The Public Dental Health System in Israel

Over the past week there has been much criticism of the Israeli Health system in the media. We have heard of hospital wards operating at 200% capacity. The OECD issued a report ranking Israel very poorly on its expenditure for health services. It has been reported that there is an acute lack of medical personnel and a shortage of hospital beds. This week a pipe burst in the “new building” (only 70 years old) of Haifa’s Rambam hospital, causing millions of shekels of damage, which showcases the aging infrastructure in the health care system.

According to the Jerusalem Post, Deputy Health Minister Litzman welcomed the findings of the report “which again point to the system’s excellence.” I have heard multiple interviews with heads of medical departments who have claimed the health system is collapsing, so who are we to believe?

I myself am a healthcare professional, but as I am a mere dentist, I have no more insight into the realities of our general health care system than the average Israeli citizen who reads the newspaper and listens to the news. I am relatively healthy, so I have no personal incidents to relate. However, I do have some insight and opinions regarding the Public Dental Care program in Israel. Today there is free dental treatment for children up until their 18th birthday under the basket of health services. There is also coverage for seniors over the age of 75, but I will limit my comments to the services for children, because the senior coverage is very recent and because my involvement has been solely with children.
I will cover 3 different aspects of the overall system.

First of all is the Department of Dental Health Care program of “examinations” in schools. The Health Ministry sends a dentist once a year to every classroom in the country. A dentist makes a visual examination of the teeth of the child, using a pen flashlight. The dentist is not supposed to make physical contact with the child. Each examination takes a few seconds. In truth, this is not an examination, but a “screening”. It is useful to pick out children with very obvious dental problems, but it has no benefit for the majority of the children. In my 6 or 7 years of working for this program I estimate that I saw issues in approximately 20-25% of the children.

Many of the children were already aware of their situation, as they had been to the dentist and were in the middle of their treatment. I had an issue with the wording of the notice that the child took home after the screening. If the child needed treatment, it advised the parents to schedule an appointment for an exam with their kupah (health care provider) dental clinic. However, if the dentist did not see any problems with his 3 second visual exam, the notice said that no problems were found and that the child should visit the dentist according to need. Many parents mistake the screening as a competent dental examination and do not send their children for yearly exams.

I brought this issue up with Prof. Shlomo Zusman, head of the Department of Dental Health at the Health Ministry a few years ago. He listened politely, said he would think about it, and did nothing. I also brought the issue up at a meeting I attended of the Health Committee in the Knesset, and while it initiated a little discussion among the Knesset members present, nothing was done to change the wording of the message. The message should state that irregardless of the answer on the form, every child should have a dental checkup including x-rays, at least once a year.

The second aspect is the way the free dentistry system is set up, and the budget it entails. The government pays each kupah a capitation payment of about 170 NIS per child registered with the kupah per year. The kupah is then responsible to provide all of the child’s dental health needs, that are covered by the plan, for the year. This is a ridiculously low amount which does not come close to the real costs. The kupot pay their dentists per procedure. The payments are low, so in order to make a living, the dentist must work fast. The more treatments done in a shift, the more money earned. For a dentist working in a kupat cholim clinic, the compensation is around 40 shekel for a filling, and 8 shekel for an exam. Do the math to figure out the quantity of treatment necessary to earn a decent day’s wage. Obviously this system is not in the patient’s best interest. The kupot also try and save money on equipment and materials. Not all materials are available to the dentist, who on many occasions has to make do.

The kupot do not supply enough treatment hours to treat the children’s needs. They limit the number of dentists treating children in each branch. This causes a long waiting period for appointments. Many parents have told me they have waited as long as three months for an appointment. There is no shortage of qualified dentists in Israel. The reason the kupot do not add more dentists to treat children is that this significantly increases expenses but does not add income, because the capitation money has already been paid. The individual branches are held accountable for their profitability. Branches are not allowed to lose money.

One of the kupot does not have dental clinics of their own. They provide their services to their members by signing up a limited number of private clinics , outsourcing the treatments. The kupah requires that the dentist submit the treatment plan to the kupah, for approval. This process is done through one of the dental insurance companies. Many necessary treatments are not approved, for purely financial considerations. I worked with this kupah for over 2 years and can attest to numerous necessary treatments that were rejected by the kupah. If a treatment was done on the specific tooth 3 years before and now there was new decay, requiring the filling to be replaced, the treatment plan was rejected.

According to the law, the kupah had to provide this treatment. The kupah continually rejected these procedures, creating a tremendous amount of bureaucracy and in many cases still refusing to approve necessary treatment. I remember one case where a 12 year old girl ended up needing a root canal treatment in a permanent molar because the kupah refused to approve a filling 11 months before and the parents didn’t realize the importance of fighting for their daughters rights. When I terminated my affiliation with the kupah I made an official complaint against the kupah with the Department of Dental Health at the Ministry of Health. I brought documentation of 75 cases of inappropriate rejections of treatment plans. They claimed they were taking my accusations very seriously, but 2 years later I have not received any report on my accusations. They swept it under the rug.

The third aspect is perhaps the most serious, as it effects the weakest patients in the most serious way. A certain percentage of children can not be treated in conventional ways. This includes most children under the age of 4 and older children with severe dental anxieties. The only way to treat these children , many of which can have severe dental problems is with general anesthesia or sedation.

According to Ministry of Health regulations, these treatments must be done by a pediatric dental specialist in a hospital setting. For children under the age of 5 the treatment is free, and for over 5 the parents must pay for the cost of the anesthesia, but the dental treatment is free. The waiting period for such treatments can be 6 months or longer. A 4 year old child who is diagnosed with multiple cavities can not wait 6 months for treatment. The cavities will grow and in the end much more serious treatment is necessary.

On many occasions parents have brought in little children suffering serious tooth pain, on emergency. These children are not treatable under normal conditions. This puts more stress on an already overburdened system, and we dentists have no solution. The parents say they have an appointment at the hospital, but it is in three months or more. The clinic in the hospital will not and cannot accept emergency patients. We do not know what to tell these parents!

This past Friday a7 or 8 year old girl was brought in by her mother, on emergency. The 30 minutes she was in the clinic she did not stop crying. Her lower right jaw was swollen to twice its size, with cellulitis. She had been diagnosed in our clinic 3 months before with multiple carious lesions and a broken down milk molar that needed to be extracted. The child was not cooperative and it was decided she would be treated under general anesthesia. Her appointment is in January! This child came in suffering from incredible pain with an infection that could become life threatening. Our recourse now was to send her to an overcrowded (200%) hospital emergency room to receive antibiotic treatment by infusion.

A proper system would have a waiting period of not more than 3 – 6 weeks for these children. We are talking about 3 and 4 year olds. The situation we have now is totally unacceptable, but Deputy Health Minister Litzman claims the system is excellent. I beg to differ.