In January 2009, the Health Ministry launched an advertising campaign urging senior citizens who underwent serious operations to demand that their health maintenance organization send them to rehabilitation, as required by law, and to complain if it refused.
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The timing was not coincidental. The then-health minister, Yacov Ben Yizri, was from the now-defunct Pensioners Party, and he commissioned a study which found that many elderly patients were not being sent for rehabilitation. Instead, the HMOs preferred to put them in long-term hospital care - because while the HMOs must fund rehabilitation, the state pays for long-term geriatric hospitalization.
But a Haaretz investigation has found that the biggest impediment to geriatric rehabilitation is the shortage of beds in rehab hospitals - and the ministry itself is preventing private institutions from adding beds that would ease this shortfall.
It is currently barring the use of dozens of beds that already exist in a private facility in Nesher run by the Maccabi HMO, even though it is one of Israel's most advanced geriatric rehabilitation facilities. It has also prevented a private facility in Tiberias from adding rehab beds, and has reversed an earlier decision to approve a new private geriatric facility in the north - an issue now before the High Court of Justice.
The ministry's own data, published here for the first time, leaves no doubt about the magnitude of the shortage: Israel currently has 900 geriatric rehabilitation beds, which is 1,200 less than the ministry's lowest estimate for what is needed. Consequently, a 2009 survey of 26 general hospitals found that only 60 percent of those who need it benefit from inpatient rehabilitation. Another 13 percent get outpatient rehabilitation, and 27 percent get no rehabilitative treatment at all.
Moreover, many of those who do get inpatient rehabilitation are released too early: 28 percent of stroke patients, for instance, were released before the end of the 25-day minimum specified by law.
Nevertheless, the ministry refuses to allow the use of beds in private facilities. At Maccabi's facility in Nesher, for instance, half the 36 beds in one rehab ward stand empty; the other ward was completely empty until Maccabi recently gave in and redesignated it as being for short-term recuperation after serious operations.
The ministry says it is doing this for the public good: Before approving beds in private or semi-private facilities, it wants to make sure the public hospitals have enough. But many in both the health system and the Finance Ministry say the real problem is a conflict of interests: The ministry is looking out for government hospitals' financial well-being at the expense of patients' welfare.
Currently, government hospitals charge the HMOs about 50 percent more for a day of rehabilitation than private facilities do - NIS 850-950 compared to NIS 550-650. Thus their revenues would suffer if competition forced them to lower their rates.
Not far from Maccabi's Nesher facility, for instance, lies the state-owned Fliman rehab hospital. This facility, located on Mount Carmel, has 144 of the north's 170 rehabilitation beds, and the HMOs are pressing it to lower its prices. A few months ago, the Clalit HMO - which insures 80 percent of the country's elderly - even decided to stop sending patients to Fliman because of its high rates (NIS 850-950 a day ), noting that private facilities give quality care for much less money. As a result, Fliman's occupancy dropped from 150 to 70 patients a month.
The ministry recently forced Clalit to give in - and even to raise its payments by 10 percent - by refusing to let it sign new agreements with government hospitals unless it also signed agreements with state-owned rehab hospitals like Fliman. But if private facilities were providing competition, Fliman might have no choice but to lower its rates.
Another financial conflict of interests stems from the 2010 Economic Arrangements Law, which sought to correct a long-standing distortion: Since regular hospitalization rates were lower than geriatric rehabilitation rates, the HMOs often left elderly patients in regular hospitals rather than sending them to rehab facilities. The law therefore stated that after the first month, if a patient approved for transfer to rehabilitation was not transferred in three days, the HMOs would have to pay a much higher rate.
During the debate on that law, the ministry pledged to ensure that enough rehab beds were available to enable the HMOs to comply. But since it hasn't, HMOs must now keep patients in regular hospitals and pay the higher rate - thereby enriching the state-owned hospitals. That in turn encourages the HMOs to refer patients instead to outpatient rehabilitation.
Some in the health system also cite a third reason: Tel Aviv's state-owned Ichilov Hospital has a long-running feud with Maccabi's private hospital in the city, Assouta, and some say Ichilov's former deputy director, Prof. Roni Gamzu, carried this feud with him when he became the ministry's director general. But the ministry scoffs at this claim. Indeed, Maccabi isn't the only private facility in the north to suffer from its policy.
In January 2010, the ministry's then-director general, Eitan Hai-Am, agreed to let the Naot Tveria facility in Tiberias add 18 geriatric rehabilitation beds. But the head of the ministry's northern district objected, saying the beds should instead be added to the city's state-owned Poriya Hospital, so the ministry agreed to reconsider.
In February 2011, the ministry's projects committee reapproved the beds for Naot Tveria. But a few days later, Gamzu - who had since replaced Hai-Am - overturned that decision and ordered the beds added to Poriya. "The first priority is opening beds in public hospitals," he wrote.
But so far, no new beds have materialized at Poriya.
Maccabi, for its part, asked the ministry to approve 72 rehab beds in its Nesher facility back in December 2007, but the ministry refused. After Maccabi asked it to reconsider, it approved 18 beds - a quarter of what Maccabi requested - in October 2009.
Maccabi nevertheless prepared 72 beds, saying it had been told the ministry would approve the remainder at a subsequent hearing. But in August 2010, the request was "temporarily" rejected again.
In January 2011, Deputy Health Minister Yaakov Litzman toured the facility and promised to approve the beds; the treasury also urged the ministry to do so. But in April 2011, the request was once again turned down.
Meanwhile, Maccabi is losing NIS 54,000 a day because of the empty beds - a loss that endangers not just that facility, but its entire chain of eight hospitals, one rehab hospital and four assisted-living facilities.
The ministry's official reason for refusing is that the beds are needed further north, not near Haifa. But without those beds, patients in the north must often travel much further, to hospitals in the center of the country. As a result, those hospitals' rehab wards are overcrowded, often operating at 150 percent capacity, and have waiting lists to boot.
Yochanan Steseman, a former National Insurance Institute director general who now heads a special ministry committee to plan a national geriatric system, says this is a case of penny wise, pound foolish. As people age, their physical capabilities often deteriorate, even if they don't have any special medical problems. Rehab can restore their ability to function and keep them from being bedridden, he said, and "that has great importance, from both the medical and the economic standpoint."
Meanwhile, the biggest financial beneficiaries of the ministry's policy are the HMOs. In the absence of enough rehab beds, they can continue sending patients to long-term hospitalization instead. And since the state pays for that, they save about NIS 700 per day per patient. The state comptroller, Micha Lindenstrauss, complained about this practice back in 2008; this year, he plans to revisit the subject, this time focusing on the ministry's behavior.
The ministry insisted that its most recent surveys show the percentage of elderly patients getting rehabilitative care has risen. It also said it is working on the problem, having recently approved 18 beds in Poriya and 20 in Afula's Haemek Hospital.
As for the spat with Clalit over Fliman, it said the lower prices the HMO seeks "do not allow the provision of reasonable service. Approval was not given to other facilities to prevent increased competition among the region's hospitals that might increase the HMOs' pressure for higher discounts on geriatric hospitalization rates."