Push Comes to Shove

Industry insiders say Zeev Rotstein, the controversial head of the country’s largest hospital, gets away with his antics − which recently included a violent altercation − because of his considerable administrative success, including keeping the hospital in the black.

Nothing like this had ever happened here: The head of the biggest hospital in Israel, Prof. Zeev Rotstein, got into a violent fight with employees that ended with two workers requiring medical attention, and with a police complaint.

It all began about two months ago, when Sheba Medical Center at Tel Hashomer unveiled its new parking system. The parking attendant's booth was replaced by an automated system, and the parking rates and arrangements were changed. Previously, the 150 employees of Magen David Adom's blood bank had enjoyed free parking. From now on, they were informed, they would have to pay NIS 20 a day to use the lot.

Zeev Rotstein
Tali Meyer

Complaints by the MDA people about worsening work conditions turned into protests, fruitless negotiations between the managements of the two institutions, and then, on February 20, a violent incident. A few hours later, Rotstein took off for a scheduled family vacation in Romania. The Israel Medical Association, the organization of hospital directors and the country's doctors publicly came to his defense (see box with response from Zeev Rotstein ).

Despite their shock over the violence, many were not surprised by who was involved: Magen David Adom, which, while perceived by the public as dedicated and clean, is known within the health system as a combative organization; and Rotstein, who is considered one of the stronger, more colorful and controversial figures in the health system.

Rotstein, 61, is an interventional cardiologist by profession and a health management expert. He began his career as a senior executive at Sheba 23 years ago, as a protege of the medical center's then-director Prof. Mordechai Shani. After serving as the deputy director and later as director of Sheba's acute care hospital, Rotstein was appointed director general of the public medical center in 2004 - and has been generating headlines ever since.

"He is one of the sharpest, most talented and charismatic people in the health system, and he also stretches the boundaries as far as they go," a senior Health Ministry official says of Rotstein. "He is positive that his way is always right and there is no other, and it is very hard to get him to compromise."

In a state comptroller's report two years ago, Micha Lindenstrauss wrote that in addition to his position as director of Sheba Medical Center, Rotstein worked 11 other jobs, four of which had not been authorized for him. According to the report, Rotstein's income from private work between 2000 and 2006 exceeded the percentage of total income permitted public servants by Civil Service regulations, and he underreported hours to the Health Ministry and Civil Service Commission.

Rotstein explained that five of the jobs mentioned in the report involve corporations within Sheba and are part of his executive capacity, and that others involve university instruction. In a response unprecedented in its belligerence, Rotstein wrote: "The state comptroller comes across as someone who has marked a target and will not desist even when the results of the inquiry refute all his preliminary hypotheses. He sends out a teaser for a tabloid press headline."

In a press interview at the time, Rotstein said: "We have a comptroller who barks a lot; he looks for the scandals and the newspaper headlines. You in the media know this better than I do."

In a letter Rotstein sent to Sheba's doctors, he announced unilaterally that teaching students during regular hospital work hours would henceforth not be considered "private work," and that doctors would be exempt from having to fill out a private-work form if they wished to undertake such efforts - contrary to the state comptroller's stance, which is based on Civil Service regulations.

The final paragraph of his missive reads: "In view of this absurdity manufactured by the state, there ought to have been a great hue and cry from teaching hospitals, but for some reason a hush fell. Sheba is forced to be the avant-garde and bravely and tenaciously make its voice heard."

The state comptroller did not take this lying down: "The memo and the letter accompanying it are an attempt to distract from the fact that Prof. Rotstein devotes a significant portion of his time to working in private places, instead of focusing on taking care of patients at the medical center he heads."

Robbed Cossack

Rotstein currently is locked in a bitter confrontation with the Maccabi health maintenance organization over a three-year contract for Sheba's services. Rotstein accuses Maccabi of reducing the number of patients it is sending to Sheba in order to twist his arm, while Maccabi charges that Rotstein is "inciting" patients against it and taking unilateral steps such as ousting Maccabi's coordinating nurses from their room at the hospital, changing the lock on their door, and cutting them off from the hospital's computer network.

Three years ago Rotstein had a dispute with Clalit Health Services on the very same matter - a three-year contract for services. For several months, until the agreement was finally signed, Clalit accused Sheba of deliberately lengthening its members' hospital stays in an attempt to compensate itself for its losses due to the decrease in referrals.

