Israel trip day 13 - 23 December

Well, this is it - our final day in Israel. We met as a group first thing in the morning to debrief the trip on a number of levels: content, culture and logistics. The comments from everyone in the group were so helpful as we begin the work of planning the next study tour to Israel. The one thing that we must do is thoroughly brief the participants about the US healthcare system if we expect everyone to be on the same page when comparing  the US system with any other. We also need to make sure that the students arrive in country first thing in the morning and then give them that day to rest and prepare for subsequent activities.

I want to be sure to thank Orly Manor, Director of the Braun School of Public Health at Hebrew University for making herself and her faculty available to us at every turn. All of the Braun School faculty are truly wonderful and dedicated teachers and scholars. Dr. David Chinitz is truly a mensch. His vision and energy gave us access to the breadth and depth of the Israeli health care system in a way I could have never imagined. He is also a passionate and inspiring teacher and is someone who I look forward to working with long into the future.  Thanks to Vardit Luzon who worked so hard to put together a travel package that came in under budget while at the same time meeting and exceeding all of my expectations.  Thanks to Nathan our guide whose encyclopedic knowledge of Israel was something to behold. Thanks as well to Sami whose skill at maneuvering our bus through impossibly crowded and busy streets was nothing short of magical.  Thanks to Laura Ochs at the George Washington University International Studies Office for all of her efforts to keep me calm and focused during the planning of the trip.  Thank you to Bob Burke, Chairman of the Department of Health Services Management and Leadership and Lynn Goldman, Dean of the School of Public Health and Health Services for your trust, confidence and commitment.

Special thanks and appreciation must go to Arthur Shorr. Three years ago, Arthur had a vision to bring a group of students to Israel and provide them with an opportunity to learn about the way health care is delivered in this very special nation. He remained persistent and focused throughout. I am glad that we gave him a chance to upgrade his Hebrew since he was speaking it like a native at the end. Arthur is an inspiration to me and I am so grateful he was here with us.

Finally, thanks to Teke, Vincent, Karen, Bijay, Morgane, Jeremy and LeMia - our students for whom this trip was intended and who were always fully engaged and energized even when it seemed like the days would never end.  The seven of you are truly wonderful and special people and without you, none of this would have happened.  Thanks to the seven of you for helping me to learn more.

So, on this early Saturday morning 24 December, let me wish all of you Shabat shalom and best wishes for a happy and healthy 2012.

Israel trip day 12 - 22 December

I have difficulty believing that we are just about done with our trip to Israel.  The last 12 days have flown by in a blur.  Today we began with a visit to the National Library of Israel which is on the campus of Hebrew University of Jerusalem. The National Library is equivalent to our Library of Congress.  It is housed in a building that is clearly too small for the collection and the many scholars, librarians and visitors that come in each year.  We spent the large part of our time in the archives and rare books section where we were treated to an up close view of a number of books that focused on the history of medicine including a first edition of the book written in 1543 by the Flemish anatomist Andreas Vesalius.

Our visit to the National Library was done too soon and we took the short walk to the Israel Museum. This is truly one of the most magnificent museums in the world that combine multiple worlds including art, culture and history.  Spending 3.5 hours at the was far too short a time to take in everything from the Dead Sea Scrolls, the extensive archaeology section, sculpture throughout the exterior, Impressionist galleries, Jewish art and life and the Second Temple Model.

In mid afternoon, we met up with David Chinitz and walked to the Brookdale Institute for Applied Social Research.  There, we were met by Dr. Bruce Rosen, Director of the Smokler Center for Health Policy Research. According to their website and verified by David Chinitz and others, "The main objective of the Smokler Center for Health Policy Research is to contribute to reforms and the development of Israel's national health services by offering objective data and independent analysis to improve the organization, delivery and financing of health services. In addition to hearing about the important work done by the Smokler Center, Dr. Rosen was particularly interested in hearing from our students about their impressions of Israel's health care delivery system.  Wanting to hear from our students was so gratifying to me as I listened to what they shared with some of the leading figures in health services research in Israel.

