so in most cases it refers its patients to its own hospitals. This can limit the ability of its health fund members to choose other hospitals on the basis of shorter waiting times. Secondly, there are claims that Clalit Health Services has succeeded in limiting the impact of private funding within the hospitals it operates, and so the pressure on the publicly funded procedures is greater.

In an international comparison, the Taub Center study found that wait times for elective surgeries are shorter in Israel than in other OECD countries, although one difference must be taken into consideration. In most developed countries, waiting times are measured from the point when the patient is referred for treatment until surgery is performed while in Israel, the wait time is only measured from the date when the surgery in the hospital is set. 23 of the OECD countries (including Israel) determined that waiting times are an important healthcare policy issue and 15 of these countries have addressed this issue via a national strategic plan. Israel has yet to have a plan of this type.

The state’s role – guarantees, incentives and enforcement

According to Bowers and Chernichovsky, there are several steps that the state can consider to deal with this issue. First, there is tremendous importance to improving the Ministry’s ability to evaluate the performance of the healthcare system. The Ministry of Health declared in 2014 that the measurement of waiting times for elective procedures from the time of referral as well as real-time data accessibility was on its agenda, although it’s unclear if there has been progress on these issues. Nonetheless, the initiative by the Ministry to collect data on waiting times for elective procedures at the various institutions and to publish these figures regularly (this has begun only partially) is a significant step. Transparency and efficiency in the system will allow patients to choose a hospital in real time on the basis of waiting times, which will help to balance demand.

An additional step that is likely to help is to require health funds to meet waiting times that are considered reasonable from a medical perspective and to track this information. One of the central issues on this subject is how to enforce such waiting times guarantees. An OECD study examining 13 countries showed that all of those countries provide patients with guaranteed waiting times, so that the patient knows what to expect. Some of the countries use a model of negative enforcement. In England, for example, a medical department that does not meet the waiting time targets could lose 5% of its monthly funding. There are also examples of positive enforcement. Sweden gives a generous budget to municipalities that provide medical treatment or surgery within 90 days of the referral – and this method has proven to be very effective. Another option is to give the patient the right to choose between public and private care. For example, in Portugal, the patient can turn to the private system – at the state’s expense – once the waiting time in the public system has reached 75% of the pre-established waiting time.

The Taub Center study also underlined the importance of cooperation among stakeholders. “A reform in waiting times will not succeed if it is not done in cooperation with the health funds,” state the researchers. They write that one of the recommendations of the German Committee to Strengthen the Public Health System (2014) was that the health funds would allow patients to choose from among three different public hospitals; and in this way, disparities in waiting times could be lessened. In addition, better integration between community care and hospital treatment could reduce the need for inpatient medical care. Another action that could help address this issue is to provide payments to hospitals on a per case basis rather than a per day basis, which improves incentives to treat more patients.

In conclusion, Bowers and Chernichovsky say, “in the last 15 years, there has been a substantial rise in the percent of Israelis purchasing private medical insurance, and it may be that the lengthy waiting times in the public system play a key role in this trend. A combination of transparency and reporting on accurate waiting times data, alongside the commitment of hospitals to meet guaranteed waiting times and their enforcement by the state, will help the general public to manage its expectations, and will help to lessen uncertainty and restore patient faith in the public system.”

The Taub Center for Social Policy Studies in Israel, headed by Prof. Avi Weiss, is an independent, non-partisan institution for socioeconomic research based in Jerusalem. The Center provides decision makers, as well as the public in general, with a big picture perspective on economic and social areas. The Center’s interdisciplinary Policy Programs – comprising leading academic and policy making experts – as well as the Center’s professional staff conduct research and provide policy recommendations in the key socioeconomic issues confronting the State.

For details, or to arrange an interview, please contact Itay Matityahu, Director of Marketing and Communications at the Taub Center for Social Policy Studies in Israel: 052-290-4678.