I am a senior neurologist in Hadassah Ein Kerem. I am writing here to confess that I, personally, have probably cost Hadassah a great deal of money. I am not talking about malpractice suits, sending patients for unnecessary tests or accidentally dropping a bottle of expensive medicine on the floor. I am talking about something much more troubling.

I would like to illustrate my wrongdoing with a real example (some key facts have been changed to prevent identification of the patient involved). A patient, lets call him Reuven, went to his family doctor because he was having muscle cramps and later noticed that his left arm was getting weaker. His family doctor promptly referred him to a neurologist in the local kupat cholim clinic. This neurologist quickly identified that this was a more serious issue than he was used to seeing in his clinic, and after spending around 10 minutes with Reuven, sent him to the neurology clinic in the local hospital. Reuven was re-examined by the local hospital neurologist and after 12 minutes the neurologist said, “I think you have a nerve or muscle problem” and that he needed a “neuromuscular specialist.” He was referred on to my clinic in Hadassah Ein Kerem.

Reuven came to see me with his wife. My meeting with them lasted around 90 minutes. I was able to take a more complete history where I discovered that he had an older brother who died from ALS (a progressive almost inevitably neurodegenerative disease sometime called Lou-Gehrig’s disease). I carefully examined him and found some subtle signs in his tongue and legs that showed that his disease was not restricted to his left arm, but was affecting most of the muscles in his body; sadly, Reuven also had ALS. I started the process of breaking the news to him and his wife, answering all of their questions and discussed the plan for further testing and continued follow-up.

As the nature of my crime may still be unclear to some of you, I will now explain. Most neurologists in the kupat cholim clinics in the community receive payment on a per-patient basis; this amounts to around 150 NIS per patient seen. In the local hospital, the neurologist will usually be able to spend more time with the patient, but will sometimes feel out of their depth with more difficult cases; in these situations they often need to turn to a specialized clinic, such as those run in Hadassah. Nevertheless, the local hospital in question received a similar financial contribution (around 150 NIS) from the kupat cholim for the 12-minute consult with Reuven. The problem is, that Reuven’s 90-minute consult in the neuromuscular clinic in Hadassah resulted in a similar (though slightly lower) reimbursement figure of around 135 NIS (90 NIS per hour).

It is not difficult to understand the ramifications of this system. A neurologist (and other specialist doctors) in the community kupat cholim clinic is motivated to see as many patients as possible, as quickly as possible. Sure, you can spend an hour with each patient; you will simply get paid 150 NIS per hour (before tax). To make money as a specialist doctor within this system, you need to aim for the “low-hanging fruit.” You want to be spending your hour giving repeat prescriptions for 8 migraine-sufferers (around 1200 NIS before tax), not dealing with a single patient with a challenging diagnosis requiring lengthy explanations (around 150 NIS before tax).

Hadassah is a center of excellence where it is fitting that specialized clinics should run. When someone with a complicated condition remains undiagnosed after visiting the family doctor, the specialist in the kupa community clinic and the specialist in the local hospital, the “buck” stops with us (no pun intended). We are expected to spend as long as it takes to get the job done, whether or not this is “profitable.” When I read that Hadassah will be turned over to a manager instructed to “remove unprofitable services” I am scared, though not for myself and my family. Whilst an “unprofitable doctor” will always be able to find profitable work, an “unprofitable patient” will be left with no-one to turn to.

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