Sarit, the mother of a 6-year-old boy and an insured of Kopfh Klalit from Netanya, needed a referral for surgery for her son. But for no apparent reason they refused to refer her to Hillel Yaffe Hospital in Hadera, where an appointment was available within three months. Instead, they insisted on referring her to the general hospitals, where the next available appointment was no less than five months away (and in some cases even eight).
Only by applying to the Public Acceptance Commission at the Ministry of Health was it determined that she was entitled to receive the referral to Hillel Yaffe.
But Sarit is not alone.
"Israel Hayom" has received additional inquiries and claims from the general insurance policyholders in the Hadera area, who complain that the fund is refusing to make referrals to Hillel Yaffe.
In general, they claim that these things are not true, and that 90 percent of the requests are approved.
General Health Insurance Fund, photo: Yehoshua Yosef
Already a year ago, we published a request from the heads of authorities in the Hadera area, according to which Klalit is holding its patients "hostage" and preventing referrals to Hillel Yaffe, but the situation has not changed since then.
"My son suffered from a third almond and everything that goes with it, such as breathing pauses in his sleep," Sarit says.
"When an appointment and date was set for surgery at Hillel Yaffe, I had to bring Form 17, and they refused and said they don't approve. According to them, you can get this service at other hospitals. In a conversation with the Meir and Billinson hospitals, I was told that they don't accept Hillel Yaffe's doctor's examination and that they need their doctor , that is to wait five months for surgery.
Schneider told me that the waiting period is about eight months.
opacity.
Head of the General Community Division, Yoram Segal, photo: Moshe Buchman
"I was harassed in front of the cash register for a whole month to appeal and get a referral to Hillel Yaffe. At the Sharon district admissibility commission they told me there was no settlement and to 'wait as long as you have to wait.' Insist on what is due. The ward at Hillel is excellent, and I worked hard to get there.
"I am fully insured from birth and I don't understand this opacity and this insistence. They know the child's medical condition. They also know the availability of surgery appointments everywhere. It makes it difficult to keep the money in the coffers, because when they refer me to Schneider or Meier - they They transfer money from pocket to pocket. They treat me like a captive customer. The acceptance commission at the Ministry of Health saved me."
In the coffers, they "prefer" hospitals that they own.
Meir Hospital, photo: no credit
A life-threatening delay
Sima Miyos (74) from Hadera also had to appeal again and again just to get an appointment with an orthopedist in Hillel Yaffe.
Miyos is sick with arthritis and is not mobile, so she requested treatment close to her home.
"Since June I have been waiting for approval. Only in the last few days, after I appealed twice, did I receive a positive answer," she says.
"At Kellit they told me that I should go to their doctors, but I couldn't find a knee specialist. They wanted to refer me to the Emek Hospital in Afula, and I told them that I don't go far when I have a hospital nearby.
They insisted, and I was already thinking of going and paying out of my own pocket, then after I appealed twice I received form 17. This week I can finally get to my appointment.
For older people, for whom mobility is difficult, I recommend appealing and getting what they want."
In general, we noted that the referral given to the privileged was for treatment within the framework of "community medicine", but the referral was not approved because there was no knee orthopedic examination in the community.
According to them, the referral to the hospital was given "before the rule of law", despite the fact that she did not go to the doctor of Klalit in the community first.
Only treated when it comes to human life
Another case in which Klalit refused to give a commitment to treat Hillel Yaffe was that of a 61-year-old woman, who was hospitalized last March in the internal ward of Hadera Hospital due to worsening heart failure.
While she was in the hospital, it was found that she needed a defibrillator pacemaker implant, to prevent death.
For three days, Hillel Yaffe tried to get permission from "Moked Kotzavim" in general, while during that time the woman's condition worsened until she lost consciousness.
She needed CPR and was ventilated and sedated.
Three days later permission was received from the college to perform the operation - in Bilinson.
Only after a senior doctor from Hillel Yaffe appealed to the General Assembly again and warned that "it is a human life," permission was received to perform the urgent transplant.
The case was reported to Dr. Iris Leitersdorf, the director of the Department for the Control of Health Insurance Funds at the Ministry of Health, who made it clear to the General that Hillel Yaffe Hospital is in the selection arrangements, and that patients should not be diverted to other hospitals.
She further emphasized that "it is prohibited for a fund to prefer one hospital over another and to apply additional screening or restriction beyond the need to receive a commitment."
In general, we noted that it is possible that due to a malfunction they were not aware that the patient was already hospitalized.
Dr. Dudkevich,
A big hassle for patients
What does the law actually say?
The health funds are obliged to purchase services from the hospitals for a minimum amount ("floor"), beyond which they receive a discount on the purchase of services for their insured in a larger scope.
It was recently announced that the Maccabi Medical Center refers only the residents of Ramat Gan and Bnei Brak (along with the residents of the south and the north) to Sheba Hospital, while it refers the rest of the residents of the center to other hospitals, for financial reasons (see separate box).
In Hillel Yaffe, they point out that in recent years there has been a downward trend in the procurement of services on the part of Klalit, and that this causes a "blockage of inquiries."
