Association between trust in the public healthcare system and selecting a surgeon in public hospitals in Israel: a cross-sectional population study

In January 1995, the National Health Insurance Law came into effect in Israel [1]. This law redefined the healthcare services that permanent residents are entitled to receive from the public health system. Within this law, the state undertook to provide permanent residents with a basket of health services through health maintenance organizations (HMOs), independently of the individual’s ability to pay (In some situations there is a payment of deductible from the insured). The HMOs provide health services to the insured within their respective communities or within the HMOs’ network of affiliated hospitals. These services are provided in HMO clinics or through the purchase of services from external suppliers (for example: independent doctors, laboratories, medical Center’s and more), primarily hospitals, which account for the main HMO expenditures.

The law sought to break the link between the individual’s economic ability and the receipt of needed (i.e., medically justified) treatments, and all in accordance with the basket of medical services and the conditions defined by law. Services are provided by four competing HMOs (Clalit Health Services, Maccabi Healthcare Services, Leumit Health Care Services and Kupat Holim Meuhedet) to which an individual registers. Individuals can also switch from one HMO to another, under certain limits defined by the law. Members of each HMO have the freedom to choose between service providers, including physicians; however, since the resources of the public health system are limited, the law allows for some limits on this freedom of choice in order to enable HMOs and hospitals to plan and manage resources efficiently. Hence, according to the National Health Insurance Law, an HMO member is entitled to choose a service only from among a list of national or regional providers approved by the HMO or by the national health system. The law further stipulates that each HMO can determine the criteria for selecting between service providers and their scope in accordance with guiding criteria set out in the regulations [2]. These criteria must be transparent and available to the public. In recent years, and following policy changes, regulatory rules have been created that have also influenced the issue of choice (e.g. new rule requiring waiting period between seeing the same doctor in a public clinic and after in private).

The issue of the “scope of choice” within the public health system preoccupies all elements in the healthcare system, hinging on the axis between increased recognition of the individual’s autonomy and the desire to allow more patient choice within the system, and between recognizing the limitations of resources and the influence of choice on the realization of the principle of equitability and on the makeup of the public health system. This professional and public discussion has accompanied the health system since the beginning, intensifying over the years. Especially because studies indicate that the public in Israel believe it is important to choose hospitals and surgeon’s [3].

One of the main problems of the Israeli public health system is the steady decline in public trust and confidence in the public health system that may be attributed to various incentives, the lengths of public service queues, a sense of uncertainty and bureaucracy [4, 5].

One of the expressions of this trust decline was a sharp increase in the rate of individuals holding private and commercial health insurance policies, so that many Israeli residents have both the public health insurance they are entitled to by law and a commercial/private insurance [5, 6].

It was hypothesized that the public’s perception of the public health system as unequitable and untrustworthy nourishes the public’s sense of need to select their service provider, e.g., a surgeon, and therefore to hold private insurance, which allows greater choice of service providers. As a result, the public’s perception translates into large private health expenditure [6‐11].

As a preliminary stage for this study, qualitative research was conducted among senior policy makers in the health care system. Semi-structured interviews were conducted with 27 senior managers and policy makers from the Ministry of Health; Ministry of Finance; health clinics; public hospitals; private hospitals; academia; insurance companies; organizations and associations. In-depth, semi-structured interviews, were used as a window for understanding and structuring processes from the point of view of this unique and essential group. The qualitative analysis was performed using the ‘Narralizer’ software that helps the researcher to encode the interviewed meaning units, and to identify and map patterns and categories. As part of integrative methodology, the qualitative research findings served as the basis for the quantitative survey which is the focus of this article.

The qualitative preliminary study found that, in the opinion of the policymakers interviewed, the public’s trust in the public system constitutes an essential factor for its functioning, and for the efficiency of the health system in Israel. Public trust was identified by the policymakers as having a major and significant impact on public behavior (purchasing insurance and turning to private medicine). They also indicated that the patients’ sense of uncertainty in the public health system as a factor that undermines trust. In the opinion of policymakers, it is the public’s confidence in the public health system that affects the feeling of having to choose a surgeon. The lower the confidence in the health system, the greater the patient’s desire to choose the surgeon’s identity [12].

