Physicians for Human Rights-Israel: Physicians Speak About Low-Income Patients

8/8/2019 Physicians for Human Rights-Israel: Physicians Speak About Low-Income Patients

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PHYSICIANS SPEAK ABOUT LOW-INCOME PATIENTS

AN ANALYSIS OF PHYSICIANS' TESTIMONIES ABOUT

PATIENTS WHO CANNOT AFFORD PRESCRIBED

MEDICINES AND TREATMENTS

MAY 2008


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PHYSICIANS SPEAK ABOUT LOW-INCOME

PATIENTS

AN ANALYSIS OF PHYSICIANS' TESTIMONIES ABOUT

PATIENTS WHO CANNOT AFFORD PRESCRIBED

MEDICINES AND TREATMENTS

Written by: Dr. Yuval Livnat

Testimony collected and recorded by: Daniella Cheslow


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CONTENTS

Summary 4

Introduction 6

Presentation of the project 6

Methodology

Research Findings 12

The dynamic between the physician and the 12

low-income patient

The medical implications of poverty 14

The physician as a detective: How physicians 20

track down patients who fail to obtain treatments

and prescription medicines

Creative ways of coping with the patients 24

inability to pay

Drug samples 25

Substitute drugs 26

Prescriptions for fictitious dates 28

Transferring medicines from patient to patient 28Paying from their own pockets 29

Summary and conclusions 31

SUMMARY

The report Physicians speak about low-income patients is

based on a series of interviews conducted by Physicians for


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Human Rights with 44 primary-care physicians (family

physicians and pediatricians) who provide community medical

services.

The aim was to learn, this time from the viewpoint of the

physicians, about the phenomenon of low-income patients who

cannot afford to buy prescribed medicines or medical

treatments and services which are available as part of the

national health insurance basket. It should be noted that

this phenomenon, namely inability to pay because of the co-

payments required of patients, has been documented in

several scientific studies.

Many of the physicians we interviewed reported cases in

which they discovered that the patient had not bought a

medicine or a treatment because he or she could not afford

the co-payment. They described the medical implications of

failure to receive the medicine or treatment. In some cases,

the patients condition worsened to the point where it

required hospitalization. Sometimes the delay in receivingthe required medical treatment caused irreversible damage.

In light of the medical expertise of the interviewees, we

asked them to tell us in greater detail about specific

patients whose health was damaged because they could not

afford the medicines or treatments. We have interwoven

reports of such regrettable cases in the report.

The interviews revealed that, due to their dissatisfaction

with this state of affairs, the physicians often adopt

various creative methods in their desire to help the

patient. For example, some doctors reported that they

distributed medicine from the supply of samples provided by

drug company salespeople, gave out prescriptions for cheaper

(and less effective) substitute drugs, or prescribed

medicines for a fictitious date (so that they were included

in an earlier or later calendar quarter), or even resorted


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to personal subsidy of the medicine or treatment. However,

these solutions as is clear from the report attest to

the severity of the problem rather than to its solution.They also raise ethical dilemmas for the doctor, as will be

shown.

The testimony recorded in the report indicates the need to

consider revocation of the co-payment system.


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INTRODUCTION

PRESENTATION OF THE PROJECT

Over the past few years, several research studies have

indicated that co-payments those payments which patients

are required to pay for prescription medicines or medical

services within the framework of the national health

insurance basket 1 create an economic obstacle for an

increasingly large proportion of the population, who forgo

vital treatment because of the cost. The health basket is aset of medical goods and services insured under the national

health insurance law.

For example, a study conducted by the Brookdale Institute

found that 27% of Israelis (and a third of the low-income

population and as much as a third of the chronically-ill)

reported that payments for health constitute a heavy burden

for them. It was also found that 30% of low-income patients

and 20% of the chronically ill waived medical treatment or

medications because of the co-payment involved. 2

These important studies focused on the viewpoint of the

patients in light of the National Health Insurance Law,

mostly by conducting surveys among a representative sample

1

The co-payment for visits to the physician ranges from 6-18 shekel percalendar quarter, while co-payment for visits to outpatient clinics orinstitutes amounts to 24 shekel per calendar quarter. Payment formedicines is as follows: Clalit Health Services 10% of the maximumprice or 11 shekel, whichever is highest; Maccabi - when the maximumcost to the consumer is less than 98 shekel 12 shekel perprescription, above 98 shekel 15% of the price; Leumit and Meuhedetif the maximum price is less than 92 shekel 12 shekel perprescription, above 92.shekel 15% of the maximum cost. With regard tochronic patients there is a self-participation maximum of 228-241 shekelper individual.2Revital Gross, Shuli Barmali-Greenberg and Ronit Mazliah, Publicopinion regarding the level of service and function of the health systemon the tenth anniversary of the National Health Insurance Law (Hebrew)March 2007.


