Analysis |

How Israel’s Powerful, Well-connected Institutions Are Jumping the Vaccine Line

The task of prioritizing who would receive the coronavirus vaccine when was done in an entirely professional way. What followed was something else

Meirav Arlosoroff
Meirav Arlosoroff
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Prime Minister Benjamin Netanyahu prepares to receive the coronavirus vaccine at Sheba Medical Center in Tel Hashomer, December 19, 2020.
Prime Minister Benjamin Netanyahu prepares to receive the coronavirus vaccine at Sheba Medical Center in Tel Hashomer, December 19, 2020. Credit: Tomer Appelbaum
Meirav Arlosoroff
Meirav Arlosoroff

The 22,000 police officers who have begun receiving the coronavirus vaccine at Sheba Medical Center, Tel Hashomer aren’t the only people under age 60 being vaccinated against the virus in Israel. Members of the Mossad, the Shin Bet and other security services are among those getting the first vaccines – along with the administrative members of their organizations. And then there are the disabled army veterans, who are getting vaccinated at Ichilov, and reportedly also the family members of the hospital’s medical staff.

For once, the Health Ministry was well prepared when it came to determining who needed to be vaccinated first. A panel, which has been working in the ministry’s pandemic department for years and specializes in drafting vaccine policy, determined which population groups would be given priority for vaccines based on purely professional considerations.

They determined that first to be vaccinated should be the groups at highest risk in order to minimize cases of serious illness and death. Therefore, first priority was given to medical staff, including at nursing care facilities, as well as those at the highest risk – people age 60 and up, and those with serious underlying health conditions. These groups include some 2 million people.

The second group – after Israel receives more vaccines – includes people with less serious underlying conditions, and workers who come into contact with significant numbers of people such as teachers, social workers and prison employees, as well as prisoners.

The priority list was set in an entirely professional, appropriate way, but everything that has happened since then is less professional and appropriate. The health maintenance organizations and the major hospitals went to war against each other and among themselves over how many vaccines each would receive.

The conflict between the various HMOs stems from their differences. Clalit has the oldest population – some two-thirds of its members are over age 60. The other three HMOs have younger patients. Each one received a vaccine allocation from the Health Ministry based on how many older patients it has, but since Clalit has the most elderly patients – nearly 1 million, and more than twice the number at Maccabi, the second largest HMO – it also has the longest wait time.

This created conflicts of interests between the HMOs. While the other three HMOs have been able to charge ahead and reach a vaccination rate that enables them to move past their initial vaccine allocation, Clalit still has several weeks of work to finish vaccinating the highest priority group. Therefore the other three HMOs are pushing for approval to move on to the second-level priority group, while Clalit is objecting and demanding that no vaccine be wasted on patients who are not in the highest priority group.

In short, Clalit is demanding that the other HMOs idle – meaning close vaccination centers and let go of nurses and paramedics who were hired to give vaccines – and wait until Clalit finishes its first round of vaccines.

The other HMOs are up in arms, arguing that this would be a waste of time and expensive staffing and logistics. Clalit argues for its part that the most expensive asset is the vaccines themselves, and that they shouldn’t be drawn into vaccinating secondary priority groups before the first group is fully vaccinated.

Within the HMOs another question is raging: Is vaccinating 70-80% of the target group enough to declare the process done, and what incentives would the HMOs have to use in order to reach the remaining 20-30% of recalcitrant patients?

The Health Ministry tends to side with Clalit, and prefers not to move on to the second priority group before the HMOs have all made the effort to complete vaccinating the first group. This means that the daily vaccination rate is likely to slow over the next few weeks.

A woman receives the coronavirus vaccine in the southern city of Rahat, December 21, 2020.

Hospitals vs. HMOs

This conflict among the HMOs comes alongside another clash between the HMOs and the hospitals, primarily two powerful institutions in central Israel – Ichilov Hospital and Sheba Medical Center, Tel Hashomer – which are demanding their own allocation of vaccines in order to start inoculating the population at large.

The HMOs argue that by giving in to the hospitals, the Health Ministry turned the hospitals into a way of skipping the priority line. The two hospitals are vaccinating powerful, well-connected groups tied to the defense establishment – the Shin Bet, the Mossad, the Dimona nuclear reactor and police officers – even though it’s clear they’re not in risk groups. And then there’s the disabled Israel Defense Forces veterans, to whom Israel has a high moral obligation, but it’s still not clear that they need preferential treatment when it comes to vaccines. And that’s not the end of it. The hospitals apparently also decided to vaccinate those who are close to them – all their employees, including those who aren’t among the medical staff, as well as their family members. That’s starting to smell like inappropriate favoritism.

The bigger problem emerged when the hospitals started vaccinating the population at large. Allegedly they’re vaccinating only people aged 60 and up, but in practice they’re vaccinating only sixty-somethings living in the center of the country (who are again getting preference over residents of outlying areas in the form of tens of thousands more vaccines). They’re also vaccinating people under 60 with underlying health conditions.

“Every day people try to pressure me into giving them a vaccine appointment,” says the CEO of one HMO. “A 50-year-old with serious asthma contacted me and asked for an appointment, even though he’s not on the top priority list. I asked to see his medical history in order to examine the case, but before I managed to respond I was told it wasn’t relevant because he’d already gotten an appointment at a hospital,” said the CEO. “The hospitals don’t have the patient’s medical files; they don’t know who should be getting preference.”

The HMOs argue that not only do the hospitals not have patients’ medical histories, but they also aren’t tracking patients to find out what happens after they’ve been vaccinated, such as whether any of them go on to catch the coronavirus or have other health events. The HMOs’ massive advantage – their huge databases – is lost when other bodies start vaccinating as well. “This is the time for the Health Ministry to start showing leadership and make sure that the vaccines are given only to those with priority,” said HMO sources.

A man receives the coronavirus vaccine at the Meuhedet HMO in Jerusalem, December 21, 2020.Credit: Ohad Zwigenberg

A solution

The hospitals reject these allegations and say that they’re vaccinating only in accordance with the Health Ministry’s priority list, including the inexplicable priority for defense establishment members. But according to Health Ministry data, while some 75-88% of HMO vaccines have gone to people age 60 and up, at the Rambam, Sheba and Ichilov hospitals that figure is only 40-52%.

The figures back the argument that the strong hospitals have made themselves into means of skirting the priority list, and are undermining the crucial principle of first vaccinating people most at risk – the elderly and those with serious preexisting conditions – before moving on to other groups.

The fact that the Health Ministry sees this and isn’t doing anything about it is more evidence of the ministry’s conflict of interest – the ministry both supervises and owns the hospitals.

The solution should probably be as follows: Instead of letting the hospitals vaccinate whoever they want, the Health Ministry should order them to vaccinate based on the HMOs’ priority list, and primarily the over-60s who are facing the longest wait times – namely, Clalit members.

This way precious vaccines won’t be wasted, and Clalit will manage to shorten its wait times. It’s just not clear whether the weak Health Ministry will manage to impose this on its strong hospitals.

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