Lost in the High-cost Maze of Long-term Healthcare

Relegated to system's forgotten backyard, prolonged medical treatment can easily bankrupt a family.

Ronny Linder
Ronny Linder
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Ronny Linder
Ronny Linder

Nava's husband was young when he became seriously ill. His condition was debilitating, and his body became severely disabled. Watching the man they loved suffer, Nava and her husband's family were devastated, not least by the exorbitant cost of care.

"I realized very quickly that the cost of our insurance co-payment was so high that I might as well pay to have two foreign workers care for him at home," Nava says. "So that is what I did."

Nava's husband's condition continued to deteriorate. Today, he is in a nursing home, and Nava has exhausted all her resources. "I had to empty my savings to care for my husband," she says. "I am 58 years old and have no money left for retirement."

Hannah, a Jerusalem resident, had a similar encounter with sky-high family medical expenses. When her husband was incapacitated by illness, she had no choice but to tap into her small pension and retirement fund.

Because costs are determined by the Health Ministry on a sliding scale based on means, both her finances and those of her children were taken into account. In the end, her family was required to pay NIS 1,200 per month to cover the costs of her husband's hospitalization.

Irena, who was 61 when her father died, also found herself a victim of the health care system. In her father's final weeks, Irena found herself shuffling from one authority to another, trying just to find him a nursing home where he could live out the last days of his life in comfort. But each office, she says, tried to direct her elsewhere.

'Bureaucratic torture'

"For three months, I was running back and forth, from the Health Ministry to our social worker and then back again, when I should have been caring for my father," she says. "To this day, I can't understand why, when I was already suffering from my own father's illness, I had to take this bureaucratic torture."

These maddening encounters with the local health care system have apparently become the norm; the country is filled with families whose savings were ravaged by the cost of critical nursing care, and who lost precious time because of it.

A coalition called the Public Network for the Advancement of Healthy Equity in Israel has documented the experiences of Nava, Hannah and Irena and is pushing for the state to subsidize both inpatient and outpatient nursing. Patient care organizations, civil rights groups and pensioners have also joined the movement.

Nursing care, they say, is akin to the medical system's neglected backyard. It lies there, overgrown and ignored, until that critical moment when one of us needs it - and nearly all of us one day will.

There are two types of nursing: One is provided under the auspices of nursing homes and hospitals, and the other comes in the form of in-home care. Yet both branches are beleaguered by a complex, overly bureaucratic system, a tangled mess of authorities with no clear lines of communication, and, of course, the looming economic boulder of cost, which crushes so many families.

In 70% of the cases of inpatient nursing care, public funding covers a portion of the costs. But even in these instances, patients are often still responsible for a chunk of the bill. Co-pays alone can range from NIS 2,350 to NIS 9,000 per month. The size of the deductible varies according to the incomes of the patients' children, and sometimes even their daughters- and sons-in-law.

For the 30% of patients who are not eligible for public funding, hospitalization can run them between NIS 12,000 and NIS 15,000 a month.

For patients who require in-home care, assistance is more limited. Some 55% of these patients receive 9.75 hours of nursing care per week, and 25% receive 16 hours a week. The final 20% are considered "completely dependent" on care, yet they only receive, on average, 22 hours of care per week. To cover the remainder of the week's 168 hours, these patients must depend on family members or hired help to fill the gap.

The burden for families who require nursing care is not just financial or psychological. The labyrinth that is the bureaucratic health care system also presents a serious headache. The gaps between the HMOs, Health Ministry, Social Affairs Ministry, National Insurance Institute, local authorities and insurance companies are all filled with red tape.

And, as Irena learned the hard way, it is the families who are forced to navigate the authorities. They face a confusing range of services and a serious dearth of clear information about their options. This lack of a centralized health care system creates inconsistency in treatment - and, in the end, the patients as well as their families suffer.

What's more, family members are left to manage the patients' medical records on their own. There is no unified organization for overseeing patients who require medical care or for moderating the service they receive. Treatments are not carried out by a multidisciplinary team overseen by a single responsible body. Rather, care is scattered among organizations with no real incentive to invest in patient care.

"Providing for a parent who needs nursing care is particularly tough for middle-aged adult children. For people who live full lives, which include working and looking after their own children, caring for a sick parent is a serious psychological burden," says Yifat Solel, an attorney and legal adviser for Ken Lazaken, an organization promoting the rights of senior citizens. "

And then, instead of being able to concentrate on care, they also have to contend with an enormous financial burden, with no well-organized solution within the health care system available to them."

