What should health insurance cover? A comparison of Israeli and US approaches to benefit design under national health reform.

What health insurance should cover and pay for represents one of the most complex questions in national health policy. Israel shares with the US reliance on a regulated insurance market and we compare the approaches of the two countries regarding determining health benefits. Based on review and analysis of literature, laws and policy in the United States and Israel. The Israeli experience consists of selection of a starting point for defining coverage; calculating the expected cost of covered benefits; and creating a mechanism for updating covered benefits within a defined budget. In implementing the Affordable Care Act, the US rejected a comprehensive and detailed approach to essential health benefits. Instead, federal regulators established broadly worded minimum standards that can be supplemented through more stringent state laws and insurer discretion. Notwithstanding differences between the two systems, the elements of the Israeli approach to coverage, which has stood the test of time, may provide a basis for the United States as it renews its health reform debate and considers delegating decisions about coverage to the states. Israel can learn to emulate the more forceful regulation of supplemental and private insurance that characterizes health policy in the United States.

Revealed Opportunism: How Physicians "Game" Prior Authorization Protocols Until They Are Rescinded.

BACKGROUND: Prior authorization (PA) is a management technique that has been implemented to manage the utilization of expensive drugs and to improve the precision of drug prescribing. PA requirements may incentivize physicians to document adverse effects, sometimes falsely, to meet the eligibility requirements. OBJECTIVES: To identify documentation patterns that may facilitate the quantitative analysis of physician gaming and underreporting behaviors associated with the prescribing of angiotensin-converting enzyme (ACE) inhibitors in a primary care setting, and to evaluate the effect of a PA requirement on the documentation of adverse events as a way to receive approval for more expensive drugs. METHODS: We conducted a retrospective analysis of physician electronic reporting of adverse effects associated with ACE inhibitors before and after the revocation of a PA requirement for angiotensin receptor blockers (ARBs) between 2004 and 2013 in an Israeli HMO. The data were stratified into 2 groups-patients who were newly prescribed an ACE inhibitor or those who had been receiving an ACE inhibitor for at least 1 year. The annual rate of adverse events related to ACE inhibitors (ie, the number of reported cases of adverse events per 1000 patients receiving an ACE inhibitor) was calculated from data captured on the date the events were first reported for the 5 years before and 5 years after the revocation of the PA constraint. RESULTS: A total of 151,845 patients treated with ACE inhibitors were identified during the 10-year study period. The reported adverse events among patients newly treated with an ACE inhibitor peaked in 2007 to 10 cases per 1000 patients, and gradually decreased to 4.6 cases in 2012, which was the year after the PA requirements for the ARBs valsartan and candesartan were rescinded by the HMO. Among previously treated patients, adverse events rates decreased from a high of 5.4 per 1000 patients in 2008 to 1.9 in 1000 patients in 2012, the year after the PA restraints for the last 2 ARBs with a requirement were revoked. CONCLUSIONS: The PA requirement influenced physician propensity for reporting drug side effects, possibly encouraging reporting inaccuracies. The decline in the incidence of reported side effects, in both subpopulations in the study, with the revocation of the PA requirement confirms our hypothesis that physicians were incentivized to document the side effects related to ACE inhibitors to meet the eligibility requirements for the approval of an ARB by the HMO.

Governance: Blending Bureaucratic Rules with Day to Day Operational Realities Comment on "Governance, Government, and the Search for New Provider Models".

Richard Saltman and Antonio Duran take up the challenging issue of governance in their article "Governance, Government and the Search for New Provider Models," and use two case studies of health policy changes in Sweden and Spain to shed light on the subject. In this commentary, I seek to link their conceptualization of governance, especially its interrelated roles at the macro, meso, and micro levels of health systems, with the case studies on which they report. While the case studies focus on the shifts in governance between the macro and meso levels and their impacts on achievement of desired policy outcomes, they also highlight the need to better integrate the dynamics of day to day operations within micro organizations into the overall governance picture.

Saltman on solidarity.