Leaving the Brookdale Institute, we had come to the end of our formal academic segment of the trip. One more day on Friday and then it is time to depart.

Israel trip day 11 - 21 December

We were packed and on the bus early today for our 8:00 AM appointment with the chief medical officer at the 669th Airborne Division of the Israeli Air Force housed at Tel Nof Air Base located about a half hour south of Tel Aviv. We were not permitted to take photographs while on the base and while the CMO was giving his presentation, there were two intelligence officers present to make sure he did not say anything against the rules. We were given a very thorough briefing of the activities of the 669th including a lengthy discussion of the role they played in the immediate aftermath of the Haiti earthquake in 2010 when the physicians and medics were sent to Port au Prince to establish a field hospital that treated hundreds of victims during the time they were in country. We were shown their search and rescue gear and got to see their training hanger where they can simulate virtually any environmental condition to allow their paramedics to practice their skills at rescue and patient evaluation.

Once we were escorted out of Tel Nof, we drove back to Tel Aviv where we bid farewell to our guide, Nathan. He was wonderful and was an absolute treasure trove of insights and information.  We headed for lunch at a wonderful seafood restaurant in Old Jaffa named, Old Man and the Sea (note the Ernest Hemingway allusion).  Small plate after small plate of Mediterranean inspired salads and wonderful pita bread  followed by your choice of whole fish that was likely swimming nearby not long before.  Simply seasoned and grilled, the only hassle was that you had to work around the bones.

Once lunch was done, we went to headquarters of Maccabi Healthcare System in Tel Aviv where we were met by Dr. Rachelle Kay, Deputy Director of the Division of Finance and Planning and Director of the Maccabi Institute for Health Services Research.  Maccabi is the second largest HMO in Israel with 1.9 million members and 5,000 employed physicians.  They have contracts with every public hospital in Israel and owns Assuta Medical Centers.  Last year, Maccabi rolled out a comprehensive electronic health record connecting every one of their physicians to their hospitals. This EHR allows every physician access to a dashboard looking at multiple quality indicators. Data is pulled from a data warehouse that contains comprehensive clinical information for each and every Maccabi patient. We were joined by a number of other key Maccabi staff members who shared with us the work they were doing in medical informatics, telemedicine and quality management. The only comparable non-federal US health care organization doing similar work is Kaiser-Permenante. I was very impressed with their dedication to using data to make good clinical and administrative decisions. Dr. Kaye did acknowledge that for the first time Maccabi was running a deficit and this was an important focus for the organization.

Just as the lights for the second night of Hanukkah were being lit, we got back on the bus for the long drive back to Jerusalem.  It was comforting to get back to Jerusalem where we knew our way around.  It was a bit like coming home.

Israel trip day 10 - 20 December

This was a bit of an out of the ordinary day.  Up until now, we had focused on the delivery and payment of health services in Israel. This morning, we were dropped off near a local shopping area and walked to the offices of the Migrant Workers Hotline. We received an in-depth briefing from one of their senior staff on the plight of foreign workers who enter Israel to typically work in a variety of service or agricultural activities. There are over 100,000 legal migrant workers in Israel who are typically here from either the Philippines or China.  These workers are allowed to be in the country for up to five years if they have a contract from their employer who is responsible for purchasing health insurance for these workers. We learned that these workers can not become Israeli citizens even if their children are born in Israel. 

Another group we learned about were refugees, typically from Eritrea. Israel has a relatively open border to the non-Arab parts of Africa and many refugees enter the country by crossing into the Negev Desert. While the living conditions of the refugees is pretty sad, it is far better than what they left behind in Eritrea. Many of these people earn a living as a day laborer or in some cases, run their own businesses in an area close to the Central Bus Station. Walking through this area was certainly not something typically found in the tour books.

