המכון הלאומי לחקר שרותי הבריאות ומדיניות הבריאות )ע”ר( The National Institute for Health Policy Research

International Workshop Report

HOSPITAL BUDGETING

Chairmen: Gabi Bin-Nun & Yitzhak Berlovitz

July 2016 , Israel The Israel National Institute for Health Policy Research

HOSPITAL BUDGETING International Workshop Report

Chairmen: Gabi Bin Nun & Yitzhak Berlovitz

July 2016 Tiberias, Israel Hospital Budgeting 3

Table of Contents

Page

Workshop Program 4

List of Speakers 7

Introduction and Summary 8

Abstracts 15

Biographies 29

List of Participants 52

4 International Workshop Report

Workshop Program

Wednesday, July 6th, 2016

09:00-10:00 Gathering & Welcome Coffee

10:00-13:00 OPENING SESSION Chair: Orly Manor, NIHP Introductory Remarks: Orly Manor, Chairwoman, Board of Directors, NIHP Moshe Bar Siman Tov, Director General, Ministry of Health

INTERNATIONAL PERSPECTIVES Valérie Paris, OECD, OECD Health Alexander Geissler, Germany, Berlin University of Technology Donald Franklin, UK, NHS England

ISRAEL PERSPECTIVE Gabi Bin Nun & Yitzhak Berlovitz - Background of Israel's Hospital Budgeting, Ben-Gurion University of the Negev,

Discussion

13:00-14:00 Lunch

14:00-16:00 THE ISRAELI SCENE: PROBLEMS & CREATIVE THINKING Chair: Gabi Bin Nun, Ben-Gurion University of the Negev Vadim Perman - Budgeting and Hospital Reimbursement, Ministry of Health Eli Cohen - Budgeting in Clalit Hospitals, Clalit Health Services Orly Weinstein - The New Division of Government Hospitals, Ministry of Health

Discussion Hospital Budgeting 5

16:00-16:30 Coffee Break

16:30-18:15 REFLECTIONS OF HOSPITAL MANAGERS Chair: Yitzhak Berlovitz, Wolfson Medical Center Shimon Reisner - Government, Rambam Medical Center Ehud Davidson - Sick Fund, Clalit's Jonathan Halevy - Not-for-Profit (NGO), Shaare Zedek Medical Center

Discussion

18:15-19:00 Matan Hodorov - The Privatization of the Israeli Health System in the Eye of the Media, Channel 10 News

20:30 - Dinner

Thursday, July 7th, 2016

09:00-11:00 PLANNING REFORMS IN ISRAEL Chair: Shlomo Mor-Yosef, National Insurance Institute of Israel MK Rabbi Yakov Litzman, Minister of Health Moshe Bar Siman Tov, Ministry of Health Ran Ridnik, Ministry of Finance Commentators: Nisim Alon, Leumit Health Service Yitshak Kreiss,

Discussion

11:00-11:30 Coffee Break

11:30-13:00 RESPONDING PANEL Chair: Alik Aviram, NIHP Shuli Brammli-Greenberg, Myers-JDC-Brookdale Institute Yair Birnbaum, Clalit Health Services Avi Israeli, Ministry of Health Nir Kaidar, Ministry of Health , 's Salman Zarka, Ziv Medical Center 6 International Workshop Report

13:00-14:00 Lunch

14:00-16:00 CLOSING SESSION: REMARKS & SUMMARIES Chair: Bruce Rosen, Myers-JDC-Brookdale Institute Donald Franklin, NHS England Alexander Geissler, Berlin University of Technology Valérie Paris, OECD Health Moshe Bar Siman Tov, Ministry of Health Yitzhak Berlovitz & Gabi Bin Nun, Wolfson Medical Center, Ben-Gurion University of the Negev

