|Implemented in this survey?|
The first Equality Report of Maccabi Health Care Services identified disparities in health outcomes by socioeconomic and ethnic backgrounds of members, serving to identify groups at risk for worse outcomes. Consequently, Maccabi has decided to adopt equity as a major strategic goal and to implement a set of measures to reduce disparities: cultural adaptation of services; adoption of community-orientation in care; and preferrential allocation of resources to its social peripheries.
Background: Maccabi Health Services (MHS) is an Israeli health plan (HMO) providing community-based care to 1.8 million beneficiaries (25 percent of the Israeli population) throughout 5 regions and 150 branches. Since 2004, MHS is operating a computerized system named Health Value Added (HVA) to manage care improvements according to measurable goals.
30 performance indicators represent major clinical domains, such as early detection of breast and colorectal cancer, influenza and pneumococcal vaccination, diabetes follow-up and control, and care for cardiovascular disease (CVD). For each indicator, an organizational benchmark is set, from which annual goals are derived for the units (regions and branches). Achieving the goal is followed by recognition and a modest reward. This system produces monthly reports to managers and caregivers describing actual performance and how far they are from the goals. This ongoing quality measuring and reporting exposed MHS's managers to disparities existing between branches and sub population groups and gradually made equity issues part of the managerial discourse. As a result, in 2008 MHS management has decided to implement a long-term and comprehensive strategy to promote equity and equality in care provision, as well as in health outcomes.
The goal was to promote equity by reducing disparities among sub popualtions of members: ethnic minorities, members from low socio- economic background and from the geographical peripheries.
The main objectives were:
It was expected that identifying populations at risk would a) increase the organizational awareness to equity issues ( "it is not only in the literature but in our data as well....") and b) contribute to the planning and implementation of better strategies to reduce disparities. MHS, as a provider of health care services, has adopted an ethical attitude that makes it the organization's mission to provide equal services and to help its members to achieve more equal health outcomes.
1) Evidence based action plan: It is based on a comprehensive report (The first MHS Equity Report) which summarizes the analysis of associations between health measures and the demographic and socio-economic characteristics of MHS members. The report was published in June 2009.
Methodology: Data were extracted in November 2008 from the HVA computerized system with additional information gathered from the MHS billing system and the Israeli Census (Israel Census Bureau 2007). The analysis included all MHS adults 18-80 years of age, who had visited their general practitioner at least once during the previous two years. Data were gathered retrospectively for 18 health measures (dependent variables).
The dependent variables were:
These indicators were chosen to reflect the major indicators that MHS is measuring on a regular basis at the regional and branch level (the HVA system).
The independent variables were:
Socio-Economic Ranks (SER): 9 percent of the MHS population belong to the lowest SER categories (1-5), while 26 percent belong to the highest (16-20). Of the five MHS regions, the northern and the southern regions, considered the Israeli periphery, have higher rates of members belonging to the lowest SERs and higher rates of immigrants, compared to other MHS regions. Two-thirds of MHS' Arab members belong to the northern region, while the southern region is characterized by the highest rate of poor members compared with other regions.
MHS members who belong to the lowest SERs have greater prevalence rates of chronic illness (diabetes and CVD), lower rates of diabetes control and early detection of colorectal cancer compared to members from the highest SERs. Diabetes was 1.4 times more prevalent in men and 2.1 times more prevalent in women from the lowest SERs compared to those from the highest SERs. CVD was 1.2 times more prevalent in men and 1.6 times more prevalent in women who belong to the lowest SERs compared to those who belong to the highest ones. Poor diabetes control was twice as common in females from low SERs compared with high SERs. Screening for colorectal cancer was half (57%) as common among male members who belong to the lowest SERs compared to those in the highest SERs. Disparities in mammography screening among different SERs were relatively small. Half of the health measures did not demonstrate disparities between low and high SERs.
Ethnicity: Analysis revealed large disparities between Arabs and non-Arabs in most health measures. Prevalence of diabetes is greater in Arabs compared to non-Arabs, especially among females. Optimal follow-up for diabetes was similar among the two ethnic groups. Arab females achieve less favorable diabetes and CVD control. While comparing Arabs and non-Arabs belonging to the lowest SERs (1-8), disparities usually diminish but do not disappear. For example, the rate ratio of Arab to non-Arab females achieving poor diabetes control is 2.22 among the overall population and 1.49 among the poor.
Immigration: 15 percent of MHS members are new immigrants from the Former Soviet Union countries who immigrated to Israel during the nineties of the last century. No robust differences were found between immigrants and Israeli veterans after controlling for SER and geographic regions regarding the variables under investigation.
