Clalit Health Services, the country’s largest HMO, has asked the Health Ministry to allow it to continue to offer private psychological counseling as part of its supplementary health coverage, but the ministry has refused.
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When the mental health reforms went into effect half a year ago, the HMOs were told to stop covering private psychological consultations and to focus on developing services to be offered to all members of the HMO.
Under those regulations, HMO members are eligible for state-funded treatment when there is a diagnosis or suspected diagnosis of a psychiatric condition. The diagnosis is registered in the HMO’s database and in some cases in the patient’s medical records as well. Clalit contends that many people want to see a psychologist for so-called milder issues — such as a marital breakup, loss of a loved one or employment difficulties — do not meet the criteria for treatment under the new regulations.
Before the reform went into effect, Clalit offered members who had supplementary insurance, known as Clalit Mushlam, private psychological consultations for 160 shekels ($41) a session. This was provided as a separate service and the meetings were not recorded in the company’s database or the patients’ personal medical records. Members could choose from some 600 psychologists who worked with Clalit, with the policy covering 30 sessions per year, and up to 60 sessions altogether.
When the reform went into effect in July, Clalit was allowed to extend the service by a few months to allow patients to gradually complete their treatment. The service is meant to stop next month. It is estimated that tens of thousands of treatment sessions took place in this framework every year.
Now the HMOs must offer psychological treatment in two tracks — one that’s free, and one that has a co-payment. Neither is optimal for many patients.
For the free track, the patient must be referred for treatment by his primary care physician and must then undergo a diagnostic session to determine if he meets the criteria for psychological treatment. If he meets the criteria, a psychiatric diagnosis is noted in his medical records, and he is permitted to begin treatment, but he cannot choose his therapist. The HMO oversees the treatment and can decide at any point that the therapy has run its course and must be terminated.
Under the co-payment option, which costs 132 shekels a session, the patient can independently approach any therapist that works with the HMO without needing a medical referral. Here, too, he undergoes a diagnostic session, and the diagnosis is reported to the HMO, which can ratify or reject it, with the result recorded in the patient’s medical records. This track also allows the HMO to stop treatment at any time.
The Health Ministry denied Clalit’s request to continue its private service out of concern that the existence of a private track, particularly so early in the reform’s implementation, would lead to the HMO shunting patients, even borderline ones, from the public health program (in which billions of shekels is being invested) to the private track. As a result, as has happened in many other areas of the health system, mental health outlays will end up being paid mostly by the patient.
However, many experts believe the criteria for publicly funded treatment are too narrow, and the halting of the relatively inexpensive private track creates a void for people seeking treatment that’s affordable and discreet. In October Haaretz reported on a new independent initiative by a group of psychologists and social workers called Tene (a Hebrew acronym for “accessible psychological treatment.”) The group offers therapy under terms similar to what had been offered by the HMO’s supplementary insurance schemes.
The ministry confirmed that Clalit had made the request to continue its service, but was refused for the following reasons:
“The line that divides those conditions included in the basket and those described in the request is not firm. When an alternative exists in the supplementary health plan, it’s hard to believe that there will be mechanisms for screening the requests. The result is liable to be a diversion from the public basket to the supplementary plan... . Leaving an alternative via supplementary insurance will intensify the redirection to private therapists even more.
“In this case, we were not convinced that the way to prevent diversions from public to private care lies with the supplementary health plans, which is why we did not see a reason to restore this coverage.”