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of patients. They compared such variables as income level,

gender, chronic illness, etc.

In this report we focus on a different angle: that of the

primary care physician. Through personal interviews with

physicians and through questionnaires, we sought to discover

whether they were familiar with the phenomenon of patients

unable to afford basic medical care; how the question of

co-payments" affects the dynamics between the physician and

the patient; how physicians respond when they encounter

patients unable to afford medicine and treatment; and what

medical implications are engendered by this phenomenon.

METHODOLOGY

The study was conducted by means of in-depth interviews and

questionnaires. We interviewed 31 physicians. Eight of the

interviews were conducted in person, the rest by telephone.

In addition, another group of 13 physicians responded in

writing to a questionnaire on the co-payments system. Inthe interviews and in the questionnaires we emphasized that

we were requesting answers solely with regard to medicines

and treatments included in the national health insurance

basket.

Of the 31 physicians, 26 are family doctors and five

pediatricians, 21 are male and 10 female. Thirteen are Arabs

and the remainder Jewish (it should be noted that some of

the Arab physicians work in Jewish or mixed settlements). Of

the physicians who responded to the questionnaires, seven

were family doctors and the remainder pediatricians, nine

male and four female 11 Jewish and two Arab.

Of the physicians we interviewed (in person or by

telephone), we first approached those who are registered

members of Physicians for Human Rights. Later we also


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approached non-members to whom we were referred by the

member physicians we had interviewed. In the end, of 31

physicians we spoke to, 27 are members of PHR while four arenot. The physicians who filled in the questionnaire are all

PHR members.

Most of the physicians we interviewed work in low-income

settlements or neighborhoods mostly Ashkelon, Beitar, Beit

Shemesh, Bartaa, Haifa (Wadi Nisnas), Taibeh, Tira, Jaffa,

Jerusalem (Old City, San Simon, Ir Ganim), Kafr Qara, Arad,

Furadis, Petah Tikva (Kiryat Alon), Rosh Haayin and Tel

Aviv (Yad Eliyahu); the minority work in more prosperous

settlements including Mevaseret Zion, Haifa (Ahuza),

Jerusalem (Beit Hakerem), Raanana and Kibbutz Beit Oren. Our

focus on physicians working in low-income neighborhoods was

deliberate as we anticipated that these physicians would be

more exposed to disadvantaged patients. Twenty-one of the

physicians are employed by Clalit Services, eight by

Maccabi, two by Meuhedet and one by Leumit. The

questionnaires, on the other hand, were sent to members ofthe PHR without selection by place of employment or any

other parameter.

It should be noted that in the interviews and

questionnaires, we did not ask the physicians whether they

thought the co-payments should be revoked..We asked only

whether they had encountered the phenomenon of patients

unable to afford medicines or treatments, how this inability

affected the patients medical condition and how they

themselves reacted to the problem. Despite this, some of the

physicians chose to expound their views as to whether co-

payments for services and medicines included in the health

basket should be reduced or revoked. Some favored this move

and some opposed it. Some of the physicians, despite their

reports of the deterioration of some patients health


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because of inability to fund medicines and treatments, did

not favor the cancellation of the co-payment policy.

As can be seen from the above, it was not our intention to

conduct a scientific study based on stringent academic

criteria certainly not a quantitative study. The fact that

most of the interviewees are members of PHR can reasonably

be assumed to constitute a bias, since it is by no means

clear that the profile of a physician member of PHR is

compatible with the profile of the average physician. It

should be further emphasized that we had no special interest

in the standpoint of the physicians on the question of

revoking co-payments (we do not believe that physicians

views have any priority over those of various researchers,

health economists or public health experts). Our objective

was to conduct in-depth interviews, collect answers to

questionnaires, and receive information of fundamental

rather than statistical significance. Thus, for example,

some of the interviews included information which raised

questions relating to the ethical commitments of physicians.These questions raise issues of principle and it is

important to clarify these ethical questions without regard

to their statistical frequency.