After our morning walk and post graduate education about a part of Israel most people don't think about, we stopped for lunch and then gave everyone the rest of the afternoon off. While the students went off in various directions to explore Tel Aviv, Arthur Shorr and I went to the old city of Jaffa. This is a beautiful destination that hugs the coast just south of Tel Aviv. Lots of art galleries, shops, museums and places to stop and enjoy a cappuccino at a sidewalk cafe. 

The evening was spent grading final exams and posting grades. Later in the evening, was met by the brother and sister in law of the travel agent who set up the trip.  Both Ruthie and Miky are pediatricians who work for one of the large health plans in Tel Aviv.  They were absolutely lovely people and I thoroughly enjoyed my time with them.

Israel trip day 9 - 19 December

The Madison Nahariya hotel won the prize with the students for the best dinner and breakfast so far on trip.  We packed up and boarded the bus for a short drive to the Western Galilee Hospital.  We were met by their director Masad Barhoun who shared with us the history and interesting attributes of the hospital.  In contrast to Hasassah Hospital, Western Galilee is a public hospital dependent almost totally on funding from the government. The hospital has 660 beds and is considered a rural hospital despite its size. One other thing of note, is that the hospital is just six miles from the border with Lebanon and came under fire during the 2006 war with Lebanon.  Over 800 rockets fell in the vicinity of the hospital and one struck the ophthalmology wing.  Fortunately no one was killed since the hospital had moved all the patients and staff into a subterranean hospital that had been designed just for this type of event.  We took a tour of the hospital including the new ER which is designed to withstand virtually any type of attack scenario as is the new women's health center and cardiac wing.  One of the things that was emphasized over and over was the drill and training all the staff go through to confront any type of emergency.  This continuous drilling gives the hospital and the staff the resilience to respond to essentially any type of disaster scenario.  How amazing would it be if US hospitals were equally prepared to deal with a disruptive event?

After departing the hospital we, made the short drive to a community clinic run by Clalit, the largest of the four national HMO's in Israel.  We got to meet the director, Dr. Saab Anwar who took us through the organization and operation of Clalit and his clinic in Nahariya. One of the notable attributes to Clalit is their dedication to health and wellness with the focus on the patient first and foremost. We visited with the staff from the pediatric clinic, women's health clinic and pharmacy. Their electronic health record ties together all patient encounters whether with a physician or a hospital.  I think that all of us came away impressed by the passion and dedication shown by all the persons we met at the Nahariya Clalit clinic.

When finished at Nahariya, we drove south into Tel Aviv. With afternoon traffic it took two hours but we would our hotel adjacent to the beach and close to Ben Yehuda Street. Thankfully, there was a coffee shop nearby that had blazing fast internet access since the hotel's router was down and out. 13 shekels for a cappuccino and internet access until they closed at 10:00 is a great deal.

Israel trip - weekend activities

As previously noted, I took a break from the blog when we took a break from the academic part of our visit. Unfortunately, between very spotty internet in Nahariya and our hotel in Tel Aviv coupled with the need to get grades done for my class, I am only returning to my writing tonight. Rather than provide an overly long and overly boring essay, I will start with the weekend activities and begin anew with our activities and impressions on Monday, Tuesday and Wednesday.

Friday morning was dedicated to touring the Old City of Jerusalem. We started in the Jewish Quarter and made our way through the Muslim and Christian Quarters. For those of you who have never been here, the Old  City is truly the crossroads of the three monotheistic religions yet all seem to be able to successfully coexist. We   started in the Garden Tomb in East Jerusalem then made our way through Herod's Gate and into Muslim Quarter. After walking past store after store and vendor after vendor, we entered the Church of the Holy Sepulcher where we spent a significant time exploring this amazing structure.  Once the Old City was done, we gave everyone the afternoon off to spend the rest of the day on their own. In Israel, Shabat effectively begins at 3:00 when almost every retail outlet, bank and restaurant shuts through Saturday at sundown.  This was also the day we said farewell to my lovely wife Lydia who had to fly back to Washington that evening.

