Nefesh BNefesh

Written by: Stuart L. Fischman, DMD
(Submitted for publication in the Buffalo Jewish Review)

For some time, I have been planning to write about “Healthcare in Israel,” but something “always came up.” I did not wish to have the article viewed as a critique of the “Obama-care” legislation pending in Congress. There was Operation Cast Lead in Gaza, there was the “flotilla incident,”there was the “settlements issue,” etc. Late in 2010, “something came up,” which made the topic very relevant and timely! From December 9th through 23rd, I was a patient in the Hebrew University-Hadassah Medical Center here in Jerusalem. Let me “cut to the chase” and let the readers know that thanks to Hashem, prayers of many and the compassion and skill of my doctors, I am now recovering at home.

Healthcare in Israel, both as a “system” and available professional resources, is among the best in the world. The National Health Insurance Law took effect in 1995 and defined the State of Israel’s responsibility to insure all residents. Coverage is mandatory and every resident must be a member of one of four private health funds, each obligated by law to provide a uniform “basket” of services to their members. The fund must accept all applicants for services regardless of age or prior medical history—pre-existing conditions are irrelevant. The “basket” includes: physicians’ visits, diagnostic and laboratory services, paramedical services (e.g., physical therapy), medical equipment, rehabilitation, hospitalizations and prescription medications. In order to supplement the services guaranteed by law, the health funds also offer the option of supplementary insurance for an additional fee. (Dental care is not part of the “basket.” However, the a program began in July 2010 to provide preventive and some restorative dental care to children under the age of 8.)

What does this cost? As “pensioners” who immigrated to Israel after the age of retirement and never paid premiums to the National Insurance Institute, we pay approximately 160 shekels per month per person (about US $530 per year for each of us). There are some 2 co-payments required. For example, we pay 6 shekels (US$ 1.67) per quarter for visits to our primary care physician. The co-pay on most prescriptions is 15%, but the “list” cost of most medications is considerably less than in the US. The maximum co-pay per quarter for those over 65 is 51 shekels ($US 14) per quarter. Many preventive procedures are provided at no charge; e.g., mammograms every 2 years, colonoscopy every 5 years (there are exceptions for persons at higher risk). Preventive “reminders” (immunizations, diabetes management, mammograms) are made by regular telephone calls—sometimes even in English!

How does this work? When we made Aliyah we were given a “voucher” to join our choice of the four health funds. We chose Maccabi and I shall describe our experience, without any “endorsement” of this health fund. Maccabi has a clinic a few blocks from our apartment and also has a “voucher-less” referral arrangement to the Hadassah Medical Center where I “work” and where I have many colleagues. Several family physicians and specialists have regular office hours there, usually in the evenings. The laboratory is open daily from 7 to 9 AM, and this is convenient for fasting procedures, etc. Patients may “download” the results of their own laboratory tests after 5 PM that day. The report includes the test result and the range of normal values. When signing up, we were asked to select a “family physician”. Not knowing any of the staff, the receptionist asked us a few questions about our medical and personal backgrounds and suggested a clinician. It was a wise and fortuitous suggestion! Our physician is conscientious and compassionate and regards me as a colleague. He is a pulmonologist (lung specialist) at Hadassah, in addition to his family practice at Maccabi.

How did it work in practice? I’ll describe my recent illness in “broad strokes,” to avoid some personal details and to obviate the need to have HIPPA clearance for privacy under US regulations. Shortly after my 75th birthday, I developed a persistent cough, which made some of the Chanukah festivities uncomfortable. Jane had a previously scheduled visit to our personal physician on a Sunday evening and my cough was obvious to him. After listening to my chest, he sent me across the street to a private radiology facility. I brought the CD of the chest radiograph back to his office. The following morning, at 8 AM, he phoned advising me that I had pneumonia and that he had left a request for a 3 battery of laboratory tests at the clinic, as well as a prescription for antibiotics. At 5 PM, I looked at my lab results and it was clear that “all was not well”! My physician called me later that evening, advising me to come to the clinic on Wednesday evening for follow-up. At that time he determined that on auscultation, my lungs were no better and that my blood oxygen saturation was quite low. He suggested immediate hospitalization at Hadassah and explained the seriousness and prognosis, in professional terms. We “negotiated” a night at home and admission via the Emergency Room the following morning.

The Hebrew University-Hadassah Medical Center is a major academic health center and acknowledged to be the best in the Middle East. (Better to know it as a staff member, than as a patient, however!) When I reported to the Emergency Room, I was not asked for any financial guarantee or credit card and the referral from my physician had the information on my health fund. I arrived at 9 AM and by 9:30 I had been seen by the Attending Physician, his resident, had a cardiogram and several blood samples drawn. By noon, I had been started on supplemental oxygen, intravenous medication, had a chest x-ray and high resolution CT scan of my chest, as well as a consultation. My personal physician, the Infectious Disease Service, Renal Disease Unit, and Internal Medicine were all notified and I was given a bed in the E R facility. My physician visited me there and explained the severity of my overall health status. Later that evening, I was moved to a bed on Internal Medicine A, one of the teaching units.

As the Israeli weekend begins on Friday and continues through the Sabbath, I expected only minimal professional attention for the next two days. Wrong! On Friday morning, regular rounds began, headed by an Attending Physician, Chief Resident and an entourage appropriate to a teaching hospital. All records at Hadassah are electronic and a work station accompanies the physicians. The staff treated me as a colleague and invited me to view the computer screen along with them. All my radiographs, both in the hospital and prior to admission, were available for comparison, enhancement, etc. All laboratory values were available, along with trends. Consultants’ notes and comments were similarly on line. It was interesting to note that “SOAP notes”, the standard protocol at US hospitals, were also used. (The accepted procedure at any patient encounter is to enter 4 notes as: Subjective, Objective, Assessment, Plan). SOAP was in English, but the “notes” were in Hebrew. Medications past as well as those prescribed in hospital were also listed.

When an order was written for a medication, any medical contraindications or interactions were immediately displayed. Procedures and orders were transmitted electronically to the appropriate facility. Professional care was superb and comparable to that of any major academic facility in the United States. I was seen on a regular basis by Directors and Professors of all necessary services (Internal Medicine, Haematology, Immunology, Rheumatology, Infectious Disease) and presented at Grand Rounds, as well as a few teaching rounds. Medical students were assigned to “write up” my complete history and Fellows on specialty units prepared a case presentation for their rounds. As I noted, I was regarded throughout as a colleague, as well as a patient. Additional procedures included a chest ultrasound examination and a full body CT scan as well as a number of advanced laboratory tests, available only at a facility of this level. My personal physician, on the faculty of the Pulmonology Institute, performed a bronchoscopy and obtained tissue and fluid samples for further studies.

Nursing care was both professional and compassionate. All staff members were fluent in at least three languages: Hebrew, English and Arabic. Russian was also frequently heard. Showers were available and all food was Kosher! (Of course cuisine was not five star, but that was not the reason for my visit.) After two weeks my status had stabilized to the point where I was discharged to home and the continued care of my personal physician. At discharge, the Chief Resident called me to his office for a half hour conference to review my hospitalization, medical condition and prognosis. I was given a typed 8-page discharge summary, including a complete summary of my clinical course, laboratory reports, radiograph findings, results “pending” and appointments with appropriate specialists at Hadassah.

Obviously, the Israeli healthcare system works! As the New Year begins, I am well on the way to recovery.

I almost forgot to mention—the only cost to me was for the rental of a television set. I just walked out the door after my conference with the Chief Resident.

2 January 2011
Shalom from Jerusalem
Stuart L. Fischman, DMD