We obtained a large amount of information of essential

significance, which is detailed below. For example, the

interviewees described the dilemmas they face because of the

obligation (of some of them) to collect a fee for the visit

and in light of their awareness that some low-income

patients cannot afford prescribed medicines or treatments.

They described the various measures they adopt in order to

solve or minimize the problem but, as will be shown below,

these creative measures raise certain ethical, moral, and

legal problems of their own. We also tried to discover

whether doctors believed the poverty of their patients can

have implications for their health. On this question,


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physicians can provide informed and expert opinions, and we

were interested in their views. They were also asked to

detail specific cases they have encountered where thepatients health deteriorated because of inability to pay.

This is essentially a medical issue as distinguished from

the question of whether the co-payment policy should

continue even as the cost of deterioration in health

which is a question of morality and of policy.


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RESEARCH FINDINGS

THE DYNAMIC BETWEEN THE PHYSICIAN AND THE LOW-

INCOME PATIENT

The patient comes in to see me, hes in a bad condition and

he doesnt expect to pay for the visit. It disrupts the

therapeutic process the flow, the empathy. The patient

comes in, sits there facing me and I start talking to him.

Suddenly I have to stop and ask him if he has six shekels.

(Dr. A., family physician, Herzliya )

In several of the interviews, the physicians reported

tension between them and their poorer patients because of

the payment required for the visits. Since in-person

interviews were conducted only with family physicians and

pediatricians (and not specialists), the subject was raised

only by physicians employed by Maccabi, the one sick fund

that exacts a fee for visits to primary care physicians. A

the same time, it is noteworthy that the problems cited by

Dr. A. (who is a Maccabi family physician) could arise in

the other sick funds as well, at least with regard to

independent specialists (as distinguished from physicians

who are employed by the sick fund). When a physician works

with the sick fund independently, with the status of

service provider and not employee she is responsible for

collecting the fee from the patient. However, the problem ismost frequently encountered, as noted above, in Maccabi,

which charges a fee for visits to the family physician and

also works mainly with independent physicians.

The Hippocratic Oath states that every physician must take

into consideration the benefit of the patient and that

benefit alone. When the sick fund assigns to a physician


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responsibility for collecting a fee from the patient as a

condition for receiving treatment, the physician may face a

serious ethical dilemma. In practice, the very demand thatthe physician function as a fee collector is problematic. A

physician should focus on providing medical care and not on

collecting money. Moreover, what should a physician do when

faced with a patient who makes it clear that he or she

cannot afford to pay? The physician quoted above said,

Maccabi demands six shekels for a calendar quarter from the

patient (for primary care)the doctor is responsible for

collecting this sum. Then the discussion of money begins. If

someone doesnt have the money, the doctor has to decide

whether to accept him or not. This doctor added that

Maccabi goes even further and deducts the cost of the visit

from the physicians salary if she chooses to see a patient

who has not paid for treatment!

It should be noted that some low-income patients, who are

often in frail condition exacerbated by their need to tackle

bureaucratic obstacles, have a negative opinion of doctors.Dr. Aharon Karni, a primary care physician from Nataf, said,

Because of their emotional distress they are often

problematic patients. They identify the doctor with the

system, and then there is hostility and alienation. It is

reasonable to assume that when a physician asks a patient

for payment in return for treatment, the patients sense of

alienation, and his identification of the physician with the

system becomes more acute.

THE MEDICAL IMPLICATIONS OF POVERTY

I have had many cases where a child is brought in with a

fever and I prescribe something some drug to reduce the

fever. They return the next day and I ask the mother what

she gave him, and she says nothing, theres no money.