Saturday we got an early start when we headed south into the Judean desert to visit Masada and the Dead Sea. For those unfamiliar with the story of Masada, you might want to check out where you can read the complete story. Rather than climb the snake trail up the side of the mountain, we took the tram and had an amazing visit to this truly wondrous sight.  Returning from Masada, we stopped at a beach next to the Dead Sea.  Located almost 1,400 feet below sea level, it is the lowest spot on earth.  A number of our students took a dip in the ultra salty water and then came out to cover themselves in Dead Sea mud. The day was perfectly clear and we could see the coast of Jordan directly across the Dead Sea.

Sunday was a day of transition. We checked out of our hotel to head north but first, we were able to get into the tunnels beneath the Western Wall. Our guide gave us a wonderful introduction to the tunnels and pulled together for us how the Old City has evolved since the time of Herod. We said farewell to Jerusalem and drove north to the north coastal site of Casearea.  These old Roman ruins date back to the time of (you guessed it) Herod who found it a convenient port to resupply his efforts to build his little empire. There are a number of lovely little seaside restaurants, art galleries and other vendors. After our visit to Casearea, we drove through Haifa and stopped in Akko for an all too brief visit to this amazing underground city. By all indications, Akko is one of the oldest continuously occupied cities in the world dating back to the time of ancient Egypt and the Pharaohs. Departing Akko after dark, we drove another 45 minutes or so until we arrived at our final destination for the day, Nahariya, a beautiful coastal resort just 10 kilometers (6 miles) from the border with Lebanon. Just a side note, the hotel was hosting a convention of police officers from across Israel and everyone of them was packing heat.

Israel Trip Day 5 - 15 December 2011

Today was less hectic than we had experienced previously. We heard two lectures at Hebrew University and the Braun School of Public Health.  The first was jointly conducted by Professor Orly Manor, Dr Amnon Lahad and Dr. Dina Jaffe on the theme of  the Community Medicine Quality Standards. In 2004, the Ministry of Health adopted a program for quality indicators in community health care. It was designed to provide consumers and policy makers with information on the quality of community based care delivered by the four HMO's in Israel. Virtually the entire population is part of the database. The data is developed on the basis of: importance/relevance; evidence based; ability to quantify; available electronically; and possible to be implemented.  There are six broad measures including: asthma; cancer screening; rate of immunizations for older adults; child and adolescent health; cardiovascular health; and diabetes.  A number of quantifiable measures are associated with each measure.  The main findings from 2007-09 were that in most areas, healthcare quality had increased over the prior five years  and that disparities continue to exist.

The second and final presentation was on economic behavior in Israel's health care system. Dr. Amir Shmeli, a very well known and respected health economist here pointed out that the HMO system was based on managed competition and that risk selection is a crucial part of the larger system. Budgets to the HMO's is based on age based risk insurance adjustment. I am certain that what Dr. Shmeli was presenting was very important but I felt like I needed to be a health economist to understand and appreciate what he was sharing with everyone.

The afternoon took us to a flaffel stand downtown for a particularly yummy lunch then it was off to the Knesset. We were given a guided tour of the Knesset by Daniel who explained very clearly the way in which the Israel Parliament was structured and the way in which Knesset members were elected (by party and not as individuals). He took us to the Plenum and pointed out that the seats for the 120 members were arranged like a menorah. We then went into the Great Hall and stood in awe of three Chagall tapestries along with his mosaics on the floor and the wall.  There is a replica of the Proclamation of Independence in the hallway that spells out the key provisions of the State of Israel.