Richard Saltman suggests that solidarity, a cherished notion at the heart of West European health care systems is being reconsidered in the light of today's austere economic conditions. Solidarity, he argues, has always been a flexible moral guideline, one that allows for policy responses, such as limitations on health benefits or increased out of pocket payments, that challenging fiscal conditions are said to demand. Here we consider what the basic elements in solidarity - universality, redistribution, and uniformity-- mean in health as compared to other social policy realms such as pensions. Traditionally, the commitment to solidarity said little about the contents of services, but the latter is perhaps subject to increasing scrutiny under the health policy microscope. Saltman is right to emphasize the conceptual and cross-national flexibility of solidarity, but the notion retains a solid and durable core that continues to give valuable direction to policymakers in search of acceptable strategies and structures for decision making.

On Health Policy and Management (HPAM): mind the theory-policy-practice gap.

We argue that the field of Health Policy and Management (HPAM) ought to confront the gap between theory, policy, and practice. Although there are perennial efforts to reform healthcare systems, the conceptual barriers are considerable and reflect the theory-policy-practice gap. We highlight four dimensions of the gap: 1) the dominance of microeconomic thinking in health policy analysis and design; 2) the lack of learning from management theory and comparative case studies; 3) the separation of HPAM from the rank and file of healthcare; and 4) the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking the field of HPAM by embracing broader perspectives, e.g. ethics, urban health, systems analysis and cross-national analyses of healthcare systems.

Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan.

AIMS: To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). METHODS: HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin-converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. RESULTS: The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1-28.4) of patients receiving losartan met the criteria for receiving ARBs. CONCLUSIONS: Rescinding the PA requirement for this drug alone was an effective limited-duration strategy for reduction of prescription of relatively expensive drugs.

Empiric treatment of uncomplicated urinary tract infection with fluoroquinolones in older women in Israel: another lost treatment option?

BACKGROUND: Current guidelines for the treatment of uncomplicated urinary tract infection (UTI) in women recommend empiric therapy with antibiotics for which local resistance rates do not exceed 10-20%. We hypothesized that resistance rates of Escherichia coli to fluoroquinolones may have surpassed this level in older women in the Israeli community setting. OBJECTIVES: To identify age groups of women in which fluoroquinolones may no longer be appropriate for empiric treatment of UTI. METHODS: Resistance rates for ofloxacin were calculated for all cases of uncomplicated UTI diagnosed during the first 5 months of 2005 in a managed care organization (MCO) in Israel, in community-dwelling women aged 41-75 years. The women were without risk factors for fluoroquinolone resistance. Uncomplicated UTI was diagnosed with a urine culture positive for E. coli. The data set was stratified for age, using 5 year intervals, and stratum-specific resistance rates (% and 95% CI) were calculated. These data were analyzed to identify age groups in which resistance rates have surpassed 10%. RESULTS: The data from 1291 urine cultures were included. The crude resistance rate to ofloxacin was 8.7% (95% CI 7.4 to 10.2). Resistance was lowest among the youngest (aged 41-50 y) women (3.2%; 95% CI 1.11 to 5.18), approached 10% in women aged 51-55 years (7.1%; 95% CI 3.4 to 10.9), and reached 19.86% (95% CI 13.2 to 26.5) among the oldest women (aged 56-75 y). CONCLUSIONS: Physicians who opt to treat UTI in postmenopausal women empirically should consider prescribing drugs other than fluoroquinolones. Concomitant longitudinal surveillance of both antibiotic utilization patterns and uropathogen resistance rates should become routine practice in this managed-care organization.

Suboptimal pneumococcal pneumonia vaccination rates among patients at risk in a managed care organization in Israel.

