Amir Shmueli

Consumer mobility in social health insurance markets : a five-country comparison.

During the 1990s, the social health insurance schemes of Germany, the Netherlands, Switzerland, Belgium and Israel were significantly reformed by the introduction of freedom of choice (open enrolment) of health insurer. This was introduced alongside a system of risk adjustment to compensate health insurers for enrolees with predictable high medical expenses. Despite the similarity in the health insurance reforms in these countries, we find that both the rationale behind these reforms and their impact on consumer choice vary widely.In this article we seek to explain the observed variation in switching rates by cross-country comparison of the potential determinants of health insurer choice. We conclude that differences in choice setting, and in the net benefits of switching, offer a plausible explanation for the large differences in consumer mobility.Finally, we discuss the policy implications of our cross-country comparison. We argue that the optimal switching rate crucially depends on the goals of the reforms and the quality of the risk-adjustment system. In view of this, we conclude that switching rates are currently too low in the Netherlands, and an active government policy to encourage consumer mobility seems warranted. In Germany and Switzerland, high switching rates call for an improvement of the rather poor risk-adjustment systems. Given low switching rates in Israel and Belgium, improving risk adjustment is less urgent, but still required in the long run.

Optimizing Admissions to an Intensive Care Unit

This paper presents a model for optimizing admissions to an intensive care unit (ICU) where the objective is to maximize the expected incremental number of lives saved from operating the ICU. The probability distribution of the number of occupied ICU beds is modeled using queueing theory. Three different admissions policies are considered: first come first served (FCFS), first come first served for all referrals whose expected incremental survival benefits gained from ICU admission exceed some hurdle (FCFS-H), and first come first served for all referrals whose expected incremental survival benefits exceed a bed specific hurdle (BSH) that depends upon the number of occupied beds (FCFS-BSH). The model is applied to data describing patients referred to the ICU at Jerusalems Hebrew University – Hadassah Hospital. After statistically estimating the distribution of expected incremental survival benefits among those referred to the ICU, we show that if only those referrals where ICU admission would improve the probability of survival by at least 19.4 percentage points were admitted, an additional 18 statistical lives would be saved annually compared to the FCFS policy, a relative life saving improvement of 17.9%. Implementing the more complex optimal bed specific hurdle policy would save an additional 1.4 statistical lives annually beyond what can be achieved with FCFS-H, a marginal improvement of only 1.2%.

Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland?

CONTEXT From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). METHODS We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. FINDINGS After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. CONCLUSIONS Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences.

Do we know what global ratings of health-related quality of life measure?

Information is lacking about the publics perception of the term health-related quality of life (HRQL). Specifically, what are the relations between the domains included in the operational definition of HRQL tools and global health ratings. The purpose of this analysis was to identify factors associated with global rating of HRQL. We conducted a survey of a representative sample of 2,030 Israeli adults, aged 45–75 years. Multiple linear regression analysis was used to identify associations between the dependent variable, the global rating, and socio-economic details, presence of disease states, and each of the domains of the SF-36. The results demonstrate that the model explains only 52% of the variance of the global rating score. The general health domain of the SF-36 explains the vast majority of the variance, 38.5% . Another important explanatory variable was physical functioning domain, which explains 7.0% of the variance and to a lesser extent vitality. The other domains of the SF-36, socio-economic details and presence of disease states contribute only small percentages to the total explained variance of the global ratings of HRQL. It seems that there is a considerable difference between the operational definition of the research community of HRQL and the public perception of this term.

Economic assessment of screening for pre‐eclampsia

Pre‐eclampsia is a major contributor to maternal and neonatal morbidity and mortality. Our objectives in this study are to economically assess, from the payer perspective, routine screening for pre‐eclampsia using placental markers ‐placental protein 13 and placental growth factor ‐ and uterine artery Doppler compared with standard care.

The SF-36 Profile and Health-Related Quality of Life: An Interpretative Analysis

The purpose of this investigation was to explore the relationship between the SF-36 scales and a direct, category-scaling, self-evaluation of health-related quality of life in a sample of healthy persons. The study of the relationship between the two provides a deeper insight into the structure and meaning of the SF-36 profile and explores its interpretability in terms of a comprehensive, subjective evaluation of health. Furthermore, this study leads to a preliminary interpretation of the profile in terms of a utility scale.

