From public vs. private to public/private mix in healthcare: lessons from the Israeli and the Spanish cases

Managers' perceptions of organizational readiness for change within disability healthcare: a Swedish national study with an embedded mixed-methods approach

BACKGROUND

People with disabilities experience significant health inequities compared with the general population. Addressing these inequities requires the development and implementation of tailored interventions, but a gap often exists between recommended best practices and the actual care provided. Successful implementation is complex, involving multiple organizational factors. Assessing organizational readiness for change is crucial to overcome barriers and improve health outcomes for people with disabilities. This study aims to examine managers' perceptions of their organization's readiness for change regarding the implementation of interventions within disability healthcare in Sweden.

METHODS

This descriptive cross-sectional study employs an embedded mixed-methods approach. The primary approach for the overall study is based on quantitative data, while qualitative data is analyzed to provide supplementary deepened information. Both types of data were collected simultaneously through a web-based survey. The data analysis involves various statistical techniques for the quantitative data and inductive content analysis for the qualitative data.

RESULTS

Several key factors influence managers' perceptions of their organization's readiness for change, including gender, age, tenure, organizational type, managerial level, and experience. Enabling factors for implementation include trust-based leadership, staff involvement, motivation, and engagement. Barriers include complex processes, lack of support, resistance and fear, and insufficient time and resources.

CONCLUSIONS

This study highlights the complexity of organizational readiness for disability healthcare interventions, shaped by both individual and organizational factors. In particular, managerial characteristics, organizational dynamics, and resource availability play key roles. These findings suggest that a comprehensive strategy can strengthen healthcare organizations' ability to navigate implementation challenges effectively.

Socioeconomic marginalization is associated with delayed medical consultation among endometrial cancer patients presenting with postmenopausal bleeding

OBJECTIVE

The key presenting symptom of endometrial cancer is abnormal uterine bleeding, most commonly postmenopausal bleeding (PMB), which facilitates early-stage diagnosis. This study aimed to investigate factors influencing delayed medical consultation for PMB, and particularly its association with social determinants.

METHODS

This is a retrospective study that included endometrial cancer patients receiving care in a gynecologic oncology department of a tertiary medical center who presented with PMB. Demographic and oncologic data was collected from the electronic medical charts. Israeli bureau of statistics data was used to assess community socioeconomic index, based on address. Women seeking consultation more than 1 month after experiencing PMB were compared to those seeking earlier care.

RESULTS

Two hundred ninety-five women were included in the study. One hundred seventy-three sought care after less than 1 month of PMB (early presenters) and 122 sought care after more prolonged PMB (late presenters). Late presenters were more likely to be socioeconomically marginalized (odds ratio [OR], 1.8; P = 0.018), higher body mass index (OR, 1.040; P = 0.022), and greater parity (OR, 1.170; P = 0.032). Socioeconomic marginalized patients experienced a 7-day longer delay from diagnosis to surgery compared to their privileged counterparts (59 vs 52 d, P = 0.022).

CONCLUSIONS

Among women with endometrial cancer, longer duration of PMB before first seeking medical consultation is associated with socioeconomic marginalization. This highlights the need for targeted interventions to minimize delays in diagnosis and treatment initiation among patients from marginalized communities.

Utilization of second medical opinions as a function of the payment method

BACKGROUND

The cost of a medical service and its mode of payment are known to play a role in patient decision-making, as demonstrated by the pioneering RAND Corporation Health Insurance Experiment (HIE). This study explores second medical opinion (SO) utilization by payment tracks- "financial reimbursement track" and "network track" by holders of an optional supplementary health insurance. It estimates SO utilization patterns before and after a "Reimbursement-to-Networks Arrangement" regulatory reform initiated on 2015 that eliminated the reimbursement option for SO consultations specifically involving surgeons, and identifies demographic and clinical predictors associated with each payment track before the reform.

METHODS

Retrospective analysis of medical records data, including secondary care visits data from Clalit Health Services, Israel's largest healthcare provider, and claims data from Clalit's supplementary insurance. An algorithm based on data from Clalit's electronic medical records was used to identify SO instances by payment method. Multivariate logistic regression was used to identify characteristics of SO seekers by their payment method.

RESULTS

There was an increase of 28% in patient demand for SO consultations via the supplementary insurance's co-payment track from 2015 to 2017 due to the regulatory reform initiated in 2015. Before this reform, patients from the Arab sector, low socio-economic groups, immigrants, and residents of central geographical areas tended to seek SO via the "network track". Whereas patients from peripheral areas and Jewish Orthodox tended to seek SOs via the financial reimbursement track.