Rotstein commented at the time, "The HMO gripes like that robbed Cossack who burns down the fuel depot and then complains about the shortage and price hike. Because Clalit blocked its patients from going to Sheba, the surgical wards are seeing only serious and urgent cases who were admitted through the emergency room. That explains the prolonged hospitalization."

In another instance, Sheba workers were given anti-Clalit bumper stickers and asked to display them on their cars. Rotstein even applied to the antitrust commissioner, calling the HMO "a monopoly that extorts the hospitals."

When the rival government-owned hospital Ichilov took Clalit's side, Rotstein wrote: "I wonder how a subsidized 'gladiator' like you allows himself to sing commissioned praises to the monopoly that is smiling at you today, but which will brutally ignore you tomorrow." This query was addressed to Dr. Ronni Gamzu, then the director of Ichilov Hospital at Tel Aviv Sourasky Medical Center, and now the director general of the Health Ministry, and thus Rotstein's boss.

Two years ago the Israeli company Ventor Technologies Ltd. was sold to Medtronic, an American firm, for $325 million. The scientist behind the Ventor Embracer - a heart valve that can be put in place without open-heart surgery - is Prof. Ehud Schwammenthal, a doctor at Sheba. After lengthy talks between the Finance Ministry accountant general, Rotstein and Schwammenthal, it was decided that Sheba and the treasury togethewould get 30 percent of Schwammenthal's profits, a sum estimated at NIS 100 million.

Despite the agreement, Rotstein attacked the Finance Ministry in TheMarker: "The treasury's contribution to technological development, particularly at hospitals, is negative," he said. "When the American buyers heard that they had to deal with the state as well, their initial response was to cut and run, because there is a sentiment that you can't do business with Israel - it's bureaucratic, and impossible to get past the battery of officials and legal counsels at the various ministries."

1.5 million patients

Sheba, Israel's largest medical center, sprawls over 800 dunams (200 acres ), employs 7,000 people, and serves close to 1.5 million patients a year. On its grounds are four hotels, three bank branches, two shopping malls, seven restaurants and 100 taxicabs.

Beyond the responsibility for tens of thousands of human lives at any given moment, the director general of this hospital must contend with the regulator and owner (the Health Ministry ), the Civil Service Commission, the HMOs, insurance companies, pharmaceutical and medical equipment suppliers, thousands of workers, medical staff, the media and the courts. At the same time he has to maintain a balanced budget, improve the level of medicine and equipment, do fund-raising, and compete with the other major hospitals in the Dan Region and with private medical care that lures away doctors and profitable surgical procedures.

"His power stems from one single thing: the fact that the hospital's budget is balanced," says a senior health official. "Through the years this has been the only hospital that finishes the year with a check for the Health Ministry, and thus helps finance other hospitals' deficits. This is why he can threaten the ministry."

According to the Health Ministry's recently released financial report on the hospitals, Sheba's income in 2009 grew 11 percent over the previous year, and it was the only medical center with an operating profit.

"Sheba Medical Center stood out in 2009 and throughout the years due to its efficiency, which is mainly reflected in wage expenditures equal to 58.7 percent of base income - the lowest of all the medical centers," the report states. "Its efficiency is also reflected in material expenditure of 15 percent, which is considered low relative to the hospitals' average, and this is despite the fact that its income includes complex activities. Its efficiency is also reflected in the fact that it has the lowest rate of managerial and general expenses."

"Judging by the results, there is no doubt that the man is a good hospital director," says a senior official from a rival hospital. "The hospital is big, strong and constantly developing. If there's any reason to complain, then it's only about the means."

Rotstein also has no hesitations about confronting doctors at his hospital. There were two final candidates for a senior position, director of the cancer center: Rotstein's candidate, Dr. Raanan Berger, a relatively young expert; and another candidate whom Rotstein opposed, the veteran Prof. Jacob Schachter, who heads the Ella Institute for Treatment and Research of Melanoma and Skin Cancer. To Rotstein's astonishment, the Civil Service Commission's selection committee chose Schachter.

According to various testimonies, Rotstein pushed Schachter to withdraw his candidacy. At first Schachter tried to fight for the job, and even sought legal advice, but after just four days he announced he was out of the race.

Rotstein claims the hospital director does not wield any influence over the selection of personnel for such senior positions, and that the decision lies with the selection committee, where the hospital merely has representation. In a harsh letter to the Health Ministry and the Civil Service Commission, Rotstein wrote that directives like the one prohibiting the hospital director from recommending a candidate "are fated to be rejected out of hand for their extreme unreasonableness, since otherwise the selection committee had better also run - and take responsibility for - the hospital's operations. I was taught that there is no responsibility without authority. And if it is none of a hospital director's business who gets chosen by the committee, and he is not allowed to make a recommendation, then in practice there is no management. And if it's just artifice, count me out. We seem to have lost our bearing."