Cost-of-living issue

Rami Adut, director of the Right to Health Program at the Association for Civil Rights in Israel, is a member of the interdisciplinary project to push for subsidized nursing care. She says nursing is as critical an issue as the cost of living in Israel, which was the focus of the widespread protest movement last summer.

"If the heads of that protest movement had been two or three decades older, there is no doubt in my mind that we would have seen nursing also at the top of their agenda," Adut says.

The problem of inpatient care will only grow as the population's life expectancy increases. Senior citizens (those over age 65 ) and the very elderly (over age 80 ) make up 10% of Israel's population. The rate of that sector's growth, however, is the third-fastest among OECD countries.

Concurrently, the number of patients from this sector who require nursing care has jumped during the past few years. In 1995, 15% of Israelis over the age of 65 needed nursing; by 2009, that number jumped to 23%. Meanwhile, seniors are living longer under care, from an average of 18 months in the mid-1990s to a full 36 months today. That means a longer period of financial strain on the family and a much higher accumulation of debt.

According to a March report from the Bank of Israel, the burden of caring for the nation's elderly is already increasing - and the country is woefully unprepared to deal with it. Despite the uptick in demand for care, public expenditure for the elderly in Israel is among the lowest in the West, while private expenditure is high compared to other countries, according to the report.

The national expenditure for treating the elderly - public and private funds alike - currently stands at NIS 9.9 billion - which is 1.2% of the country's gross domestic product. That's a tiny proportion compared to other OECD nations.

According to the Bank of Israel report, public spending on extended medical treatment for the elderly is expected to grow by at least 30% by 2019, and by more than 300% by 2059.

The Healthy Ministry, aware of the dire situation, last year drafted an ambitious plan to overhaul nursing care. The ministry project, which calls for reform in both inpatient and in-home care, would cost NIS 1.2 billion per year and would be implemented in three stages.

The overhaul has several key principles. To create public nursing insurance, the health tax would increase by 0.5% - a progressive rise that would see the poorest sectors of the population paying only a few extra shekels per month while the wealthiest pay tens of shekels more, up to a maximum of NIS 105 per month.The deputy health minister's 'baby'

The deputy health minister's 'baby'

The most significant reform, considered the "baby" of Deputy Health Minister Yaakov Litzman, would consolidate all the health providers under one umbrella organization and provide full funding for nurses working both in hospitals and out in the community.

The change would affect everyone. Patients who receive in-home care would be eligible for a 50% increase in the number of hours of care available to them (from 22 to 33 hours per week ); the current sliding-scale billing system would cease; caregivers who look after their own family members would be provided a budget for rehabilitation and psychological services; and every patient would be assigned a single caseworker who would manage all files and coordinate all treatment. In addition, HMOs would be given incentives for investing in preventative care and rehabilitation.

Under the proposal, all nursing care and supervision of HMOs would be regulated by a single body - the Health Ministry. And the country's wealthiest taxpayers, who have been paying for national insurance their entire lives but are currently ineligible for nursing care, would now be able to receive it.

Despite the additional tax involved, the public apparently approves of these measures: A Health Ministry survey found that 78.7% of Israelis support the 0.5% increase, which would add nursing care to their medical services package.

"This is a tax reduction, not an increase," says Litzman. "At the moment, two-thirds of the population is paying hundreds of thousands of shekels to insurance companies each month, out of their own pockets. These reforms would cut down on the dependence on private insurance, reducing how much a household has to pay for these kinds of services."

There are those who oppose Litzman's reforms. The Finance Ministry says the gravity of the country's nursing problems has been exaggerated, and that it is in fact relatively simple for families to obtain care. The National Insurance Institute, which would see some of its authority handed off to the HMOs if the reforms go through, has also raised objections.

As an alternative, the National Insurance Institute has suggested its own, more limited set of reforms. They advise putting the focus on the development of more services for the elderly within the community, and are opposed to the elimination of sliding-scale payment systems. Esther Dominissini, outgoing director general of the NII, told TheMarker, "In my opinion, it wouldn't be a disaster for children to support their parents, and it is entirely reasonable that they cover the costs of their parents' inpatient nursing care, at least initially."

Private insurers object

Private insurance companies, which stand to lose a great deal of income if the reforms are implemented, have also raised objections. A full 70% of the public currently has private nursing insurance policies, and the reforms are liable to eat into the company's large profits.

But Litzman says he refuses to back down. He acknowledges that when the government attempted to overhaul its mental health care system, legislation dragged on for 17 years. "I hope that these reforms will not meet the same fate," he says.

Adut, of the Association for Civil Rights in Israel, appears optimistic. "If anything good can come from this broad coalition that was created, now is the time," she says.

Patients at Haifa’s Rambam Hospital.Credit: Hagai Fried

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