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Dr. Obeid Raid, pediatrician, Haifa

Of the physicians we interviewed, only one replied in the

negative to the question: Have you encountered patients who

reported that the co-payments for drugs or the fees for

other services are a burden to them? In other words, almost

all the physicians we interviewed had heard at least one

patient complain of not being able to afford medicines or

services. In practice, a large proportion of the doctors,

unsurprisingly mainly those who work with low-income

populations, reported more than one or two patients who

complained of their difficulty in funding medical services.

Some of the doctors reported that the patients could not

afford to pay for medicines and others that they could

afford neither medicines nor medical services.

Not every case of lack of funds ends in a failure to buy

drugs or treatment. Often poor patients make a great effort

or save on outlays for other needs (food, clothing, winterheating, etc). In other cases, they take out loans or are

lucky enough to receive a positive reply to applications for

social subsidies. When we asked the physicians, How do your

patients cope with their money problems? some answered

that, despite the fact that the patients reported money

problems, in the end they paid for the medicine or medical

service. At the same time, a large number of physicians

reported that at least some of their patients who reported

financial difficulties, did in fact refrain from paying for

the medicine or service/treatment. Other replies we received

on this question were that patients purchased smaller

amounts of the drug. Most of the patients compromise; if a

child needs Augmentin, his mother will buy one bottle

instead of two, said Dr. T., a family physician in Netanya;

When you say to the parent that the child needs to take 90

pills a month, 3 a day, she says: Give me enough for half a


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month and Ill come later to take the rest, but she doesnt

return, said Dr. A., a pediatrician in Arad.

Sometimes the patients preferred a prescription for a

similar but less effective drug (or one with more side

effects) because it was cheaper. This was a solution quite a

few physicians reported being forced to accept; see chapter

on Creative ways of coping with the patients poverty.

Several physicians reported other creative solutions

adopted by their patients. For example, Dr. Naomi Stockwell,

a family physician in the San Simon quarter of Jerusalem,

related that some of her patients purchase drugs in East

Jerusalem because they are cheaper there. I had a diabetic

patient, and I saw on the computer that he had not bought

the drug I prescribed for him, she said When he came for a

check-up I asked him why and he reassured me that he was

taking the medicine he had bought it cheaper in East

Jerusalem. The problem in buying there is that often, though

not always, of course, these drugs are counterfeit orstolen. If they are stolen, that is OK ( medically speaking

Y.L. ) but if the drug is counterfeit, that is a problem.

Yet, while some patients make a tremendous effort and buy

the drugs and others find creative solutions (which may

constitute health hazards), the interviewees revealed that

there are still many patients who forgo medicines or visits

to the doctor altogether. When we asked the 31 physicians we

interviewed in person or by telephone how their patients

coped with their difficulties, 27 replied: They dont buy

the medicine, or They forgo the treatment or test. The

four physicians who did not report patients who gave up

drugs or treatment work in more prosperous communities; Beit

Hakerem in Jerusalem, Mevaseret Zion, Kibbutz Beit Oren and

Kibbutz Givat Haim Meuhad.


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Dr. Firas Azam, family physician, Petah Tikva.

The diabetic patients are not alone. The physicians reported

economic hardship of other chronic patients. The above quote

from Dr. Azam reinforces the testimony of Dr. Zohir Tibi, a

family physician from Netanya: Asthmatic patients require

preventive treatment. They need inhalers. I work with a weak

population Ethiopian immigrants and poor veteran Israelis.

They dont pay for treatment or only do so when their

condition worsens.

In addition to diabetics and asthmatics, the physicians told

us that people suffering from a range of other diseases are

also unable to afford the necessary drugs or treatments. Dr.

Ahmed Masarwa of Taibeh told us about a patient who needs

three different drugs for glaucoma and cannot afford them

every month. He buys only one. I have known him for a year

and a half. He lives on a National Insurance monthly stipend

of 1900 shekels. His condition has deteriorated since Ifirst saw him. His vision has worsened and he may become

blind. There are many other cases. Parents who did not

bring their children for treatment at the Child Development

Institute (for occupational therapy, speech therapy etc)

because of the fee of 21 shekels per treatment (reported by

Dr. A., Child Development Institute, Jaffa); patients unable

to afford drugs for ulcers (reported by Dr. Leah Lev

Luzatto, Yad Eliyahu); patients whose cholesterol level is

not balanced because they do not take Simovil regularly (Dr.