CONCLUSIONS

In line with the RAND Corporation HIE, we show that incentive structures, such as provider payment methods, can explain some of the variability seen in seeking specialists across health plans or payment tracks. Considerations other than cost, such as geographic distance from the service provider, play a role in deciding on the mode-of-payment for a SO. Analyzing utilization patterns can improve the tracking of regulations' consequences on expenditure, policy, clinical outcomes, and patient satisfaction.

Attitudes and perceived knowledge of health professionals on the food labelling reform in Israel

OBJECTIVES

To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel.

DESIGN

Cross-sectional survey.

SETTINGS

An online survey among health professionals working in the Israeli health system.

PARTICIPANTS

456 participants (118 physicians, 207 nurses, 131 nutritionists).

RESULTS

Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v. 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients' nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition.

CONCLUSIONS

There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels' meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.

Characteristics and differences of strabismus surgeries performed in private versus public settings: a national multicenter study

PURPOSE

To investigate and compare the demographics, diagnoses, and surgical procedure types of strabismus repair in public and private hospitals in Israel in order to highlight possible disparities between them.

METHODS

Retrospective descriptive study included all strabismus surgeries in seven private hospitals, compared with two large public university-affiliated hospitals from June 2016 to June 2021. Electronic medical records were directly retrieved to produce an anonymized database.

RESULTS

During the study period 2420 operations were performed. Patients who underwent strabismus surgery in public hospitals were older and had shorter procedures (p < 0.001 and p = 0.004, respectively). The median number of operated muscles and the prevalence of bilateral procedures were higher in private hospitals (p < 0.001 and p < 0.001, respectively). Surgery for common strabismus, especially esotropia, was more prevalent in private (p < 0.001), whereas surgery for vertical strabismus, cranial nerve palsies and complex syndromes were performed more often in public hospitals (p < 0.001, p = 0.008, and p < 0.001, respectively). Rectus recession and inferior oblique (IO) anteriorization were more predominant in private hospitals (p = 0.002 and p < 0.001, respectively), while recuts advancement and IO myectomies were more prevalent in public ones (p = 0.001 and p < 0.001, respectively). Reoperations were far more common in public hospitals (27.2% vs 6.2%, p < 0.0001). This was true across most age groups.

CONCLUSIONS

Candidates for strabismus surgery in private hospitals in Israel are often younger, with more common diagnoses, and are usually referred for simpler procedures.

A European arena for joint innovation in healthcare: The Platform for Innovation of Procurement and Procurement of Innovation (PiPPi)

By 2000 the European Union (EU) had recognized that its innovation capacity was underperforming in comparison to similar competitors and trading partners. Although the EU has made an effort to stimulate public research and development (R&D) through policy tools like Pre-Commercial Procurement (PCP) and Public Procurement of Innovation (PPI), starting with the 2000 Lisbon strategy and continuing through the 2021 updated Guidance on Innovation Procurement, there has remained a gap in knowledge of and use of these tools, in particular within healthcare. The past decades have seen an explosion in the number and use of digital technologies across the entire spectrum of healthcare. Demand-driven R&D has lagged here, while new digital health R&D has largely been driven by the supply side in a linear fashion, which can have disappointing results. PCP and PPI could have big impacts on the development and uptake of innovative health technology. The Platform for Innovation of Procurement and Procurement of Innovation (PiPPi) project was a Horizon 2020-funded project that ran from December 2018 to May 2022 with a consortium including seven of Europe's premier research hospitals and the Catalan Agency for Health Information. To promote PCP and PPI, PiPPi established a virtual Community of Practice (CoP) that brings together all stakeholder groups to share and innovate around unmet healthcare needs. This perspective presents a brief history of PCP and PPI in Europe with a focus on digital innovation in healthcare before introducing the PiPPi project and its value proposition.

Patient preferences and choices as a reflection of trust-A cluster analysis comparing postsurgical perceptions in a private and a public hospital

Background

Active participation of patients in managing their medical treatment is a major component of the patient empowerment process and may contribute to better clinical outcomes. Patient perceptions and preferences affect the patient–physician encounter in a variety of dimensions, such as patient autonomy, freedom of choice and trust in the healthcare system. The Israeli healthcare system is mostly publicly funded, with additional private healthcare services for surgery and other medical treatments. The aim of this study was to compare the perceptions and preferences of patients in the public and private hospitals in Israel.