Once done at the Knesset, we headed off for the Old City of Jerusalem and the Western Wall. This was a very emotional time for me when I had the opportunity to leave a note in the Wall for my old friend Steve Elefant and said a prayer for my mother who passed away in April. We were suppose to go through the tunnels beneath the Old City but the reservation was mixed up.  Our tour guide Nathan did a very nice job explaining the history of the first and second temples along with the significance of the Christian and Muslim roles in the Old City.

Tomorrow through Sunday are focused on travel and tourism. Monday, we start up the academic part of the program again with a visit to a hospital and community clinic in Nahariya. I will post my next blog on Sunday and share with you our experiences over the weekend.

Israel trip day 4 - 14 December

We got to experience a number of interesting and important presentations from Yehuda Neumark on Community Oriented Primary Care, Ted Tulchinsky on Changing Concepts and the New Public Health and finally Milka Donchin on Health Promotion in Israel. The most meaningful part for me was the lecture by Dr. Tulchinsky where as part of the new public health, he notes that health system management is a core competency for effective public health particularly in an era of chronic disease, enhanced community health and resource constraints.  His book by the same name was released in its second edition last year.  The afternoon took all us to Bethlehem where we visited the Church of the Nativity.  Traveling in the Palestinian Territorities was an eye-opener for me.

During lunch, we had a lively discussion around a question in which we again sought to compare and contrast the health care delivery systems of both countries. Granted that Israel has but 7.1 million people in a geographic area the size of New Jersey and the United States has over 300 million in a much larger geographic area with a much more heterogeneous population.  That said, in 1995, Israel made the political, social and economic decision to craft a national health plan that provided a basket of services to each and every citizen regardless of religious affiliation. While there are additional details mentioned on Day 2, the question is why Israel and not the United States. The one thing that keeps coming up over and over again is social solidarity which I think about as a pre-condition for social capital.  There is a sense that people care about one another and will sacrifice a little so that everyone has the essentials. I have a hard time imagining people in the United States agreeing to a basic basket of health services that would be paid by individual taxes. The more I listen to people at the Braun School of Public Health as well as regular Israeli's, the more I am convinced I am that legislation alone will not be enough to create and sustain a universal health plan in the US.  What is needed is a change of mind set and perspective that says it is important that we take care of each other and not just maximize our own personal economic and social benefit. How we will get there, I don't know but the journey must begin now.

Israel trip day 3 - 13 December

Another terrific day here in Jerusalem. We started at Hadassah Ein Kerem University Hospital where we arrived a bit early and got to spend some time with the Chagall windows. There was a wonderful narration explaining each of the 12 windows located in the on-hospital synagogue. They absolutely took my breath away. We then moved to the board room where we met Dr. Yuval Weiss, Director of the hospital. Hadassah Hospital was founded in1912 by three American women who were focused on Public Health and women's and children's health issues. Their current building was constructed in 1971 and many of the current med/surg beds will move into their new wing in March 2012. Hadassah serves five roles as a community hospital, tertiary hospital, university teaching hospital, military hospital and research center. Their Ein Karen campus has 775 beds while the Mt. Scopus campus has 320 beds. Their funding was particularly interesting. Revenue from patient care pays for general operations while building, equipment and all research is funded by fundraising and development.

We were taken on a tour of the hospital where we got to see their  new pediatric children's wing. A particularly interesting attribute is that the waiting area and play area can quickly be transformed into an emergency room complete with oxygen, air and suction. Our visit to the Emergency Room showed us a facility that was fully equipped to withstand a direct attach from a chemical, nuclear or biological weapon. This was truly an amazing organization whose existence is due in large part to the generosity of persons around the world.

The morning class took place in the Braun School of Public Health and was conducted by David Chinitz, Professor of Health Policy.  His lecture compared and contrasted the characteristics of the US health care system with those in Europe and Israel from 1990-2010.  Among the many distinctions between these systems of financing and delivery of care, one stood out for me. Dr. Chinitz talked about the theme of social solidarity being a critical attribute in the European and Israeli systems. Social solidarity is about the willingness of a society to consciously do for one another and that the role of government is to assure a basic level of services for everyone even if it means that those more well off have to provide a little bit more. A more complete reference can be found in the Summer 2010 issue of the Journal of Health Politics, Policy and Law.