In some health measures, such as diabetes control, immigrants achieved better results when compared with veterans, after controlling for age and SER.
Supplemental Voluntary Health Insurance (SVHI): 87 percent of MHS members own SVHI. Ownership of SVHI is more common among members from the higher SERs compared to the lower SERs. Ownership of SVHI was associated with better performance in most measures. In an attempt to understand this association, one can look at breast cancer screening - although mammography is offered free of charge to all women aged 52-74, and is relatively easy to perform, the performance of this exam was 2.2 higher in SVHI owners comparing to non-owners, after controlloling for SER. This suggests that SVHI is not the cause of disparities but rather a marker of undefined socio-demographic variables and health behaviors that are associated with less favorable health outcome.
2) Structured, consensus-oriented process: MHS First Equity Report contained a set of recommendations aimed to reduce disparities. These were based on the analysis and also on recent recommendations of leading reasearch and policy bodies in Israel . As a provider of health care services, MHS bears responsibility not only to recognize disparities but also to take actions to tackle them. Therefore the recommendations had to be translated into operative decisions. In order to achieve this goal we have intitiated a consensus-building process. A diaologue with 150 managers from all districts was conducted during a two-month period in 2009.
3) Top management support: Following the consensus achieved, MHS management has decided that equity promotion will be adopted as a major strategic objective.
4) Operative action plans. These established a "change package" in seven major areas, that has been formulated and published internally for the up coming years:
* Social peripheries is a multi-dimensional term representing a number of population features: limited access to services (including healthcare services); remoteness from centers of economic activity; remoteness from sources of political power and influence; high morbidity rate and unique morbidity patterns; low socio-economic status compared to the general population or the region; and a low level of social-communal cohesion, which is reflected in the scarcity of communal support networks and lack of communal leadership. There may be some overlap between the features of geographic and social peripheries.
Incentives to MHS Management:
The commitment to promote equity in health care is derived from the notion that all humans deserve to achieve the best health, since health is a basic human right. 
The adoption of the United Nations' declaration by the WHO in 1978  set this goal as a moral foundation for governments and health organizations.
Disparities in access to health care services as well as in health outcomes, based on ethnicity and socio-economic status, has been well documented in Israel in recent years and it is striking based on the fact that Israel has an universal health system under a National Health Insurance Law. Our health system provides primary, secondary, and tertiary services largely free of charge with a broad benefit package of services. MHS three main incentives for sthe trategic decision to reduce disparities were:
In 2010-11, an equity index to measure reduction of disparities over time will be developed and incorporated into the managerial system for monitoring, recognition and modest reward for the organizational units (regions and branches). We do not plan to provide additional incentives (e.g. financial) to caregivers (physicians and other health professionals) for disparity reduction (for ehical and methodological reasons).
 Universal Declaration of Human Rights. G.A.Res 217A(III), UN GAOR, Res 71 UN Doc A/810. New York: United Nations
 WHO. (1978). Declaration of Alma Ata, International Conference on Primary Health Care. Alma-Ata, USSR
1. Members who live in the geographic peripheries, 2. Members who belong to the social peripheries, described by remoteness from centers of economic activity and political power and influence; high morbidity; low socio-economic status and a low level of social-communal cohesion, Both peripheries are characterized by higher rates of immigrants, poor people and ethnic minorities ? the Arab population.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The plan is innovative since it is health care organizations, not the state, that publicly declared that reducing disparities in health provision and outcomes is an ultimate goal - regardless of governmental financial or any other support (other than Maccabi, Clalit, too, is implementing a similar plan since 2007).
Consensus - It seems that on the surface everybody will agree that equity is very important. However it is unclear to which degree and for how long HMOs could bear the economic consequences of investment without reimbursement by the government.
Structural Impact - depends on the success of wide implementation. There might be differences between regions, ranging from full to partial implementation.
Public visibility - is currently fair. The media are not very interested in publishing the plan although it had been exposed in details.
Transferability - too early to judge.
In 2004 Israel's Ministry of Health initiated a national program to monitor quality indicators for community care . This project has floated substantial disparities in performance measure between citizens from poor background and the general population.
No action plan was taken so far at a national level however, in 2007-8, several reports prepared by research bodies as well as by the Israeli Medical Association (IMA) were published with a general set of recommendations for the health care system. Two HMOs, MHS and Clalit Healthcare Services, initiated in 2008 and 2007, respectively, organization-wide plans to reduce disparities.