Coffee to Go Hospital Budgeting 7

List of Speakers

Mr. Nisim Alon CEO, Leumit Health Service Prof. Alik Aviram Scientific Director, NIHP Mr. Moshe Bar Siman Tov Director General, Ministry of Health Dr. Yitzhak Berlovitz Director General, Wolfson Medical Center Prof. Gabi Bin Nun Ben-Gurion University of the Negev Dr. Yair Birnbaum Chief Medical Officer, Clalit Health Services Dr. Shuli Brammli-Greenberg Senior Researcher, Myers-JDC-Brookdale Institute Mr. Eli Cohen Deputy Director General, Head of Finance Division, Clalit Health Services Dr. Ehud Davidson Director General, Soroka Medical Center Dr. Donald Franklin Senior Economic Adviser, Dept. of Health, UK Dr. Alexander Geissler Senior Researcher, Dept. of Health Care Management, Berlin University of Technology Prof. Jonathan Halevy Director General, Shaare Zedek Medical Center Prof. Avi Israeli Chief Scientist, Ministry of Health Mr. Nir Kaidar Sr. Deputy Director General, Strategic & Economic Planning, Ministry of Health Prof. Yitshak Kreiss Director General, Sheba Medical Center Prof. Orly Manor Chairwoman, Board of Directors, NIHP & Prof. of Biostatistics, the Hebrew University-Hadassah Prof. Shlomo Mor-Yosef Director General, National Insurance Institute of Israel Ms. Valérie Paris Senior Policy Analyst, Health Division, OECD Mr. Vadim Perman Manager, Pricing Dept., Planning, Budgeting & Pricing Division, Ministry of Health Mr. Ran Ridnik Head, Healthcare Division, Budget Department, Ministry of Finance Prof. Shimon Reisner Associate Director, Rambam Medical Center Dr. Bruce Rosen Director, Smokler Center for Health Policy, Myers-JDC- Brookdale Institute Prof. Joshua Shemer Chairman, Assuta Medical Centers Dr. Orly Weinstein Head, Division of Government Medical Centers, Ministry of Health Dr. Salman Zarka Director General, Ziv Medical Center 8 International Workshop Report

Introduction and Summary

Hospital budgeting is a “hot” issue in Israel as it is in many other countries that try to slowdown the growth of their health expenditure and achieve better “value for money”. The Director General of the Ministry of Health (MOH) raised the initiative to conduct the International Workshop on hospital budgeting as part of the foundation for a plan to implement hospital budgeting reform in Israel.

During the workshop that took place in Tiberias in June 2016, leaders of all the health sectors throughout Israel joined together to create a “think tank” for hospital - budgeting reform. Additionally, the workshop hosted three international experts who provided us with perspectives from the OECD countries, England and Germany. Together, we tried to identify the underlying problems and then provide creative solutions.

The workshop focused on the existing process of hospital budgeting in Israel; pointing out the advantages, disadvantages and the current alternatives that are available for decision makers.

During the workshop discussion, we covered core issues in hospital budgeting such as: What are the criteria for budget allocation to the government owned hospitals and for Clalit's hospitals? Is the decision based on the previous years' budget, or are there additional criteria to consider? To what extent should the hospital's budget be dependent upon income from services? And additional questions regarding hospital budgeting process.

During the discussion we all agreed that “hospital budget” is a mean - one among a set of tools to encourage efficiency, safety, quality and satisfaction. We also agreed to limit the discussion to a given budget (and not to discuss the need for increasing the budget).

The workshop began with welcoming remarks from Orly Manor, the chair of the Israel National Institute for Health Policy Research, who outlined the main issues for the discussion in the workshop, such as: How to determine an objective and transparent framework for setting hospital budgeting? What is the appropriate way to reflect variable volume of activities?

In the session on international perspectives, the three speakers - Valerie Paris, Hospital Budgeting 9

Donald Franklin, and Alexander Geissler - reviewed hospital budgeting practices in the OECD countries, Germany and the UK. In all of these countries, some elements of budgeting and pricing are determined at the national level, while others are determined at the local level. Moreover, there is also a mixture of decision-making: made through negotiation and government regulation. Another interesting variation from the Israeli situation is the practice, in both Germany and the Netherlands, for the health plans to coordinate amongst themselves in their negotiations with the hospitals.

Valerie Paris provided an overview of the organisation and financing of hospital care in OECD countries (share of public and private supply, hospital spending by the financing agent, share of hospital spending in total health spending, how hospitals are paid and how budgets and/or unit prices are set etc.). Valerie explored hospital care expenditures in Israel in comparison with the OECD average. She highlighted several striking similarities: that hospitals account for about a third of health care spending, that most of the financing of hospitals is via insurers, and that subsidies are often provided to hospitals facing serious financial problems.