OBJECTIVE: Pneumococcal pneumonia is a vaccine-preventable disease that poses a significant threat to immunocompromised patients. Vaccination rates tend to be low despite recommendations for vaccination in several groups of high-risk patients including any person aged 65 years or older. The purpose of this study was to (a) evaluate the vaccination rates among high-risk patients in a managed care setting in Israel and (b) gain a better understanding of the factors associated with suboptimal use of this vaccine. METHODS: Data were extracted from the electronic medical records of the managed care organization for patients with dates of service from January 2000 to December 2004 for whom the vaccine is recommended. Patients were identified via diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Vaccination rates were calculated for patients in each disease category. These high-risk patients were contacted to participate in a telephone survey to evaluate the variance in knowledge and awareness levels of the disease between the vaccinated and unvaccinated patients. RESULTS: A total of 672 patients were identified by the ICD-9-CM codes; 140 (20.8%) had been vaccinated and 532 (79.2%) were unvaccinated. Vaccination rates were highest among patients with solid organ transplants (33.3%), followed by nephrotic syndrome (29.4%), bone marrow transplants (10.2%), and human immunodeficiency virus (HIV, 9%), for an overall rate of 20.8%. Of these patients, survey responses were obtained from 364 (54.2%). Respondents who were unvaccinated tended to be less well informed about which patient populations are at risk for the disease and the availability of the vaccine. CONCLUSION: The pneumococcal vaccination rate among immunocompromised patients in this managed care organization was found to be inadequate, at just 20.8% of the target population. Approaches based on direct contact with the patient, such as by a case manager, may be more successful in the future.

When gatekeepers meet the sentinel: the impact of a prior authorization requirement for cefuroxime on the prescribing behaviour of community-based physicians.

AIMS: Prior authorization (PA), the requirement of physicians to obtain pre-approval as a prerequisite for coverage, may decrease drug utilization via a 'sentinel effect', a decrease in utilization caused by external review of prescribing. The purpose of this study was to assess the affect a PA restriction had on the utilization patterns of cefuroxime tablets in a managed care organization (MCO) in Israel. METHODS: Physician prescribing patterns were evaluated by conducting a retrospective drug utilization analysis. Data were derived from the electronic patient records of the MCO studied. All prescriptions for solid state antibiotics for patients diagnosed with an infectious disease written during three parallel 3-month segments, before, during and after a PA restriction for cefuroxime was enforced, were included. Frequency and proportion of antibiotic prescriptions for cefuroxime tablets, distribution of infectious diseases treated with cefuroxime, and the request rejection rate when PA was required were calculated. RESULTS: Prescriptions for cefuroxime declined from 5538 prescriptions (8.0% of eligible antibiotic prescriptions, 95% CI 7.8, 8.2) in the initial period to 1036 (1.2%, 95% CI 1.1, 1.3) during the PA period, rising to 3961 (4.3%, 95% CI 4.2, 4.4) in the post-PA period. Changes in the distribution of diseases treated with cefuroxime during the PA stage tended to regress after revocation to those observed in the pre-PA period. The rejection rate was found to be 8.5% (95% CI=6.9, 10.1). CONCLUSIONS: The implementation of a prior authorization requirement for cefuroxime tablets markedly reduced the use of this drug, probably due to a 'sentinel effect'.

Economic evaluation of an updated guideline for the empiric treatment of uncomplicated urinary tract infection in women.

BACKGROUND: Until recently trimethoprim-sulfamethoxazole was the drug recommended in the Leumit Health Fund for the empiric treatment of uncomplicated urinary tract infection in women. However, due to increased uropathogen resistance to this drug, the fund has designated nitrofurantoin as its new drug of choice. OBJECTIVES: To evaluate the potential economic impact of implementing this new pharmaco-policy. METHODS: Using data derived from the electronic patient records of the Leumit Health Fund, we identified all non-recurrent cases of women aged 18-49 with a diagnosis of acute cystitis or UTI without risk factors for complicated UTI and empirically treated with antibiotics throughout 2003. The final sample comprised 5,489 physician-patient encounters. The proportion of cases treated with each individual drug was calculated, and the excess expenditure due to non-adherence to the new guideline from the perspective of the health fund was evaluated using 5 days of therapy with nitrofurantoin as the reference treatment. RESULTS: Ofloxacin was the most frequently prescribed drug (30.24%), followed by TMP-SMX (22.43%), cephalexin (15.08%), and nitrofurantoin (12.59%). The observed net aggregate drug expenditure was 2.3 times greater than expected had all cases been treated with nitrofurantoin according to the guideline duration of 5 days. The cost of treatment in 53% of the cases exceeded the expected cost of the guideline therapy. CONCLUSIONS: Successful implementation of the new drug will likely improve quality of care and reduce costs to the health fund.

Physician adherence to recommendations for duration of empiric antibiotic treatment for uncomplicated urinary tract infection in women: a national drug utilization analysis.