Firas Azam, Petah Tikva); patients who suffer from high

blood pressure but cannot afford such drugs as Norvesk (Dr.

S., Jerusalem); patients who refrain from having x-rays or

laboratory tests because of the cost (Dr. Emmanuel

Kornitzer, Beit Shemesh). The list goes on and on.


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Often failure to take drugs or to receive primary medical

treatment leads to drastic deterioration in the patients

condition to the point where hospitalization is required. Wehave already noted several such cases. Here is another

example:

I have many female patients who are prescribed Fusalan for

treatment of osteoporosis. The co-payment for this drug is

almost 90 shekels. They dont have the money so they dont

take it regularly. And then they break an arm or a leg. I

remember one who broke her hip after not taking Fusalan. She

was hospitalized and underwent surgery.

Dr. H., family physician, Jaffa

These examples appear to illustrate the poor economic logic

of the co-payment policy. In other words, not only does the

demand for co-payment bar low-income patients from relief

and cure, but also, it is not economically effective. Co-

payments are often cited as an essential means of financinghealth input and as a disincentive for overuse of drugs and

treatments. But it is by no means clear that this policy

encourages saving of public funds because when patients do

not receive primary care because they cannot afford it,

their health can deteriorate to the point of

hospitalization. Since this service is covered by the

service basket, the public bears the cost.

Another point of note is that the financial outlay on

primary care is not always confined to payment for a drug or

treatment. The patient has to bear additional costs, such as

transportation, which can be unaffordable. This point was

raised by several of the physicians. For example, Dr. Zohir

Abdulla Masarwa, a family physician from Bartaa, said,

Preventive medicine, such as tests for osteoporosis or

mammographies, cannot be carried out in the village but only


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in a nearby town, Hadera or Um el Fahem. There is no public

transport in the village so they have to take a taxi which

costs 150 shekel. So patients satisfy themselves with astandard blood test that can be carried out in the village

and forgo other tests.

THE PHYSICIAN AS DETECTIVE: HOW PHYSICIANS TRACK

DOWN PATIENTS WHO DO NOT OBTAIN DRUGS OR TREATMENTS

Sometimes I see that the test results are irregular, or the

triglycerides are high and I start checking if the patientis buying the prescribed drugs. I can link up to all the

pharmacies in Clalits computerized system. If I see that he

hasnt purchased the drug, I try to persuade him that he

needs to take it.

Dr. G., family physician, Ir Ganim, Jerusalem.

We asked the physicians, How do you know if a patient is

not taking a drug or receiving treatment? A few replied

that the patients themselves confess their economic plight.

Of the rest, some replied that they had no real way of

checking. Others replied that the test results roused their

suspicions because there was no improvement (or was actual

deterioration) in the patients condition. Several

physicians told us that relatives of their patients reported

that the patient could not afford the fee for a visit to a

specialist or imaging institute.

A significant number of physicians told us that low-income

patients are slow to confess their financial difficulties.

Dr. Abed Latif, a family physician from Tira, said, I can

check on the computer program when the patient last

purchased the drug. If I see that he hasnt done so for the

past two months, sometimes I ask why, but the patients


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usually evade replying. Dr. S. told us in detail about one

such patient: I have a 65-year-old patient with high blood

pressure. I checked his pressure for several months and itdid not go down. It turned out that he could not afford the

medicines but was too embarrassed to tell me. He was polite

and continued to come for checkups but was not taking the

drugs such as Norvesk or Ethanolol. After some time, last

year, while I was checking something on the computer I

discovered by chance that he wasnt buying the drug. It was

tricky, because he hadnt been telling the truth for several

months. So I raised the subject tactfully. I said, These

are difficult times, perhaps you skip taking the drug from

time to time? And he said: I wouldnt say that isnt so.

She returned to this subject later in the interview: I

think the main problem with my patients is that they are

really embarrassed to confess and they do everything

possible not to tell me. I have been working with the same

population for 15 years. I am a kind of authority figure and

that embarrasses them.

The combination of low-income patients who cannot afford

their prescriptions and are also ashamed to reveal this to

their doctors has created the phenomenon which we might call

The physician as detective. Doctors have to track down

patients who fail to buy medicines or treatments. After

detecting, most of the physicians so it transpired from

the interviews- confronted their patients with the truth.