Alexander Geissler described hospital financing in Germany: Hospitals are financed from two different sources: investments in infrastructure are covered directly by state budgets, while operating costs are reimbursed by sickness funds and private health insurance through a DRG-based payment system. A hospital acquires a legal claim for a subsidy only as long as it is included in the ‘hospital plan’ of the respective state. Reimbursement of operating costs is, to a certain extent, limited by volume and case- mix related budgets, which are negotiated annually between every hospital accredited in the hospital plan and the sickness funds. If a hospital treats more cases than negotiated, the DRG-based reimbursement rate is reduced by a certain percentage.

Donald Franklin emphasized the weak bargaining power of purchasers in the UK, which is quite different from the situation in Israel. The NHS funding system for hospitals aims to achieve dynamic incentives for efficiency whilst avoiding the risk of skimping. The NHS National Tariff Payment System sets administrative prices for nearly 2,000 Health Resource Groups (HRGs). These prices are derived from historic average cost (averaged across all NHS providers), to reward efficiency. The pricing system is under continuous development.

In the session on the Israeli perspectives, Gabi Bin Nun and Yitzchak Berlovitz provided an overview of hospital organization and financing in Israel. They presented Israel's evolution from historical/global budgeting to more activity-based budgeting. 10 International Workshop Report

Gabi and Yitzchak described the main problem in the existing mechanism: Hospital budgeting is still based on "historical" budgets, lacking the connection between the budget and the scope of the different activity mix. There is a cross subsidization between hospitals on the same network or ownership, retroactive funding of hospital deficits at the end of the year, limited operational flexibility, and lack of incentives to encourage operational efficiency or quality goals. At the end of their presentations they also highlighted various challenges facing the system in the future.

The Development of Hospital Budgeting in Israel:

Vadim Perman (MOH) described the flow of resources within the present structure of the system and the new Ministry of Health effort to examine hospital financing on a system-wide basis. He reviewed the various iterations of Israel's hospital revenue caps and discussed the pattern of interactions between the cap and the discounts negotiated by the health plans.

Eli Cohen (Clalit Health Insurance Plan) described the movement from global budgeting in Clalit's hospitals to activity-based budgeting. The budgeting course of Clalit's general hospitals is an ongoing process, which began in the year 2000 and continues until today. Eli contended that, based on Clalit's experience, it is possible to encourage hospitals to increase activity without warping the system.

Orly Weinstein (MOH) described the process of creating and developing the MOH hospital division. She noted that the MOH's hospital division shares several important similarities and differences with Clalit's hospital division. She also reviewed the state controller report's critique of hospital budgeting practices as being overly driven by history and relying too heavily on ex poste subsidies. Hospital Budgeting 11

The next session in the workshop consisted of the reflections of hospital managers. Shimon Reisner (Rambam Government hospital) emphasized the difficult challenges facing hospital managers, with insufficient budgets and limited managerial flexibility. Ehud Davidson described how in Clalit's hospital(Soroka) extensive use is made of work plans, operational data and benchmarking to manage proactively and increase hospital productivity.

Jonathan Halevy (Shaare Zedek- not for profit hospital) emphasized the importance of the mission, value and governance structure in steering hospital activity.

Overall, the session raised questions regarding the extent of systematic differences between the Governmental, Clalit and independent hospitals on issues related to the perceived control and the availability of data needed for effective management. It also raised questions about whether, from a public policy perspective, we want the hospitals to consider activity maximization as a primary objective.

In the final session of the first day, Matan Hodorov (journalist) spoke of the responsibility of leaders of the health system, hospitals, health plans and the research community to go beyond implementation of policies determined by political leaders, by trying to influence overall public perceptions, and policy directions in health care.

The second day began with a session on planning reforms related to hospital budgeting in Israel. Moshe Bar Siman Tov (MOH) spoke of the need for major change in the current hospital budgeting system. Moshe described the main problems that exist today: unequal competitive conditions within the hospital system, governance problems in the system and inefficient resource allocation mechanisms that contribute to loss of public confidence in the system. Moshe noted that the current funding mechanisms are mainly based on "extinguishing fires" and historical budgets. the current funding lack tools to monitor, control and manage. Conditions of competition within the public and the private systems, are unequal. This has resulted in the erosion of public confidence and financial quality. Moshe argued that the main target of the reform is to create a budgeting system based on long-term objectives and criteria. The model includes resource allocation with greater transparency and fairness between hospitals, increasing the administrative responsibilities of hospitals, and creating tools for advancing health policy concerning quality, availability and financial stability. 12 International Workshop Report

Government Hospital's Subsidy (in million NIS):

Ran Ridnik (Ministry of Finance) largely agreed with Moshe's description of the current state of affairs. The main areas of disagreement appeared to relate to the desired balance of power between hospitals and Health Plans and the desired level of tension between them.

