Elsevier

Health Policy

Volume 55, Issue 3, March 2001, Pages 209-225
Health Policy

Preventive service delivery for children in a managed care environment: contrasts and lessons from Israel

https://doi.org/10.1016/S0168-8510(00)00124-XGet rights and content

Introduction

North Carolina has begun to phase-in a managed care approach to the delivery of Medicaid-financed health care services. Because a substantial number of children enrolled in the Medicaid program are in the public health system, it is important to evaluate the future role that public health clinics should play in this managed care environment, especially in the area of preventive health care.

The Israeli health care system, for many decades, had an exemplary system for the delivery of pediatric preventive services. Recently, Israelis have begun to compare the advantages and disadvantages of several models for the delivery of preventive health care, including both a governmental delivery approach and the incorporation of preventive services delivery in managed care [1].

The societal imperatives pushing for a change in the Israeli system are similar to the forces at work in North Carolina, namely to

  • •

    constrain the growth of public expenditures for health care by organizing the delivery system more efficiently;

  • •

    maintain the quality of services and the coverage of the health care needs of the citizens, including preventive services, and

  • •

    move the public health agencies from the direct delivery of health care services toward a monitoring and oversight role.

This report describes the Israeli models of preventive health care delivery, focusing on the incorporation of preventive health services into a regulated managed care approach. It addresses the risks and advantages of such changes and provides recommendations regarding the future direction of public health practice in the US and Israel.

Section snippets

Overview

Historically, Israel has maintained a public-sector system of pediatric preventive care and child immunization delivery for the entire population. In Israel, children's preventive and curative care has been provided through two separate administrative, financial, and delivery systems. Preventive services (including immunizations) for children up to the age 5 years are provided by the Ministry of Health or its designees through a system of mother and infant neighborhood clinics, called Tipat

Changes in the Israeli health care system

Economic and governmental issues in Israel have begun to force some changes in the preventive health services system, with the potential for even greater changes in the near future.

The 1998 Israeli budget debate regarding preventive services

As part of the national budget debate for the 1998 fiscal year, the Ministry of Finance again raised the issue of divesting the Ministry of Health from the provision of preventive services and turning over this responsibility to the HMOs. The motivation of the Ministry of Finance was predominately financial and secondarily ideological. In looking for ways to trim the health budget, the Ministry noticed that some of the HMOs had opened Tipat Halav clinics (for marketing purposes) near

Rationale for examination of the Israeli health care system

The Israeli Ministry of Health operates a system for preventive care separate from curative care. This is similar to the operation of many health department clinics which traditionally have provided preventive care in North Carolina. Many children in North Carolina are classified as ‘underinsured’ and have insurance coverage for curative services but not for preventive care [10]. As such, they utilize the public health system in a similar fashion as the Israeli public uses the Tipat Halav

Issues to be addressed regarding managed care responsibilities for preventive health services among Medicaid-eligible children

Many issues must be addressed by states in considering whether or not the responsibility for the provision of preventive services to children receiving Medicaid benefits should be contracted to managed care providers. If the public health system is to limit its role in the delivery of clinical services and assume more of a regulatory and policy-setting role for children, assurances must be made that populations traditionally served by the public health system will still receive services in this

Ensuring preventive services delivery

In the US, as opposed to the system in Israel, there is a long tradition of primary care providers who attend to the needs of children by incorporating both preventive and acute illness care into the scope of their practices [12], [13]. This is especially true for the field of pediatrics, which has taken an aggressive stance in setting itself apart from most other medical specialties whereby professional involvement in the provision of preventive health services is seen as a basic component of

Responsibility for outreach programs

Pediatric preventive service utilization is often unpredictable and less than recommended for specific populations [25], [26]. For these ‘at risk’ populations, outreach and recruitment efforts are considered an integral and essential component of the health care system. When public health agencies are the providers of preventive health care services, it is often the case that these services are coupled with organized programs of outreach (e.g. consumer/patient education, community-based service

Assuring quality of preventive services

The assurance of the quality of preventive services delivery is important, but not an effort done with great care under the present systems in the US [29]. Managed care organizations are expected, in most markets, to report data pertinent to the HEDIS criteria from which the proportion of specific services provided to their enrolled populations can be ascertained. These data, especially for such services as childhood immunizations, may be used by employers and patients at the time of open

Mandated public health reporting requirements

Whether or not a separation of preventive and curative services is attempted for Medicaid-eligible populations in North Carolina or any state, there is a need for standardized reporting of population-based access to basic preventive health services and their utilization, especially for expectant mothers and children. To some extent this occurs annually on a population-wide basis through the cooperation of public and private agencies. For the past 3 years, the North Carolina Institute of

Coordination of service delivery to vulnerable populations

At the present time, there is a disappointing level of coordination between private sector and public health providers of preventive and/or curative child health services in the US. This lack of private-public sector coordination is of variable significance from one jurisdiction to another depending on the leadership of local medical societies and public health agencies. One reason these problems of coordination are so difficult to overcome involves the absence of effective child health

Conclusion

The challenge of developing an effective system for the delivery of preventive services to economically disadvantaged populations is vexing. Examining systems of care from other countries may be helpful in learning about strategies that have been successful or have failed. In any assessment of the exportability of programs from countries however, the programs must be viewed through the societal and cultural perspective of the ‘importing’ country. No matter how successful a program may be in one

Acknowledgements

Supported by a grant from the North Carolina Department of Health and Human Services Division of Medical Assistance, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, and Division of Women's and Children's Health. This project was performed with the assistance of the North Carolina–Israel Partnership, Inc.

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      In 2016, 94% of the population in Israel were vaccinated against diphtheria-tetanus-pertussis (WHO-UNICEF, 2017). Although other models of preventive medicine for mothers and children (Freed, DeFriese, Williams, & Behar, 2001; Hemminki & Blondel, 2001; Oldenburg & Owen, 1995; Sarkadi, Gulenc, & Hiscock, 2015) exist worldwide, the preventive services as currently provided in Israel are perceived by the Israeli public as professional, friendly, and non-discriminatory. As already discussed, Putnam (1993) referred to social capital as “a complete set of characteristics of a social organization such as trust norms and social networks that can improve and rationalize the functioning of an organization or community by accelerating coordinated actions” (Putnam, 1993, p. 167).

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