In this quantitative study presented in this article, we evaluated the attitudes and beliefs of a representative sample of Israeli adults regarding trust in public health system, equitability and choice a surgeon’s within the public health system.

A total of 865 Israeli adults responded to the survey (sampling error +/− 3.2% at 0.95 statistical interval), and the response rate was 31%. Table 1 (Socio-demographic characteristics of the study participants) presents the raw sample data prior to the weighting, the data after standardization and the data from the Central Bureau of Statistics. In purpose to express a representative sample of the Israeli population each group as been sampled went a process of standardization to got a relative weight in the population of Israel according to data from the C.B.S. Most participants were women (51.8%), Jewish (68.6%), and married (73.0%). A quarter of the participants (162, 18.8%) were older than 65 years and 34.1% (294) were 45–64 years old. In terms of religious orientation, over half of the participants (350, 47.8%) defined themselves as traditional or religious. Most participants were first-generation Israelis (367, 50.3%) and over a quarter (198, 27.1%) were second-generation Israelis. Half of the participants (415, 48.0%) had a Elementary and high school education and another 52.0% (450) had post-secondary education. Most of the participants (728, 84.1%) reported having good to very good health; 242 (27.9%) reported a chronic illness. Considering that the average wage in Israel at the time of the study was 9800 New Israeli Shekels (NIS), about a quarter of the participants (194, 22.5%) had an income below NIS 8600, and 24.2% (244) had an income between NIS 8600 and 16,600. As with the distribution of the population, about half of the sample reported that they were registered at Clalit Health Services, about 23.7% at Maccabi and the small number of participants in the Meuhedet / Leumit health fund. The overwhelming majority of the sample (83.5%) reported that they had supplementary health insurance (SHS) through the HMO, and about half of the sample (48.3%) reported that they had private / commercial health insurance.

The importance of the National Health Insurance Law lies in its defining principles: justice, equability and mutual assistance. These three principles determine the ideals and the service benchmarks set by the public health system. The survey results emphasize that there is a possible association between three meaningful factors: the trust in the public health system, the perception of the system’s equitability and the public’s perception of the importance of selecting a surgeon. This study did not examine the causal relationship between the various factors, but the study data suggests a possible connection between lower trust in the system and lower perception of its equitability, and a subsequent associated increase in the public’s desire to select a surgeon and thus to have an influence on their choice of service provider. The public’s confidence in the health system has been identified and marked as a significant and critical factor by the public whose views are reflected in the research data (Note: reference to the issue of agreements at the limitations section) .

It seems that after three decades during which senior policymakers have attempted to warn the government and health investors that the public health system is “dying” and/or “collapsing,” this message perhaps has permeated the public, and influenced its perceptions and contributed to its growing distrust of the public health system’s capabilities. In other words, it seems that this perception came from “above” to the Israeli public, rather than from the people to the policymakers. As such distrust has a systemic impact on the health system, it should be defined as the most significant and critical problem of the public health system.

Support for the issue of public trust in the health system and its various implications can be found in several surveys conducted over the last few years. For example, in a survey conducted by the Brookdale Institute, 84% of the respondents claimed that it was necessary to use personal and/or professional connections in order to receive good treatments quickly during a serious illness [13]. These reports are similar to the findings of a corresponding study in which 54% of the respondents reported that they are “not sure” or “not so sure” that in case of a serious illness they would receive the best and most effective treatment in the Public health system [13]. In another survey that examined the public’s attitudes towards health services in Israel, only 39.5% of the respondents expressed their trust in the health system, reflecting “a doubt that exists among the public regarding the ability of the public health system to provide an appropriate response.” Similar results have been shown in other studies that each group of non-Jews (Muslims, Christians, Druze) believes that the healthcare system has a great deal of equality (38%+), compared to only 28% of Jews [11, 14]. Similar results were also found in this survey (group of “Jewish” being significantly correlated with a view of system as being inequitable). The survey also found significant differences between the public’s image of the family physician (community medicine) and the image of hospital staff. The respondents expressed greater trust in their HMOs than in the hospitals [6]. similar results have been shown in other studies [3, 11]. As stated, these data correspond to data that underlie this work, and they can reinforce the findings and conclusions.

