The case of the basket

Last week, after preliminary discussions in the health basket committee concluded in a relatively calm atmosphere, Deputy Health Minister Yaakov Litzman kicked up a storm when he announced his intention to divert some NIS 65 million of the basket's budget to dental care for children. The final discussions on the move being held this week, during which it will be decided which medicines and treatments will be available to the health system in 2010, will no doubt take place under heavy volleys of criticism.

The health basket is the annually updated list of basic medications and treatments that are available for free or at a subsidized price. The update is made in accordance with budgetary constraints and on the basis of the committee's recommendations. Litzman's announcement preceded the recommendations of the health basket committee, thus effectively bypassing it.

In previous years, the committee chairmen would raise their voices when the government attempted to cut the allocation for the basket, but this year all is silent. Perhaps that can be attributed to the fact that the committee is now headed by Prof. Rafael Beyar, the director general of the Rambam Medical Center in Haifa, a government hospital that is under the authority of the deputy minister. Dr. Bracha Zisser, who has been a committee member for the past three years and is director of the Bone Marrow Donor Registry of Ezer Mizion, is one of the few who openly criticized the manner in which it was decided to take the millions out of the sphere of the committee's judgment. "This is a dangerous precedent," she said. "The committee members are respected people from the health system who spend many long hours, on a voluntary basis, discussing the composition of the health basket. The feeling that we were not consulted leaves a bad taste in the mouth."

The silence emanating from the committee's meeting hall is echoed in the offices of the Israel Medical Association, which has twice come into conflict with Litzman in the past few weeks - following his intervention in establishing the death of a baby girl who had already been declared brain dead at the Schneider Children's Hospital, and over his decision to separate men and women in Jerusalem psychiatric hospitals.

"We don't hear opposition from the members of the health basket committee because they are afraid," says Dr. Leonid Idelman, who chairs the IMA. "Employees of the Health Ministry are also in the grip of terror, and no criticism of the move has been heard from them. This is the silence of the lambs. The money was taken out of the health basket in a political maneuver in the wee hours of the morning. This is blatant political interference, without discussion and ignoring the professional decisions of the health basket committee. The committee has been left devoid of content."

Prof. Yehoshua Shemer who was a member of the committee for a decade, heading it during its first three years of operation, is of the opinion that "it is wrong for the committee to be politicized. It has to decide on grading the medications according to the budget that has been set."

Is it forbidden for it to express criticism?

"If the committee feels that the absence of additional resources from the basket will be the cause of injustice and discrimination, for instance, if the reduction in funds will create a clear lack of equality, it must make its position known and state explicitly if it is unable to carry out its function," he says.

Shemer, who is now chairman of the Assuta chain of private hospitals and a lecturer on medical administration at Tel Aviv University, stresses that "introducing dental care to the national health basket is the right direction." However, he adds that "the decision to transfer money for dental care is a sharp change in the government's policy and it has medical implications." He says: "The system in Israel must be changed so that the resources and the criteria for choice will be clear."

By a single vote

The committee does not have a set doctrine for choosing the medications that go into the basket. Its 17 committee members were required this year to choose between 420 medicines and new technologies whose total value would be more than NIS 1.5 billion that were brought up for their approval, while the budget at their disposal was a mere NIS 350 million. To date, the committee has held 13 sessions. Last week it arranged the list of medicines in order of priority, and these were to compete for a place on the final list during the concluding discussions, which began yesterday.

The highest priority was given to a series of psychiatric medicines, including Cipralex, for the treatment of depression, anxiety, and obsessive-compulsive behavior; a new kind of treatment for wounds that are difficult to heal; a medication for retinal atrophy in the aged; new medicines for diabetics and people with Parkinson's disease; new treatments for heart disease and cancer; and Revlimid, for treating multiple myeloma, which last year was defined as a life-saving treatment but was excluded from the basket by a single vote.

A lower order of priority was granted to medications for the treatment of erectile dysfunction (Viagra, Cialis and Levitra), medications for obesity (Xenical, Reductil), treatments for stopping smoking, new treatments for light or moderate Alzheimer's Disease, and a medication for epilepsy. On an even lower order of priority are a drug to treat anemia among persons with kidney insuffiency, treatments for eye infections, and a new treatment for sleep disorders connected with restless legs syndrome.

"This is not a binding list, and the committee will also consider during the concluding discussions other medications that are not at the top of the list of priorities," said a Health Ministry source. However, the distribution of the list to the committee members and its publication have already led to pressure on the committee members in the past few days - letters, appeals from Knesset members and medical institutions, and threats of court appeals, as well as planned demonstrations outside the hall where the committee is convening this week.

A spokesman for the health basket committee said: "The committee members were appointed to recommend to the government which new technologies should be included in the basket in the framework of the budget that the government places at their disposal .... They have no say in deciding on the budget and they were also not party to the government's decision about its scope. It is therefore not fitting to make them a party to the discussion about the government's latest decision on the subject. The members of the health basket committee are not authorized to intervene in political decisions of the government; their task is to act according to professional, public and ethical considerations, cut off from any political influence."