BACKGROUND: Current guidelines for the empiric treatment of uncomplicated urinary tract infection in women recommend that first-line trimethoprim-sulfamethoxazole (TMP-SMX) or ofloxacin be given for 3 days and nitrofurantoin for 5 days. Increasing the duration of treatment raises costs, and perhaps, the incidence of adverse effects, without contributing to effectiveness. The aim of this study was to investigate physician adherence to these recommendations. METHODS: The electronic patients record system of a nationwide health management organization in Israel was reviewed for all primary care visits by adult women treated empirically for cystitis or urinary tract infection from January 2001 to June 2002 (n = 7738 patient-physician encounters). The proportion of cases treated according to the guidelines, with regard to duration, was calculated for each drug used. RESULTS: Rate of adherence was 3.36% for cases of TMP-SMX treatment (95%CI: 2.56%, 4.15%), 22.23% for nitrofurantoin (95%CI: 19.81%, 24.65%) and 4.08% for ofloxacin (95%CI: 2.88%, 5.28%). The crude rate of adherence for all cases of treatment with these drugs was 8.67% (95%CI: 7.82%, 9.52%). CONCLUSIONS: The high rate of nonadherence observed (91.33%) indicate a need for a remedial education program for physicians to improve empiric treatment of urinary tract infection in women. Since this issue is of global importance, we believe our evaluation can serve as model for other settings and countries.

Urinary tract infection in women--physician's preferences for treatment and adherence to guidelines: a national drug utilization study in a managed care setting.

BACKGROUND: The treatment of urinary tract infection (UTI), the most common bacterial infection in most Western countries, is a global clinical and economic issue. Trimethoprim-sulfamethoxazole (TMP-SMX) and nitrofurantoin are the two drugs currently recommended in clinical guidelines in Israel for uncomplicated UTI in women. OBJECTIVES: This study evaluates physician preferences for treatment and adherence to guidelines. METHOD: Data were derived from the electronic records of Leumit Health Fund, one of four health management organizations in Israel. Non-pregnant women aged 18-75 years with a diagnosis of acute cystitis or UTI without risk factors for complicated UTI who were empirically treated with antibiotics from January 2001 to June 2002 were identified. The final sample comprised 7738 physician-patient encounters. Physician prescription behavior was analyzed by evaluating the proportion of treatments with each individual drug. A binary regression model was implemented to identify factors associated with suboptimal adherence to the guidelines. RESULTS: TMP-SMX was the most frequently prescribed drug (25.81%), followed by nitrofurantoin (14.71%), for a 40.52% rate of adherence to the guidelines [95% confidence interval (CI)=39.42, 41.61]. Drugs from the fluoroquinolone family were prescribed in 22.82% of cases. Prescription behavior was also influenced by non-clinical, non-pharmacological factors, such as physician specialty, geographic setting and patient age. CONCLUSIONS: The majority of cases of UTI in the present study were not treated according to the current guidelines. Fluoroquinolones, though not recommended and relatively costly, were prescribed extensively. These results highlight the necessity for a remedial education program within the health care system designed to improve adherence to the guidelines for the treatment of UTI in women. As this issue is of global importance, this evaluation may serve as a model for similar studies in other settings or countries.

[Updating the basket of health services].

The process by which services are added to Israel's basic basket of health services constitutes a unique effort to tackle the most difficult of ethical issues. In some years, since 1997, the Israeli government allocated an increment of about 1% to the national health budget for the purpose of expanding the basic basket of health services provided under national health insurance. A public committee has been created for this purpose of deciding which of hundreds of potential entrants, should be added within the above budget constraint. The committee integrates available scientific evidence on effectiveness with social values to come up with a ranking. The process has attracted a great deal of public attention, most notably in the printed media, which usually focuses on the plight of specific individuals whose "desired drug" has not been added to the basket. In addition, the courts have, on occasion, intervened to reverse decisions of the committee in the contexts of suits brought by individuals seeking coverage for a treatment not currently included in the basket. Thus, Israel's brave attempt to cope with the necessity of health care rationing needs to be fine-tuned in terms of the information provided to the public about the process and the balance of scientific, economic, judicial and political inputs into the process.