Massive donor network

Three months ago the Civil Service Commission recommended to the Health Ministry that Rotstein face disciplinary proceedings after he traveled abroad to attend a 2009 private function held by a family of Italian donors and billed the hospital's research fund - despite the Health Ministry's decision not to approve the trip.

"Despite the fact that Rotstein's request was denied, he ignored this and went, contrary to procedure and contrary to the ministry director general's decision," attorney Asaf Rosenberg of the Civil Service Commission wrote to the Health Ministry, adding, "This conduct is unbecoming."

Rotstein, a star fund-raiser who manages to bring the medical center enormous donations, claimed in his defense that the 24-hour trip, which helped nurture ties with contributors, was an important part of his work and was far from "a great pleasure."

He also lashed out at the Health Ministry's legal counsel, attorney Natan Samuch, who had refused to authorize the trip: "I deplore that the Health Ministry's legal counsel of all people, who is supposed to understand the system's plight and try to minimize it, chose to view this lightning trip as a personal perk," Rotstein told TheMarker. "This is petty behavior and it even smacks of personal persecution. I will continue to do everything for the hospital, and if I have to stand trial, I will do so with my head high."

In the wake of this, Rotstein sent a memo to hospital employees: "In this incident too I learned from experience that the system does not like strong, independent people with accomplishments and who are not sycophantic yes-men."

The Health Ministry scheduled a hearing on the matter. After the Civil Service Commission recommended that he face disciplinary proceedings, the directors of other hospitals sent a letter to the Health Ministry director general backing Rotstein.

Rotstein is well connected in business circles as well. His 60th birthday, last year, for example, was celebrated at the Savyon home of his relative Zvi Heifetz, Israel's former ambassador to Britain. Guests included former Prime Minister Ehud Olmert and his wife Aliza, Mizrahi Tefahot Bank chairman Jacob Perry, the owners of Gitam/BBDO advertising firm Moshe Teomim and Mody Kidon, businesswoman Israela Stier, attorney Hanina Brandes and his wife and others. They were shown a film documenting the shortened pilot's course Rotstein had taken in the United States a month earlier.

Two summers ago, Rotstein attended Leonard Cohen's concert at Ramat Gan Stadium from the privacy of the box rented by Shirly and Yigal Zilkha, along with 150 politicians, celebrities and leading businesspeople such as Shari Arison, Ilan Ben-Dov, and Judy Shalom Nir-Mozes (and her husband, government minister Silvan Shalom ), Zaki Rakib, Berry Sakharof, Eli Yatzpan, Dori Klagsbald, Dov Weissglas and others.

In 2009 Sheba raised NIS 98 million in donations, 25 percent more than the second-ranked hospital (Rambam ), and twice as much as rival Ichilov (which raised NIS 46 million ).

"He has a whole lot of important people in his debt, connections everywhere and an extensive network of donors that lets him do what he wants at the hospital," a senior health official says. "That is one of the secrets to his tremendous power and Sheba's financial strength."

"He is a charismatic man, brilliant, and has incredible ideas and thinks outside the box," a senior executive at one of the rival hospitals says of Rotstein. "He sees things ahead of time, identifies processes, does a good job of analyzing, grasps technologies.

"On the other hand, he has a very childish side, such as his enormous enthusiasm for new things, gadgets and cutting-edge medical technology, and for people themselves: When someone new comes to work at Sheba he makes a fuss and rolls out the red carpet. But like a kid, at a certain point he gets bored and moves on," says the executive.

"He is totally into his workplace, picks up paper and trash as he walks down the halls, is involved in every detail and is on top of every program," a senior Sheba employee says. Rotstein was recently mentioned as a potential candidate to head Hadassah Medical Center, which is in the process of searching for a new director general. A short while later he withdrew his hat from the ring, and sent a memo to employees entitled "I am a Shebaite": "I admit, it is very nice to be courted, but beyond the good feeling of being sought after, I feel a deep commitment to our medical center and to Sheba staff. I am not exchanging home for a pot of flesh!" Rotstein continued: "No new address, however pretty, alluring and financially tempting it may be, will cause me to leave Sheba and forgo the work and growth of the country's premier hospital."