Methods

A cross‐sectional study among 545 individuals who had surgical procedures at two hospitals in Israel (one public and one private). A structured questionnaire comprising 23 items was used to collect perceptions via personal telephone interviews. The responses were categorized into five clusters and compared by type of health services provider (public vs. private) and sociodemographic characteristics (gender, age and education level).

Results

A hierarchical cluster analysis methodology identified five conceptual groups: trust, concern towards medical errors, dialogue between medical staff and the patient/patient's family, confidentiality and staff bias towards more informed patients, or those with supportive families. Four main themes that highlight patients' preferences were found: physical conditions, personal empowerment and perceived autonomy, patient experience and patient–provider encounter communication. Significant differences between the private and the public healthcare systems were found in four clusters: trust and patient care, patient's concerns, the extent of explanation and medical staff's commitment. Differences secondary to sociodemographic parameters were noticed: patients treated at the private hospital scored significantly higher items of trust, medical staff caring and the importance of choosing their treating surgeon, while patients treated at the public hospital scored higher staff commitment to the patient than those treated at the private hospital.

Conclusions

The study revealed the perceptions underlying the decisions of patients to undergo surgical procedures in public or private hospitals. Mutual learning could pave the way to better patient–physician encounters.

Patient or Public Contribution

Patients from the two hospitals were involved in this study by responding to the questionnaire. The data presented is based on the patient's responses.

Mechanisms for racial separation and inequitable maternal care in hospital maternity wards

Few studies have examined mechanisms of racial maternal separation (RMS) of birthing mothers in hospital maternity wards (MWs), and how separation might reinforce institutional healthcare racism and discrimination, leading to inequitable maternal care (MC). In Israel, while birth mothers report mostly pleasant experiences, RMS has become a matter of public debate. Although the Ministry of Health (MoH) condemns the practice, birthing Palestinian-Arab women have sued hospitals for discrimination after being assigned to separate MW rooms from other women. We drew on critical race theory (CRT) and intersectionality to uncover mechanisms for RMS and inequitable MC in hospital MWs at three levels-policy, practice, and women's experiences. In 2019-2020 we conducted 10 in-depth interviews with hospital directors (HDs) and 8 focus groups (FGs) with 40 midwives and nurses; then, in 2020-2021, we held 26 in-depth Zoom interviews with birthing women. Our findings reveal intersecting mechanisms for RMS through which structural racism and institutional discrimination outside hospitals in the form of ethno-racial residential segregation penetrate hospitals via women's requests to maintain separation in MWs. While all HDs opposed RMS and prized quality care, they instituted insufficient mechanisms to prohibit racial separation, which helped to institutionalize the practice. Commodification of Healthcare services (HCS) accelerates RMS as hospitals compete for funds derived from birthing mothers' care. Under the guise of cultural sensitivity and indirect pressure of hospital management, nursing staff comply with requests for RMS. Nurses assigned rooms based on stereotypical categorizations of women's group membership (ethno-national, religiosity level, class). RMS targeted mostly visibly religious Muslim Palestinian-Arab women. These mothers felt MC discrimination; others normalized RMS as preference. While the MoH cannot eliminate outside-hospital structural discrimination, more efforts should be made to eradicate inside-hospital RMS, as the practice violates the principle of universality enshrined in the National Health Insurance Law.

Nursing Informatics in Israel From a Historical Perspective

The field of nursing informatics is expanding in Israel, which is known as a start-up nation. This study is a systematic literature review aimed to obtain a historical perspective of the Israel's nursing informatics development. To study how nursing informatics has evolved in Israel over the past 20 years, we analyzed two major issues: (1) the development of the nursing informatics field over these years; and (2) nursing informatics studies that were carried out by nurses. The main criteria for choosing these studies were: (1) nursing informatics research conducted in Israel; (2) investigated by nurses; and (3) published in academic international journals, including PhD dissertations. Thirty studies were located, and two main issues were identified: nurse managers who were engaged in health information technology were not recognized as nursing informatics practitioners, and a minority of nurses performed nursing informatics researches. Although many health information technology projects were and are performed in Israel, the nursing informatics field is not fully recognized by Israeli nurses. Therefore, it is essential for Israeli nurses to understand the importance of advancing the nursing informatics body of knowledge, which will give nurses the authorization to become influential as health information technology professionals in areas such as health education, practice, and research-for the benefit of patients.

