Sheba, Zeev Rotstein
Sheba director general Zeev Rotstein. Issued an internal memo saying operations on medical tourists could at times be performed in the morning. Photo by Tali Mayer
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Doctors at Sheba Medical Center at Tel Hashomer are performing non-urgent operations on medical tourists during morning work hours, contrary to the recommendations of a Health Ministry panel, documents obtained by Haaretz show.

According to the committee's recommendations, which were accepted by the ministry's management, medical tourists may normally not be treated in the morning, but only during extra work hours in the afternoon.

Nevertheless, Sheba performed dozens of these operations on medical tourists over the last few months.

Among other things, in August the hospital performed a Caesarean section, eye operations, plastic surgery and hand operations, and in total at least 10 operations during the morning.

In the first part of September, four tourists were operated on. All of these activities and others that took place during the morning were defined in official hospital papers as "non-urgent," or elective, operations.

The hospital's income from such operations on tourists is much higher than what it earns from operations on Israelis, as the health maintenance organizations Israelis belong to have agreements that entitle them to discounts on the list prices.

Over the last few years, medical tourism to Israel increased significantly. According to industry estimates, each year 30,000 medical tourists come to Israel and provide the health system with NIS 200 million to NIS 500 million.

According to partial data collected by the Health Ministry, the government hospitals' income soared from NIS 34 million in 2005 to NIS 106 million in 2009 on the back of these tourists.

At Sheba too, according to data that reached Haaretz, in recent years, medical tourism operations have surged.

In 2005, 63 such patients were operated on; this year (as of early September ) there were 310 operations on tourists (out of a total of 30,864 operations ).

A November 2010 Haaretz report exposed flaws in the supervision of the growing activity.

It found that while Israeli patients wait a long time for operations, the medical tourists have short waits, receive personal care, a private room and have the option of choosing top doctors.

The report raised concerns that profit motives would spur hospitals to widen the preference given to medical tourists over Israeli patients.

Scalpels and loopholes

Following the report, the Health Ministry set up a committee to organize the field chaired by Prof. Arnon Afek, the deputy director general of Sheba Medical Center.

In May, the committee submitted its recommendation to the ministry's management, including a recommendation that non-urgent procedures for medical tourists be conducted after regular work hours, "provided that all required resources necessary for performing the activity are on par with the best operating and medical standards, and while ensuring the patient's safety."

However, the committee's recommendations included a qualifier that procedures could be done in the morning provided "this does not affect eligible Israeli citizens' access to those services."

Even before the recommendations were adopted, around two years ago, Sheba had already adopted similar internal regulations. They stipulated "service for tourists seeking elective care will not come at the expense of canceling Israeli patients' appointments."

About a year later, in December 2010, the hospital issued a supplementary directive adopted following a recommendation by the chairman of the medical institution's research fund, Prof. Mordechai Shani.

The directive stated that in any case where a medical tourist is operated on in the morning, an Israeli citizen will be operated on after the normal work hours, "as compensation for the lost hours intended for them in the morning."

In between all this, in May 2010, Sheba Medical Center's director general, Prof. Zeev Rotstein, issued another internal bulletin whereby "it is always possible to schedule a medical tourist for an operation or invasive procedure, in the morning or afternoon, for anything that is urgent or medically justified to do in the morning."

However, the documents Haaretz received indicate that some of the medical tourist operations performed in the mornings were non-urgent.

Sheba responds

In a response to Haaretz, Sheba said operating on medical tourists serves Israelis, since the extra income is earmarked for better services for Israeli patients.

"The claim that a foreign patient is taking the place of an Israeli patient is unfounded," a spokesperson said. "Sheba operates according to clear guidelines. And in the absence of Health Ministry guidelines to formalize the matter, the hospital follows internal guidelines approved by the corporation. According to these procedures, there is nothing preventing procedures for medical tourists in the morning too as an exception, so long as the principle is upheld of not performing an elective procedure at the expense of canceling an Israeli patient's appointment.

"From the beginning of August until September 10, 2011, 2,926 morning operations were performed at Sheba. 41 of them - just 1.4 percent - were performed as exceptions on medical tourists. Nearly all of the tourists' operations were therefore done after regular working hours. Sixteen of the operations were on children, who cannot be left fasting until the afternoon and in 25 cases, both urgent and non-urgent, there was a medical directive for doing a morning operation.

"The common reason for such a directive is the need for a complex procedure requiring a multi-disciplinary team, which works only in the morning. For every operation on a tourist in the morning, an Israeli patient was operated on in the afternoon and financed by the income from medical tourism.

"There is not enough space to list the extent of the critical contribution of income from medical tourism to the hospital's functioning and operation in the gloomy reality of the gradual and dangerous decline of the state of public medicine in Israel. Sheba is one of the only hospitals that reached the end of 2010 with no deficit, thanks in large part to medical tourism."