About two-thirds of the physicians told us that they check

the computerized system to discover whether their patients

are purchasing the prescribed drugs or treatments. Each of

the sick funds has a computerized system which links the

physicians to the pharmacies and other medical units so that

she can check if the patient is purchasing the drugs or

whether the prescribed laboratory test has been undergone.

Dr. Samantha Hesselton-Gabbai, a family physician in Beitar,


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said, The Maccabi site is sophisticated. If someone

purchases a drug at the Maccabi pharmacy or at a Superpharm

store, it appears on the computer. If I have a patient withdiabetes and his condition does not improve, I check on the

computer to see if he has bought the drug. I say to him, I

gave you a prescription a month ago and your sugar level is

not yet balanced. I want to know why. Dr. Maruan Hatib,

family physician from Taibe said, we have a software

program for drugs, which lists every drug a patient buys in

any pharmacy in the country. I check up on people who are

not buying their prescribed drugs and contact them.

It is important to note that not everyone who refrains from

buying drugs or treatments/services does so because of

economic need. However, from the testimony of the physicians

it appears that in many of these cases, that is the reason. 3

This idea of physicians turning into detectives is somewhat

problematic. There can be no doubt that the physicians are

acting with good intentions, but still, their actions raisethe loaded issue of the patients right to privacy. Even if

we are dealing here with a necessary evil, it is

regrettable that the policy of co-payments forces physicians

to cope with such issues as their patients ability to buy

drugs or utilize treatments. A physician should be able to

focus on administering health care, and a policy which

pushes her to tail the patient and then confront him on this

issue, has highly negative side effects.

3 Ostensibly, the patient has the right to autonomy wherein she isentitled to choose whether she wants to receive medical treatment or not(See Chapter 4 of the Patients Rights Law, 1996; also see ruling of theDistrict Court on the right of an anorexic patient not to receivecompulsory treatment. 1171/03 Anonymous versus Psychiatric Committee).However, where the decision not to purchase a drug or receive treatmentstems from the patients lack of funds, this is most certainly not anautonomous decision. In practice co-payments undermine the autonomousinfrastructure of the individual. In other words, because of the co-payments demand, the patient may act differently to what she might havedone if she had true freedom of choice (the patient wanted to take thedrug/ treatment, but did not do so because of the cost entailed).


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The ways in which physicians are compelled to deal with non-

medical matters in order to solve the predicaments of theirdisadvantaged patients are discussed in detail in the

following section

CREATIVE WAYS OF COPING WITH THE PATIENT'S

INABILITY TO PAY

Ways in which physicians coped with their patients

poverty: They gave the patients samples of drugs received from

drug companies

They prescribed cheaper, less effective drugs They recorded a fictitious date for the visit so that

it would appear in a different calendar quarter

They transferred drugs from patient to patient. They paid out of their own pockets.

Many physicians described their feelings of helplessness

when they realized that their patients could not afford

vital drugs or treatments. This feeling apparently

impelled them to take various creative measures to help

them. The following are several examples:

DRUG SAMPLES

One of the creative measures many physicians mentioned in

the interviews was giving out samples, namely samples of

drugs which the salespersons of drug companies give to

physicians when they visit their offices to promote their

products. 4 This solution is obviously far from acceptable.

4 On the marketing of drugs in Israel, including promotion by means ofsalespeople who visit physicians offices, see Roni Linder-Ginz,10000dollars per doctor, The Marker , 9.4.08, p. 28.


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First, the supply of samples is insufficient to solve the

overall problem: The companies give out samples in a

packet of 5 or 8 pills; not a months supply. In anyevent, this is not the method. I dont have a storeroom

here and this is not the right way, said Dr. G., from Ir

Ganim, Jerusalem. It should be noted that in 2004 the

Israeli Medical Association and the drug companies

operating in Israel signed an agreement to the effect

that physicians will not be given commercial quantities

of drugs, but only several packets of drugs, such as is

customary to hand out to physicians, all to be marked as

physicians samples.

Reliance on samples is also problematic because agents of

drug companies visit the outlying districts infrequently:

Drug salespersons do not often visit Taibeh, said Dr.

