Haaretz: Long an unregulated jungle, critics say tourists will still get priority over Israeli patients, while the industry frets about misguided regulations.

After a year of heated debate, the Knesset late Wednesday voted 57-4 to pass a bill regulating medical tourism in Israel.

But anyone who expected a revolutionary measure that would clearly limit the scope of medical tourism and guarantee a more-or-less equal distribution of the revenues from it among all the country’s hospitals will be disappointed.

The bill does not limit the number of medical tourists who can be treated in any given hospital, nor does it say how much money is to be disbursed to compensate small hospitals in outlying areas that do not benefit from medical tourism.

Until now, medical tourism, which generates hundreds of millions of shekels a year from some 30,000 visiting patients, has been almost totally unregulated, subject to the whims of each hospital director separately.

The system came under fire for giving priority for medical tourists, for instance by creating a separate and shorter waiting list for them in violation of the law. Doctors were being paid for medical tourism procedures at the same time they were being paid for being on duty in the morning hours on their regular jobs providing services in the public health system. In some cases, doctors were negotiating private deals for medical tourists and even accepting under-the-counter payments. In other cases, patients would leave the country with unpaid debts.

Still, it took nine long committee sessions over the course of a year for all the players — medical tourism agents, MKs, Health Ministry officials and hospital executives — to agree on the bill’s text.

Meetings often deteriorated into emotional shouting sessions fueled by the tension between the need to protect the interest of Israeli patients within the already overburdened health system and the need for income from medical tourism. Hospitals said the revenues from medical tourism were being used to improve health care for Israelis, but the Health Ministry had no authority or even knowledge of where the money was being spent.

“The public health system needs income from medical tourism like air to breathe. A medical tourist brings in four times more than a regular tourist — and Israeli patients could actually reap the benefits,” said Dr. Mickey Scharf, deputy director of Clalit Health Services, told one meeting.

But the Association for Civil Rights in Israel; Adva Center, a left-leaning policy analysis institute and Physicians for Human Rights have all called the law a failure.

In a reference to overcrowded hospitals where patients often find themselves without a room, the groups said in a joint statement: “The Knesset has thrown patients from the corridor out the window. Instead off the government investing the resources the health care system needs and helping Israeli patients, it’s caved to outside business pressures.”


“Calibrate” the profits


The new law, set to go into effect within six months, leaves all sides of the debate over medical tourism in Israel unsatisfied: While it does not limit the number of medical tourists each hospital can treat, it does bar higher payments to doctors for treating medical tourists than for treating Israelis, to avoid creating an incentive to give priority to treating tourists. However, the law does leave an opening for the health minister to make exceptions as to when doctors may receive more payment for treating tourists.

The law also states that medical tourists will only be treated in the afternoon and not during regular hospital hours, aside from emergencies or other exceptions. The sanction for treating a medical tourist during public morning hours is a severe 50,000 shekel ($13,680) fine.

The committee members, with the backing of the Health Ministry, rejected the call by MK Merav Michaeli (Zionist Union), one of the bill’s sponsors, to limit medical tourism to 5% of a hospital’s medical activity.

Instead, hospitals will have to provide the Health Ministry with a comprehensive report on the tourists treated at the hospital and the income received the in relation to the income from treating Israeli patients. Based on that data, the ministry can decide to limit the number of medical tourists a hospital may accept, if arouses concern that is impacting the availability of treatment for Israeli.

In 2014, a committee headed by then MK Yael German recommended limiting hospital income from medical tourism to between 6% and 10% of overall income and imposing a number of other restrictions. Subsequently, the Finance Ministry budget division, citing the committee’s findings, attempted to impose a tax on medical tourism income as part of the Economic Arrangements Bill, but legislation on the matter was halted, in part due to political pressure, chiefly from Yisrael Beitenu.

Income from medical tourism flows mainly to the large hospitals in the big cities and hardly reaches the outlying areas. In 2017, Tel Aviv’s Ichilov Medical Center brought in 76 million shekels from medical tourism; Sheba Medical Center, Tel Hashomer earned 39 million shekels, Haifa’s Rambam Medical Center 27 million shekels and Assaf Harofeh 9 million shekels. But Ziv Medical Center in Safed, Poriya in Tiberas and Bnei Zion in Haifa didn’t make a single shekel from medical tourism.

Michaeli’s call for a set share of medical tourism income to go to hospitals in the periphery was supposed to balance out this picture, but ultimately committee chairman MK Eli Alalouf (Kulanu) and the Health Ministry representatives decided that the ministry would “calibrate” the profits to go to the periphery and report on this to the committee without committing ahead of time to a specific sum or percentage of the income.

The absence of any fixed ceiling or formula for sharing medical tourism revenues is what most worries the new law’s critics.


Economic pressures


The law places great emphasis on protecting the rights of medical tourists, following many reported cases of fraud and exploitation. Much of the law focuses on regulating the activity of medical tourism companies and their agents, which has been fertile ground for charlatans.

The law stipulates that medical tourism agents must be over 21 and have no criminal record, and they will be required to enroll in a special registry.

The agencies will be subject to certain restrictions, such as not being permitted to make one service contingent upon another. Among other things, it bans making obtaining medical services contingent upon reserving a hotel room via the agent, entitles patients to have direct contact with doctor doctors and requires patients to wear an ID tag when on the premises of any medical institution.

A disciplinary committee for medical tourism agents, headed by a judge, will also be established, and will be empowered to impose sanctions for violations of the law. A medical tourism agent who commits a disciplinary offense may be fined 14,000 shekels.

Representatives of the industry sometimes clashed strongly with MKs at the hearings regarding the bill. In one session, Uriel Lynn, president of the Federation of Israeli Chambers of Commerce, charged that “Most of the MKs are making mistaken assumptions and fostering a negative image for the industry, implying that medical tourism harms the Israeli patient, while the hospitals have clearly stated that the opposite is true.”

He also complained that “the committee did not allow for a serious and thorough discussion and representatives from the medical tourism industry were treated with hostility and scorn.”

Alalouf said otherwise. “Medical tourism will not occur at the expense of the Israeli patients. In an ethical, transparent, orderly and fully controlled manner, we don’t want to eliminate the industry or to harm it, but the rights of the citizens come first,” he said.

In the end ,even the industry isn’t entirely satisfied with the law. Mark Katznelson, chairman of the Medical Tourism Association of the Federation of Israeli Chambers of Commerce, said the organization welcomed the law, including the sections that give priority to the Israeli patient over the medical tourist.

But he also noted serious drawbacks, most significantly the absence of any defined criteria for obtaining a license to engage in medical tourism. “Unfortunately, the law only provides for absence of being registration as a criminal offense. This is an opening for freelancers to enter the business, which we regret it,” he said.

 “In addition, the law will obstruct the work of medical tourism companies without which this industry cannot exist — for example, the responsibility for devising treatment plans will go almost always to the medical institutions, even though until now companies have been responsible for this. We will not be able to receive a referral until the medical institution sends us a treatment plan for this, which is absolutely absurd,” said Katznelson.


Ronny Linder-Ganz

Haaretz Contributor