Changes in the activity levels and financing sources of Israel's private for-profit hospitals in the wake of reforms to the public-private divide

Background

The Israeli National Health Insurance Law provides permanent residents with a basket of healthcare services through non-profit public health insurance plans, independently of the individual’s ability to pay. Since 2015, several reforms and programs have been initiated that were aimed at reinforcing public healthcare and redressing negative aspects of the health system, and specifically the constant rise in private health expenditure. These include the “From Reimbursement-to-Networks Arrangement”, the “Cooling-off Period” program and the program to shorten waiting times. The objectives of this study were to identify, describe, and analyze changes in private hospitals in 1) the volume of publicly and privately funded elective surgical procedures; and 2) private health expenditure on surgical procedures.

Methods

Data on the volume and funding of surgical procedures during 2013–2018 were obtained from Assuta Medical Center, Hertzelia Medical Center, the Israeli Ministry of Health and the Central Bureau of Statistics. The changes in the volume and financing sources of surgical activities in private hospitals, in the wake of the reforms were analyzed using aggregate descriptive statistics.

Results

Between 2013 and 2018 the volume of surgical activities in private for-profit hospitals increased by 7%. Between 2013 and 2017, the distribution of financing sources of surgical procedures in private hospitals remained stable, with most surgical procedures (75–77%) financed by the voluntary health insurance programs of the health plans (HP-VHI). In 2018, following the regulatory reforms, a significant change in the distribution of financing sources was observed: there was a sharp decline in the volume of HP-VHI-funded surgical procedures to 26%.

Concurrently, the share of publicly-funded surgical procedures performed in private hospitals increased to 56% in 2018.,. During the study period, private spending on elective surgical procedures in private hospitals declined by 53% while public funding for them increased by 51%.

Conclusions and policy implications

In the wake of the reforms, there was a substantial shift from private to public financing of elective surgical activity in private hospitals.

Private for-profit hospitals have become important providers of publicly-funded procedures. It is likely that the reforms affected the public-private mix in the financing of elective surgical procedures in those hospitals, but due to the absence of a control group, causality cannot be proven. It is also unclear whether waiting times were shortened. Health reforms must be accompanied by a clear and comprehensive set of indicators for measuring their success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00455-z.

The 2019 Health Basic Law in Portugal: Political arguments from the left and right

The Portuguese National Health Service (NHS) was established in 1979. Since its inception, the relationship of the NHS with private-for-profit and private-non-profit organisations has been controversially discussed between left and right-wing political parties, and this has also led also to academic debate. In 1990, a Health Basic Law was approved by right-wing parties, which allowed public-private partnerships (PPPs) in the health system and led to an increased role of the private sector in health care provision. During the 2015 general elections, the role of PPPs in the health system was an important topic of discussion, with all left-wing parties calling for an end of PPPs in the NHS. In 2019, after two years of intense political controversies, left-wing parties supporting the minority socialist government approved a new Health Basic Law. This paper analyses the process of policy formulation, tracing the process of adoption and the views of the main political parties involved. Although some parties wished to eliminate PPPs and to mandate that services in the NHS should be provided exclusively by public providers, this was not included in the final version of the law. Nevertheless, the new Health Basic Law re-enhances the central role of the NHS in the health system, clarifying that the private and non-profit sectors should only play a complementary role.

The role of public-private partnerships in extending public healthcare provision to irregular migrants: stopgap or foot in the door?

In this commentary to the paper “Ensuring HIV care to undocumented migrants in Israel: a public-private partnership case study” by Chemtob et al. we discuss the role of public-private partnerships (PPPs) as a mechanism for integrating previously excluded groups in public healthcare provision. Drawing on PPP case-studies as well as on Israel’s pandemic preparedness policies during the Covid-19 outbreak, we examine potential implications for the populations in question and for health systems.

In our view, Chemtob et al. describe an exceptional achievement, where a PPP served as a stepping stone for the subsequent integration of irregular migrants’ in publicly funded HIV care. However, we argue that in many other cases PPPs are liable to undermine public healthcare and inclusionary claims. This view is informed by the fundamentally different concepts of healthcare that underlie PPPs and public healthcare provision (namely, health care as a commodity vs. access to healthcare as a right) and existing evidence on PPPs’ role in facilitating welfare retrenchment. In contexts that are dominated by an exclusionary stance toward irregular migrants, such as contemporary Israel, we believe that PPPs will become stopgaps that undermine health rights, rather than a first foot in the door that leads toward equitable provision of healthcare for all.