Ahmed Masarwa. 5 In other words, the (dubious) solution

of reliance on drug salespersons is inapplicable (or is

less applicable) precisely in those areas with a large

concentration of low-income patients.

Moreover, the solution of handing out samples is

problematic from the medical viewpoint as well as

economically. The salespeople understandably distribute

samples of those specific drugs for which their company

holds a registered patent. Under certain circumstances,

it may be preferable, both medically and economically,

to prescribe a different drug for the patient (and not

the one the company is trying to promote through the

physicians). But since the patient cannot afford the

physicians first-choice drug, and since the physician

has samples provided by the salesperson, the patient

5 This phenomenon of allocation of samples to low-income patients maybe regarded as a kind of privatization. There are numerous and variedarguments against the privatization policy- mainly in the sphere ofhealth. Since the gist of the present report is the testimony ofphysicians, we did not consider it appropriate to discuss the trenchantcriticism of the creeping privatization of the Israeli health system.


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will, in the end take the latter drug. Later on, if the

patient can afford the drugs, he may continue to take the

particular medication out of habit.

SUBSTITUTE DRUGS

An additional creative solution, mentioned above, is

the substitution of cheaper drugs for the more expensive

ones. In these cases, both the new and old drugs are

included in the health basket although here too there

are differences in cost 6 . Dr. Mike Benn, family physician

from Kfar Saba, said: There is no doubt that one of my

calculations when choosing from the list of drugs is the

cost to the patientI describe both drugs to him, and

explain the advantages [of the more costly of the two].

This one works faster and has less side effects. The

patient is the one who decides which to take. Dr. Amos

Dieter of Haifa also noted: If the issue is money

first I try to replace the prescription with a cheaper

one.This solution is not always acceptable.

Under certain circumstances there is nothing wrong with

the physician prescribing the cheaper drug. It could even

be argued that it is the physicians duty to do so. The

vital question is a professional and medical one: would

the two drugs ease the patients condition to the same

extent? If the answer is affirmative, there is no reason

not to choose the cheaper alternative. But the interviews

we conducted revealed that physicians were forced to

prescribe alternative drugs even in circumstances when

6 With regard to chronic patients there is a ceiling of self-participation in the cost of drugs, namely 228-242 shekel per month perperson (there is no family ceiling). Hence the substitution of drugs hasa significant impact, mainly in those cases where the chronic patientdoes not exceed the monthly ceiling. It should be noted, however, thatin some of the health funds, the procedure is that the patient pays forthe drugs even if the sum exceeds the monthly ceiling and onlyafterwards can she receive a refund on the basis of receipts etc.


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the substitute drug would not be as effective as the more

expensive drug. For example, Dr. Dalia Morovich, family

physician from Herzliya, noted that her disadvantagedpatients cope with their inability to afford co-

payments by purchasing generic or older drugs; and she

went on to note that there are more side effects with

the older drugs. Thus, we are not dealing with a

situation where the physician chooses the cheaper of two

possible treatments which are effective to the same

degree, but with cases where she is forced -- in light of

the patients poverty to prescribe the less effective

treatment.

PRESCRIBING FOR FICTITIOUS DATES

Since payment for appointments with the physician is

assessed on a calendar quarterly basis, and since the

ceiling for co-payment for drugs by chronic patients is

determined on a monthly basis, the date of the visit or

prescription is often significant. Several physiciansreported requests of patients that they record a

fictitious date for the visit/prescription. Some people

say, give me a prescription for such and such a date so

that it will be included in the three-monthly ceiling for

payments,said Dr. L., Yad Eliyahu, Tel Aviv. From the

testimony it appears that some physicians accede to these

requests.

TRANSFERRING DRUGS FROM PATIENT TO PATIENT

Two physicians told us about creative ways of

transferring drugs from a patient who no longer needs

them to one who does but cannot afford them. Dr. Arin Abu

Amsha, family physician from Beit Hakerem, Jerusalem

reported: I have a patient who does not take drugs for

asthma. She has high blood pressure and her sugar level


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is not balanced. She is 47. If she goes on like this

(without medication) she is sure to develop

complications. I ask the pharmacy, if someone returnsmedicines, to set them aside them for this woman. Dr.

