Professional Documents
Culture Documents
REPORTS
REFORM IN MENTALHEALTHSERVICES IN
ISRAEL: THE CHANGING ROLE OF
GOVERNMENT, HMOs,AND HOSPITALS
Mordechai Mark, M.D., Jonathan Rabinowitz, D.S.W., Dina
Feldman, M.A., Dalia Gilboa, Ph.D., and Joshua Shemer, M.D.
Most western countries are reconsidering the roles of the public a n d private sectors in health care financing a n d delivery.
In the U.S., the Clinton administration has
proposed heavy regulation of private insurance and eventual full "privatization"
of mental health services by 2001 (Arons,
Frank, & Goldman, 1994). In March 1988,
Holland enacted a law that radically
changed health insurance. In December
1988, Germany enacted a law of health
care reform (Gesundheitsreform). In Jan-
uary 1989, England publicized its "Working for Patients" that called for revolutionizing the National Health Service. Previous to this, New Zealand published its
Gibbs Report entitled "Unshackling the
Hospitals."
Health care in Israel is also in flux. In
general, reform is moving toward a market-based system, a promising b u t problematic development for mental health
care. In this paper we present the evolving
reform of the mental health care delivery
system in Israel. (For a recent overview of
the mental health care system in Israel see
Kates, 1994.) First we present the problems that brought about the reform and
the historical background to these problems. Next, we discuss some of the proposed solutions. This change process is
presented from the perspective of the
Mental Health Branch team of the Ministry of Health.
BACKGROUNDOF REFORM
Currently, health care in Israel is provided by one large Sickness F u n d r u n by
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suree. This was replaced with another proposal in which coverage is given with limitation put on the provider (see next section for details). The mental health
benefits as deemed by the new law include
three types of services: hospital, ambulatory, and substance abuse treatment services. Hospital services include: emergency
and triage services, hospitalization, day
hospital, consultation liaison psychiatry in
general hospitals, alternatives to long-term
hospitalization such as sheltered housing
and hostels. Ambulatory services include
diagnostic, assessment consultation, individual, family and group psychotherapy,
crisis intervention, follow-up and supportive treatment, rehabilitation and home visits. Substance abuse treatment includes
hospitalization, ambulatory care, and
home-based rehabilitation.
Making mental health services part of
the HMOs responsibility enables integration between general medical and mental
health care, thus potentially improving the
quality of care (Mechanic, 1994). We suspect that like in the U.S. most mental
health care in Israel is provided by primary care physicians; that primary care
physicians rarely refer patients to mental
health professionals; that a majority of all
psychoactive drug prescriptions are written by non-psychiatrists; and that over one
fourth of non-psychiatrist physician visits
are for psychological problems (Schurman, Kramer, & Mitchell, 1985). Yet,
much psychiatric morbidity goes unrecognized and untreated by primary care
physicians.
A W H O study (Sartorious et ai., 1993),
that was conducted at 15 sites around the
world found that psychological disorders
comprised substantial levels of morbidity
in general health care in developed and developing countries. They also found that
"the majority of the psychological disorders were mood, anxiety, and somatoform
disorders and neurasthenia" and that only
about "one half of these cases were recognized by the health care providers in all
centers as suffering from psychological
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them to, and maintain them in, the community. Studies have suggested that high
treatment costs may be offset by savings in
inpatient use and have examined more
closely the relationship between costs and
benefits of treatment (Rosenheck, Massari, & Frisman, 1993). Clozapine has been
made available to all neuroleptic non-responsive patients who have accumulated
one year in the hospital. Although clozapine is several times more expensive than
other neuroleptics, the Ministry of Health
provided every hospital with a monthly
subsidy for each patient receiving the
drug. As a result, the treatment of these
patients costs the hospitals less money
than that of other psychotic patients. A recent national survey of patients receiving
clozapine shows that about 20% of them
were released after years of hospital stay;
over 30% improved significantly enough
to move to less restrictive care (e.g.,
locked unit to open unit).
A large scale assessment has begun of all
psychiatric patients, numbering several
thousand, who have been hospitalized for
at least 12 consecutive months. Each patient's clinical status and treatment history
are being reviewed to help identify less restrictive alternative care, and to asses patient suitability for clozapine and other
new treatment technologies. Methodology
similar to what Left has done in England
(Anderson et al., 1993) is being used.
However, in Israel, we are not closing hospitals, instead we are conducting a survey
of housing alternatives for long stay psychiatric patients and we are planning
transformation of existing hospital units
to other types of care such as halfway
houses, hostels, and sheltered housing.
The patient and housing survey will provide data for planning a continuum of
needed services.
Also, as part of the reform, the Ministry
has sponsored workshops focusing on
quality assurance and the economics of
mental health care and working gToups
with sick funds for joint planning. The
Ministry has also sent professionals to
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CONCLUSION
We have described the b a c k g r o u n d for
the reform o f mental health services in Israel. This reform is in response to public
dissatisfaction that led to the g o v e r n m e n t
to set up the Netanyahu Commission
which suggested far reaching reforms in
health care. The p r o p o s e d solutions are
integrated and geared toward making
mental health services m o r e c o m p r e h e n sive and available in the community, in
general, and specifically in the primary
medical setting. This redefines the role o f
hospital care in psychiatry for only patients who cannot benefit from less restrictive care. These changes will hopefully
r e n d e r the system m o r e c o n s u m e r oriented and financially m o r e efficient.
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posed budget for fiscal year 1993 and explanations presented to the 13th Knesset. Jerusalem:
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