The competing effects of disease states on quality of life of the elderly

During the period 1993–1994 we conducted a study in Israel on a national-based sample of 960 men to examine the relationships between urinary symptoms and various domains of quality of life (QoL). Regression analyses were performed for each of the eight SF-36 domains, separately for the entire population and for those without any co-morbidity. The dependent variable was the SF-36 domain scores. The independent variables included age, origin, education, employment and economic status, the degree of disturbance caused by urinary symptoms and the existence of co-morbidities. There was a significant difference between the entire population and the population without co-morbidities. In the entire population we found that severely bothersome urinary symptoms were related to scores on three QoL domains (social function, role–emotional and mental health) but there was no association with physical functioning and general health perceptions. In men without co-morbidity, urinary symptoms were substantially related to physical functioning and general health perceptions. These findings indicate that the relative weight of the impact of a symptom or disease on QoL domains is changed by the presence of other competing factors, such as co-morbidities or sociodemographic attributes.

Community healthcare in Israel: quality indicators 2007-2009

BackgroundThe National Program for Quality Indicators in Community Healthcare in Israel (QICH) was developed to provide policy makers and consumers with information on the quality of community healthcare in Israel. In what follows we present the most recent results of the QICH indicator set for 2009 and an examination of changes that have occurred since 2007.MethodsData for 28 quality indicators were collected from all four health plans in Israel for the years 2007-2009. The QICH indicator set examined six areas of healthcare: asthma, cancer screening, cardiovascular health, child health, diabetes and immunizations for older adults.ResultsDramatic increases in the documentation of anthropometric measures were observed over the measurement period. Documentation of BMI for adolescents and adults increased by 30 percentage points, reaching rates of 61% and 70%, respectively, in 2009. Modest increases (3%-7%) over time were observed for other primary prevention quality measures including immunizations for older adults, cancer screening, anemia screening for young children, and documentation of cardiovascular risks. Overall, rates of recommended care for chronic diseases (asthma, cardiovascular disease and diabetes) increased over time. Changes in rates of quality care for diabetes were varied over the measurement period.ConclusionsThe overall quality of community healthcare in Israel has improved over the past three years. Future research should focus on the adherence to quality indicators in population subgroups and compare the QICH data with those in other countries. In addition, one of the next steps in assessing and further improving healthcare quality in Israel is to relate these process and performance indicators to health outcomes.

Change and stability: use of complementary and alternative medicine in Israel: 1993, 2000 and 2007

BACKGROUND Complementary and alternative health care has gained increasing popularity in Western societies in recent years. The objective of the article is to explore cross-sectional variations and temporal changes in the patterns of complementary and alternative medicine (CAM) consultations in Israel in 1993, 2000 and 2007. METHODS Interviews were conducted with 2003 respondents in 1993, 2505 in 2000, and 752 in 2007, using identical questions. The samples represented the Israeli Jewish urban population aged 45-75 in the respective years. RESULTS The rate of use of CAM during the previous year increased from 6% in 1993, to 10% in 2000 and reached 12% in 2007. Women and highly educated persons have been significantly and consistently more likely to use CAM. Among the users, homeopathy, acupuncture and reflexology are the main types of CAM used. Lower back pain became the leading problem for which care was sought. A significant proportion of the users continue to use conventional medicine concurrently, and an increasing share was referred to CAM by their physician. Past good experience has become a major reason for CAM use. CONCLUSIONS Between 1993 and 2007, CAM use in the Israeli urban Jewish population aged 45-75 years increased significantly. As in other countries CAM grew from an infant industry and entered the mainstream of health care. The evidence reported here highlights the urgent need for the design of health and social policies aiming to achieve more effective integration between CAM and conventional medicine.

Risk adjustment and risk sharing: the Israeli experience

Israel, like several other countries, introduced a national risk adjusted capitation system during the 1990s. However, the Israeli move was drastic, implementing from the beginning a fully prospective risk adjustment scheme based on age, supplemented by a 100% five condition-specific risk sharing. That scheme, together with open enrollment (periodic switching options), was intended to transform an unregulated competitive health insurance market, characterized by adverse selection and preferred risk selection, into managed competition assuring quality of care, efficiency and fairness. This paper presents the Israeli experience during the first 6 years of the reformed system, focusing on issues related to the risk adjustment and risk sharing arrangements.