In 2009 the Ministry of Health has incorporated equity promotion as one of its goals. However, a concrete set of requirements or recommendations as to how disparities should be addressed and how HMO' efforts to address it should be reimbursed - have not been issued yet.
As mentioned earlier, MHS has adopted equity promotion as its ethical and professional responsibility in 2008. The commitment to its members to provide services that are of the highest possible quality (with equality being a dimension of quality) created the main incentive for the action plan described hereby. This means that our strategy and action plan started well before any external policy guided us to do so.
Following the efforts of the 2 large HMOs, the Ministry of Health is currently formulating a "resource guide" and recommendations for all healthcare providers regarding equity promotion. In 2009 it has incorporated equity as a dimension to be evaluated in its bi-annual surveys/review of the HMOs.
Porat A, Rabinowitz G, Raskin Segal A.( 2005-2007). Quality Indicators for Community Care in Israel. Public report. Retrieved from: www.health.gov.il/pages/default.asp?maincat=1&catid=98&pageid=4215
|Implemented in this survey?|
In 2002-3 MHS has identified four system and local barriers to the implementation of an organizational quality culture and environment:
Between the years 2004 and 2008 MHS has established a clear quality vision and strategy, with three core elements:
All these efforts helped implement an organizational culture committed to quality. This culture also promoted the growing equity discourse, as mentioned above. In 2008, the ideas of disparities and equity were "ripe" enough to become a major agenda in MHS. In 2/2008, top management has declared MHS is adopting a long-term commitment to promote equality in services delivery and health outcomes. After 16 months, the First Equality Report was published, summarizing disparities in health measures among MHS sub population groups (please see details of this report above).
The vision is that MHS is heading out in a path to understand the variance existing between sub groups if its members and their special health needs, in order to reduce disparities. This may require, among other measures, the allocation of specific resources to weak groups of our members.
The approach of the idea is described as:
new: The approach is new nationally as well as for MHS. In 2007-8, MHS and Clalit (the two large HMOs) initiated for the first time organization-wide programs to promote equity
Local level - Within MHS, local interventions took place between the years 2004-2008, to overcome cultural/social barriers to care, e.g., increased breast cancer screening among Israeli Arab women.
MHS management and its department for Quality Management were the main actors in this initiative. The Department of Quality Management - by creating the ideas and details of the strategy and action plan as well as leading the implementation at the organization-wide level.
The CEO and CMO - by massive support and involvement in formulating the ideas into strategy.
Top management - supported out of ethical commitment to increase equity and professional understanding that achieving higher performance requires addressing the needs of special populations of members; also the wish to promote a national agenda around health equity
Quality Management Department - since equality is a major dimension of quality, it is impossible for a healthcare provider to declare itself achieving top quality if disparities exist between sub populations of its members.
Regional & local managements - Maccabi caregivers serving at the front-line are very aware of disparities between groups of beneficiaries served by them. However, they are only at the beginning of being recruited to the practical aspects of the implementation of the new organizational goal (set formally only in 2009).
Caregivers at the front-line (doctors, nurses) - on one hand, they are aware of the need for action; on the other hand, they have not yet learnt what is required to "recruit" them to the new strategy and what difficulties are to be expected.
Ministry of Health - supports the initiative but has just started to think how they can contribute to the process of reducing equity and equality. It is too early to assess its contribution.
Ministry of Finance - is indirectly involved. According to the Israeli financing system, HMOs are reimbursed by a "Capitation Formula" which takes into an account mainly the number of beneficiaries and their age. Currently, the Ministry of Finance has agreed to add to the formula a geographical component which will compensate HMOs for providing services in geographical remote area.
|Ministry of Health||very supportive||strongly opposed|
|Ministry of Finance||very supportive||strongly opposed|
|MHS Central management (CEO CMO) and board of directors||very supportive||strongly opposed|
|MHS Regional Management||very supportive||strongly opposed|
|MHS Local Care givers (Physicians, Nurses and other health professionals)||very supportive||strongly opposed|
|MHS department for quality management||very supportive||strongly opposed|
At the moment, there is no national legislation regarding the obligation and responsibility of healthcare organizations to reduce disparities and to promote equity and equality. Until 2009, there was no robust announcement by the Ministry of Health about the necessity of measuring and analyzing disparities and furthermore, the necessity of specific actions to reduce them. Nevertheless, MHS is acting out of its specific strategic decision without neither legislation nor regulation. MHS is looking forward to collaborating with all the national stakeholders.
|Ministry of Health||very strong||none|
|Ministry of Finance||very strong||none|
|MHS Central management (CEO CMO) and board of directors||very strong||none|
|MHS Regional Management||very strong||none|
|MHS Local Care givers (Physicians, Nurses and other health professionals)||very strong||none|
|MHS department for quality management||very strong||none|
The Equality Report was disseminated within Maccabi in 2009.
