In the registry of medicines distributed by the health maintenance organizations (HMO) to all the general practitioners, there is a special notation that gives the price of each of the 200 medications on the list. One blue dot signifies an inexpensive medication "with an economic advantage," and the number of dots increases in accordance with the price of the medication, so that five dots indicate a "very expensive" medicine. The doctors of the HMO are requested to pay attention to this notation and to offer patients medications that are included in the health basket - the list of medications subsidized by the HMOs - instead of medications that are not in the health basket and which the patient can receive within the framework of the HMO's supplemental health insurance scheme.

This is just one manifestation of the continued pressure on doctors by the four HMOs to save on medications and treatments. In the first study of its kind, which examined the opinions of doctors for the Society for Patients' Rights in Israel, it was found that 40 percent of the doctors reported experiencing pressure from the HMOs not to prescribe costly treatments or tests even if they are included in the national health basket.

It emerges that the pressure pays off for the HMOs: About 30 percent of the doctors reported that they prescribe few expensive treatments and tests even if they are included in the basket. The study was conducted in 2000 by researchers and doctors from the Health Ministry and from faculty of health studies at Ben-Gurion University of the Negev in Be'er Sheva, and included a survey of 900 doctors. The study found that the most pressure is applied upon the doctors of the Leumit HMO, and the least pressure upon the doctors of Clalit, Meuhedet and Maccabi in descending order.

The study raises the suspicion that the general practitioners, or family doctors as they are known, do not always work only with the patient's benefit in mind, but are guided also by economic motives that are connected to the interests of the HMOs. Moreover, many patients are unable to afford the self-participation charged by the HMOs and thus receive cheap and less effective medications for their conditions or do not receive all the medications they need.

It was also found that the pressure on the HMOs to save on the costs of medical treatment and the increase in the rate of self-participation payments for health services lead patients to put off getting medical care even in urgent cases of severe illness. These two factors also lead general practitioners to refer fewer patients to specialists even in cases when they themselves think that this is essential for their health.

The Society for Patients Rights and the researchers, among them Professor Dina Pilpel, Dr. Michael Dor and Anat Shemesh, raise the possibility that the continued pressure by the HMOs on the doctors could lead to additional damage to the health of the sectors that are vulnerable in any case, including the elderly, people with low incomes, children in distress and the chronically ill. The researchers also explain that continued pressure on the doctors by the HMOs could also lead to damage in the trust placed by patients in their doctors, trust that is of great importance in the healing process.

The major problem is that the pressure on the doctors by the HMOs is applied with almost no public supervision and control. The Health Ministry, which has a public and legal obligation to protect the public, is the body that is supposed to supervise the financial and medical administration of the HMOs and the work of the doctors employed by them, but it has failed in this task year after year. Thus, the HMOs, which are funded by the health tax paid by citizens and by other government budgets, operate to a large extent as independent kingdoms both financially and medically.

Not only is the Health Ministry not succeeding in neutralizing or reducing the pressures applied by the HMOs upon the doctors, it has also failed for years to force the HMOs to employ only specialists at the HMO clinics, it conducts almost no supervision of the quality of medical care at the HMOs, and it has not succeeded in compelling the HMOs to report errors and hitches in good time. Nor has the ministry managed to monitor the problematic influence, which at times verges on something resembling bribery, of pharmaceutical companies on the HMOs' senior physicians.

Concrete evidence of the problem can be found among doctors who have been working for the HMOs for decades, who relate that at their clinics the Health Ministry has never monitored the medical care, nor the influence of pressure by the HMOs to prescribe few expensive medications and tests. In this matter, it all depends on the doctor's conscience and his ability to withstand pressure from his superiors.