S., also of Jerusalem (San Simon neighborhood) said that

relatives of former patients who have died sometimes

bring her drugs the patient did not take and she gives to

her low-income patients.

PAYING FROM THEIR OWN POCKETN

When I see that someones medical condition is very poor

and the money question gets in the way, I buy the drug

myself and give it to him. It happens once or twice a

month.

Dr. Zohir Abdullah Masarwa, family physician, Bartaa

Six of the physicians who took part in the survey paid

out of their own pockets to help their patients in the

most direct way possible. One of the six said it had

happened only once, the other five said it happened

often. Dr. Taufik Masalha, a family physician in Foradis

and Kafr Kara, said, There were several occasions when I

paid from my own pocket so that the patient could buy the

drugs and he paid me back later. Dr. Obeid Raid,

pediatrician from Haifa (Wadi Nisnas), said, When the

patient doesnt have the money for medication, I buy it

for him. The pharmacy is also used to this; I buy for the

patients. Two of the interviewees told us they have

established a private medication fund and an association,

which help patients who cannot afford drugs or

treatments.


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SUMMARY AND CONCLUSIONS

Both professional literature and the media have dwelt in

the past few years on the connection between economic

status and health. It is indisputable that such a

connection exists and that the more prosperous an

individual is, the better his or her health is likely to

be. This can also be deduced from the material above. Of

the physicians we approached (both in interviews and

through questionnaires) only four (some 9%) answered inthe negative to the question Do you perceive any

connection between the financial status of your patients

and their medical condition?

In the above study, the physicians interviewed were asked

to focus solely on the drugs and treatments included in

the health basket. Ostensibly, co-payment for drugs or

services is for most of the population a trivial

matter. These are, after all, sums which range from

several dozen to a few hundred shekels per month.

However, the testimony reveals that these trivial sums

constitute a real obstacle for the disadvantaged

population who want to realize their right to medical

car. The interviews included a number of stories of

patients who forgo purchase of drugs or vital medical

treatments solely because they cannot afford the payment.

As one of the interviewees said: There are drugs whichcost 20-30 shekel per month. I have patients who simply

cant afford them. (Dr. Samantha Hesselton-Gabai,

Beitar).

The interviews reveal clearly that economic hardship of

patients has manifest health implications: a considerable

number of cases were described in which the condition of


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with regard to payment for drugs and other treatments as

well (for example, various tests or X-rays).

The fact that more and more patients cannot afford to buy

drugs or treatments creates the problematic situation

whereby physicians become detectives and track their

patients conduct outside the doctors office: in other

words, they check the health funds computerized system

to discover whether the patient has purchased the drug or

carried out the test or treatment prescribed. These

physicians certainly act out of sincere concern for their

patients health. And yet their actions constitute

intrusion of their patients privacy. It is unclear

whether this is ethically or legally acceptable.

The ethical dilemmas continue to arise in those cases

where the physicians feel powerless and seek creative

solutions to their patients economic plight. The most

extreme example surveyed in this report was the

physicians decision to pay for the drug/treatment out ofher own pocket. This is undoubtedly an altruistic act

which, on the face of it, is entirely praiseworthy. But

how is a physician to decide whether the patients

situation is so bad that she cannot pay even six shekels

for a visit or a drug? What tools lie at the doctors

disposal to help her make such decisions? And in the

absence of such tools how can she avoid unfair

discrimination between patients? And what of the distress

of a disadvantaged patient who discovers that the

physician has waived payment for one patient, but has

not done so in her case? And what will happen if one day

the physician decides that she has had enough and stops

paying for the medical needs of her patients out of her

own pocket? How will she explain this to the patients?


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It seems that the conclusion is that the root of evil

lies in the co-payments policy which forces physicians to

confront such dilemmas. Doctors should be allowed to heal that is the task for which they were trained. The

measures they take in order to cope with the problems

raised by the co-payment policy demonstrate their

feelings of powerlessness on the one hand and highlight

their heroic attempts to cope with these feelings, on the

other. But these desperate efforts attest to the problem

rather than to its solution. The true solution entails

the revoking of the co-payments for prescription drugs,

visits to physicians or execution of tests included in

the health basket.

Documents

Physicians for Human Rights-Israel: Physicians Speak About Low-Income Patients