Our day ended at Yad Vashem, the Holocaust Memorial.  While similar to the US Holocaust Memorial in Washington, DC Yad Vashem is a required stop for all dignitaries visiting Israel. I was moved beyond words and continue to wonder there are so many people who want to continue the work the Hitler and the Third Reich started. I could have spent the entire day going from one exhibit to the next.

Israel trip day 2 - 12 December

Everyone met for a very good breakfast at 7:00 at the hotel then we boarded the van to drive over to Hebrew University's campus at Hadassah Hospital in West Jerusalem. We were met by Professor David Chinitz who provided an introduction to the day's speakers. We led off with a summary of payment and delivery of health services in Israel by Dr. Leon Epstein.  Among the things we took away was the passage in 1994 of the National Health Insurance Law that was based on the principles of "justice, equity and solidarity." The law provides for a number of important attributes:
  • Universal coverage for all citizens of Israel
  • Payment by a progressive health tax paid by individual taxpayers and not employers
  • Standardized basket of health services
  • Capitation to four HMO's or Kaupt Holim (sick fund)
Of the four Kaput Holim, there is one dominant player with over 50% of the market, one with about 24% and the remaining two splitting the difference. As currently structured, Israel consumes about 8.1% of GDP to cover their 7.1 million citizens. Some of the issues confronting the system are:

  • Significant problem with shortages of physicians and nurses
  • Areas of major health inequality
  • The percentage of out of pocket funding for health care continues to rapidly increase
Dr. Ari Israeli, former Director General of the Ministry of Health and current faculty member at Hebrew University was next and he continued with the discussion about the problems associated with adding new medical students in Israel. He pointed out that the basket of services specified in the National Health Law is overly long and complex including specific indicators, conditions and treatments for literally thousands of health care conditions. He also pointed out that almost 100% of every community physician had adopted electronic health records and that hospitals were approaching the 100% level. The two largest sick funds use the same EHR as do 9/26 hospitals in Israel.

Alex Leventhal, former head of Israel's Public Health Ministry and now in charge of international realtions for the Ministry of Health shared his perspective on the fact that Israel is now part of the OECD and is considered to possess one of the best health systems in the world.

Hagai Levine, a new faculty member in the Braun School shared his perspective on the role that environmental health played particularly around a process called a health impact assessment or HIA. The purpose of the HIA is to examine how policy affects the health of a population and the distribution of those effects in the population. Just imagine how different US health care would be were an HIA done prior to the passage of a particular piece of health legislation.

Finally, we were joined by a large group of International MPH students for the final lecture by Schlomo Mor-Yosef, President of the National Institute for Health Policy Research. He led off with an in depth conversation about the after affects of the recently settled Israeli physicians strike (more on that later). As a result of the National Health Insurance law, 0.1% of the tax is dedicated to conduct research, evaluation and policy oriented studies and seminars on the impact of the law and development of the health care system in Israel. The Institute exists as a independent, non-profit research center beholden to no one.

After a long day in the classroom we were escorted up to Mt. Olives, overlooking the Old City from the East. We heard about the creation of the modern state of Israel along with the history of the Old City from biblical times forward.

At the end of the day, Director Manor hosted a reception for her faculty, our students and the 36 or so students in the International MPH. It was a wonderful evening (thanks to Arthur Shorr for being our expert photographer) capped by a short presentation by Director Manor's husband who serves as a senior official in Israel's foreign ministry and is the former ambassador to Sweeden.

Overall a busy but truly memorable day!

Blogging from Israel

From December 11-24, a group of students and other HSML faculty will be in Israel studying their healthcare delivery system. Look for regular updates as we spend time with the faculty and students of the Braun School of Public Health at Hebrew University in Jerusalem.