In order to gain a broad consensus regarding the recomendations, it has been decided to expose managers both in the field and in the central administration to the findings of the report and to lead a dialogue over the resulting recommendations. This dialogue involved 150 managers during a two-month period in 2009.
Following this dialogue, a consensus was reached over most of the recommendations (some requiring fine-tunning), setting a platform for its adoption by senior management.
MHS management has decided that equity promotion will be adopted as a major strategic objective, and declared so in 2010. It means a long-term commitment, involving the allocation of special resources, in order to secure all our members' right to optimal health. It has also been decided that equity would be viewed as a filter through which every policy decision will be screened to ensure that any decision taken by the organization promotes equity, or at least does not increase disparities.
Fron this decision, operative action plans are derived. These establish a "change package" in seven major areas, that has been formulated and published internally in 2010 for the upcoming years (See above).
Starting in late 2009, all regions and branches that serve at risk populations have incorporated equity promotion into their workplans for 2010. The plans are directed to decrease disparities and promote equality in members that belong to the "social periphery" of each region: The concept of "social periphery", powerfully integrated into the MHS decision-making process, originated from civil society organizations, and allows Maccabi to approach weak communities in each of its 5 regions, according to their socio-economic or cultural characteristics, not just by geographic location.
A detailed guide as to how to choose the social periphery within each region and what should be the key elements of the plan to increase equity has been issued by the central Quality Management Department.
Currently, all 5 regions are implementing their plans for increasing equity, e.g., a plan to transform 5 primary care clinics in the Arab sector in the Northern Region to "Family Health Promotion Centers whithin the relevant communities.
Implementation is expected to be successful because of high level support from the board and measures taken to engage independent providers in implementation process:
MHS already puts an effort in gathering together governmental, HMOs, academia and other stakeholders to work together in order to develop legislative and other tools to reduce health disparities, providing support for the internal process in the larger policy environment.
MHS is currently working on the development of a unified "equity index" with which the implementation of the program will be constantly evaluated.
On a regular basis MHS continues to monitor the 40 indicators implemented in the HVA system. Data provided by this monitoring system is used to evaluate changes in disparities between regions, sub population groups and periods.
A group of researchers are currently working on following equality reports. These reports will analyze the various dimensions of equality - needs of sub-populations, access to services, utilizations patterns and health outcomes.
Mid-term review or evaluation
Structure, Process, Outcome
Early yet to present results as implementation by the regions had only begun in 2010.
Because of the strong commitment of MHS leadership to the plan, it is hoped that most parts of the plan will be implemented as recommended and decided. Initially, resources will be targetted at "social peripheries" in each of Maccabi's 5 regions.
The action plan will be a budgetary burden in the short run but might prove to be cost effectiveness in the long run.
Long-term funding remains unclear.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Since equity is a dimension of quality, we believe that it would considerably improve quality of care. The system should be more equitable once the plan in implemented.
It is unknown yet if the investment would pay itself back.
Wilf-Miron et al. (2009). The first Equality Report of MHS: health disparities and recommendations.
Porat A, Rabinowitz G, Raskin Segal A.( 2005-2007). Quality Indicators for Community Care in Israel. Public report. Retrieved from: www.health.gov.il/pages/default.asp?maincat=1&catid=98&pageid=4215
Israel Census Bureau. (2007) Retrieved from www1.cbs.gov.il/census/census/search_description_new.html?ok_button=TRUE&stage=130
Universal Declaration of Human Rights. G.A.Res 217A(III), UN GAOR, Res 71 UN Doc A/810. New York: United Nations
WHO. (1978). Declaration of Alma Ata, International Conference on Primary Health Care. Alma Ata, USSR
Dr Rachel Wilf-Miron, Dr. Einat Yaari, Orna Shem-Tov, Prof Avi Porath, Prof Ehud Kokia
Dr Rachel Wilf-Miron MD, MPH, Head, Quality Management Department, Maccabi Health Care Services
Dr. Einat Yaari, MD, Quality Management Department, Maccabi Health Care Services
Orna Shem-Tov, MA Quality Management Department, Maccabi Health Care Services
Prof Avi Porath, MD, CMO Maccabi Health Care Services
Prof Ehud Kokia, MD, MHA, CEO Maccabi Health Care Services