Another manifestation of the crisis in the public health system is reflected in the percentage of individuals who do not believe that they would be able to rely on the public health system in times of need, and therefore purchase complementary or commercial health insurance (75 and 40% respectively) [7]. These data are in accordance with a survey conducted in 2017, in which 84% of respondents reported ownership of any complementary health insurance, and 57% reported ownership of any commercial health insurance policy. The authors of the report also noted that 52% of the respondents had both supplemental and commercial health insurance, while only 11% had no additional health insurance to the basic health basket [3]. Similarly, the findings of this study showed that a high rate of respondents had supplementary insurance (82.5%) and commercial insurance (49.8%). While some see the accelerated rate of private insurance holders as an expression of free will, rational preference of risk and taking personal responsibility for health, others see it as an erosion of the public health basket and the continuing damage to its availability and quality, which has led to lower trust in the public health system and to a search for an alternative private insurance coverage [15]. This is evidence for the effects of reduced ‘public trust’ on the health system’s effectiveness, its functioning, and the realization of its goals.

In light of the public health system’s limited resources and the fear of violating the principle of equality that stands at the heart of the National Insurance Law, it seems that the key to maintaining the public health system is to enhance the public’s trust in the system as a whole, and particularly in its efficiency and various mechanisms.

The distrust in the public health system is associated in the public’s perception with the importance of selecting a physician, and particularly with selecting a surgeon in public hospitals. The ability to select a surgeon in a public hospital is the means by which the public tries to minimize the level of uncertainty, and to take more control over decisions regarding its own health and life. Here is the place to note the trade-off that can exist between surgeon choice and waiting time. For example, allowing surgeon choice can cause a long wait time for that particular surgeon; so the patient has to choose between waiting time / choosing a surgeon, in correlation to his own preferences and situation.

The findings of the study suggest that it could be useful to consider expanding the range of choices available to the public within the health system in a proportionate, responsible and informed manner while ensuring that the principle of equality is implemented in the allocation of resources in the health system.

This study is a sample of 865 participants representing all sectors of Israeli society and thus providing an accurate picture of the current perceptions about the public health system.

Israeli policymakers believe that public trust in the public health system is a fundamental condition for maintaining an efficient and equitable health system in Israel [12]. The survey of the general public suggests that uncertainty regarding the identity of the surgeon who will perform a procedure in a public hospital may be linked to a sense of insecurity and distrust of the public in the public health system. The survey also suggests that this may, in turn, encourage the public to turn to the private health system in which the individual has more control over choosing the treating surgeon.

Therefore, it may be that promoting public trust in the public health system could be a mechanism for reducing the usage of the private health system, decreasing private health expenditure in the long run. One of the ways to strengthen the public’s confidence in the public health system could be to provide the patient with reliable information regarding parameters such as the identity of the senior surgeon in the operating room or the surgeon’s suitability for the patient’s medical condition. The possibility should be accessible to everyone, procedurally and substantially - which means providing reliable information and tools for informed choice by hospital staff, free of charge from the patient or anyone acting on his behalf, etc. These possibilities should be further explored in future studies, that would be designed to more fully assess causal connections (including what the effect of media contribution to lowering trust in the public health system).

The findings of this survey can help policymakers recognized that a key element in achieving balance and regulation of fulfillment in the public health system lies in a significant and decisive component, which is, public trust in the public health system, its efficiency and its various mechanisms. Public trust through which it is possible to reduce the potential risk of inefficient or improper use of public resources in the health system.