"We see that patients are referred to very distant hospitals of the coffers, or to Herzliya Medical Center, and are unable to reach available treatment," says Dr. Miki Dudkevich, director of Hillel Yaffe, "this causes a great deal of trouble, loss of working days and burden on patients.
"The patients are not aware of all the rules"
"We are increasingly encountering situations where people are willing to pay out of pocket for advice or treatment at Hillel Yaffe for services that are in the basket. The patients are not aware of all the rules. They do not know that they are allowed to come to Hillel Yaffe to receive treatment. Klalit operates for obvious financial considerations that are not in the best interest of the patients.
"The expectation from the Ministry of Health is that it will work to oblige the health fund to allow patients to receive treatment at the hospital for those who choose us. There are cases where failure to refer to the hospital has caused damage to the patient's health and sometimes serious damage."
Hillel Yaffe Medical Center in Hadera, photo: Yehoshua Yosef
According to Dr. Dudkevich, the hospital's internal data shows that while there is an increase in purchases by other funds for treatments at the hospital, there has been a decrease in purchases by Klalit. He further noted that the number of referrals by Klalit does not even reach the minimum payment it pays to Hillel Yaffe: " An absurd situation has arisen, in which the health insurance fund pays for medical services that the insured do not receive, and still chooses not to send its insured to Hillel Yaffe."
Dr. Zeev Feldman, chairman of the state doctors' organization and a pediatric neurosurgeon in Sheba, believes that the time for selection arrangements has passed: "A person should be allowed to choose where he will receive treatment, then the 'attraction' of patients will be based on excellence and not based on the assumption that the hospital gives to the fund. The patients are held captive here by the funds. Depriving the insured of treatment at the hospital closest to their area of residence could harm their health."
A similar case of "Maccabi
A case similar to the ones detailed in the article, in which the selection arrangements between the health insurance funds and the hospitals prevented the insured from treatment, was revealed in "Israel Hayom" half a year ago.
Then "Maccabi" announced that it would not allow its insured residents of the center (with the exception of Ramat Gan and Bnei Brak) to receive treatments at Sheba Hospital. The directive did not refer to urgent treatments through the emergency room.
The background for the restriction was Maccabi's request to receive a discount from Sheba for referring insured persons.
After their request was refused, Maccabi contented themselves with referring the residents of Ramat Gan and Bnei Brak so that they would reach the minimum number of referrals for which they had already paid to the hospital.
Heads of authorities in the region petitioned the Labor Court claiming that the fact that the residents of Bnei Brak and Ramat Gan receive referrals and their residents do not - is illegal discrimination.
The court ruled that for 90 days Maccabi will return to giving references.
Maccabi Community College (archive),
The court did not discuss the claim of discrimination, and did not determine that Maccabi acted in a discriminatory manner.
The court's decision allows Maccabi to go back and change its selection procedures again and prevent referrals to Shiba, while meeting certain criteria.
Budget considerations
The tension between the health funds and the hospitals stems from economic reasons and the short budget blanket.
The largest expenditure of the health funds is for hospitalization days, and they are obliged to remain budgetary balanced.
Therefore, the funds also have an incentive to develop their own services in the community (emergency medicine centers, specialist services, etc.). On the other hand, this is also the main income of the hospitals, which strive for the funds to buy more services from them, and they also have a goal of budget balance.
In general: the volume of approved references is on the rise
The Klalit KPF rejects the claims made in the article and points out that their procurement from Hillel Yaffe Hospital is on the rise: "Sharon Shomron District is in an agreement with Hillel Yaffe Hospital.
In the last year, the volume of approved referrals has increased, and most referrals are approved.
"In the last three months, we see a six percent increase compared to last year. Unfortunately, the hospital chooses to present cases and data that do not represent and do not correspond to what is happening in practice. We will continue to act for the benefit of our patients and their well-being in every city or locality, for the accessibility and acceptance of the best medical service, as is the case with Hillel Yaffe Hospital.
As for the cases in question - without the patients' details, we are unable to refer to their bodies and examine the reason for the refusal, which may have resulted from the lack of eligibility in the basket or the patient was offered an alternative to treatment in community clinics."
The Ministry of Health stated: "We have not received any request from the General Fund to change the selection arrangements relating to Hillel Yaffe, and therefore the fund must act in accordance with the arrangements announced to the public.
The conditions for receiving the services and referrals are medical judgment, the area of residence of the insured, a medical referral based on a commitment and the degree of urgency for hospitalization services, as detailed on the fund's website.
Insureds who are entitled to this should not be prevented from reaching Hillel Yaffe, and the office will verify this.
"We do not interfere in the commercial terms between the health insurance fund and the hospital, as long as the patients receive their rights in accordance with the law and the regulations. However, a decrease in the fund's purchases at the hospital in recent years is not commensurate with the significant increase in the size of the population in the area and the need for medical services that are supposed to be provided in a hospital."
were we wrong
We will fix it!
If you found an error in the article, we would appreciate it if you shared it with us