In his commentary on the presentations from the two governmental ministries (Ministry of Health and the Ministry of Finance), Nissim Alon emphasized the vital role of health plans (and of the cap) in constraining hospital costs. Yaakov Kreiss followed up on this with a call for greater clarity in the rules of the game. The Minister of Health Yaakov Litzman concluded the session with a warning that hospitals need to stick to budgets, as the government won’t keep bailing them out.

In a panel of respondents, Yair Birnbaum and Shuli Brammli-Greenberg noted that hospital pricing systems should promote efficient division of labor between hospital and community providers, which probably varies across different types of services. Avi Israeli emphasized the importance of a historical perspective and of moving from general statements to practical plans. Nir Kaidar emphasized the importance of using the forthcoming deliberations about the hospital revenue cap to promote important policy goals. Joshua Shemer spoke of the need to treat budgets as constraints and not just recommendations and to push ahead on efforts to improve the health care system. Salman Zarka reminded participants of the unique needs of peripheral hospitals and the importance of addressing those needs. Hospital Budgeting 13

In the final session, concluding remarks were raised by the three guests from abroad, by the conference co-chairs, and by Bruce Rosen, who chaired the session. Bruce concluded that the workshop highlighted several practical issues, including: › How can we avoid chronic budget overruns? It is clear that higher budgets would help, but what else is needed? › What role do we see for global budgets vs. activity-based budgets? › Do we want hospital activity levels to increase? A little or a lot? Overall or targeted? › What message do we give to hospital directors? What constraints do we place on them and what incentives? What are the roles of regulators and owners in creating incentives? What roles should price play in creating incentives? › Do we want to change the purchaser/provider (health plan/hospital) balance of power?

One of the achievements of the workshop was that it succeeded in bringing together most of the stakeholders in the health system in Israel to discuss budget reforms to be implemented in the coming year. The workshop also provided an opportunity to exchange opinions and a chance to see, for the first time, some financial data on government hospitals.

In the discussions during the workshop there was agreement on the main problems in the current funding mechanism but there was no consensus on recommended directions for change (transparency, responsibility and authority). There were two characters of change: One mentioned minor changes in the budgeting processes and current compensation (Ministry of Finance). The other (Ministry of Health) discussed large scale changes in the budgeting processes. However, none showed irregular changes regarding upcoming rules (the scope for funding as related to the reward, whether there are any discounts or if prices are minimum or maximum etc).

Overall, the workshop raised awareness of the many different roles played by hospital budgeting (planning, cost containment, efficiency promotion, the creation of appropriate incentives, and much more). The workshop also made it clear that there are often tensions between these different objectives.

We hope that the workshop will lead to a better budgeting process and that we will all take advantage of this opportunity to brainstorm alternative recommendations that, once implemented, will aspire to improve hospital budgeting along with the quality and the efficiency of the acute hospital across Israel. 14 International Workshop Report

Finally, we would like to thank Bruce Rosen for his help in summarizing the workshop and to extend our appreciation to our guests from abroad and to the Israel National Institute for Health Policy Research which hosted this workshop.

Gabi Bin Nun & Yitzhak Berlovitz Workshop Chairmen Hospital Budgeting 15

Background of Israel's Hospital Budgeting Prof. Gabi Bin Nun & Dr. Yitzhak Berlovitz

The general hospitals in Israel are mostly public non-profit and are characterized by the existence of two main ownership networks: hospitals owned by the government or hospitals owned by the biggest health plan - Clalit Health Services.

In the public hospitals, the budget that is available is not derived only from the hospital's revenue but it also includes a built-in mechanism of budgeting and State funding (direct or indirect subsidy).

In the current funding process there are several problems. The main problem is the fact that the budget is built on the historical base, which does not always reflect the activities of various hospitals. In the historical budgeting mechanism there is not always a linkage between the budget and scope of the task, additionally, there are big differences between similar hospitals' budgets.

Another major problem in the existing budgeting process of general hospitals is the lack of built-in incentives in the budget to boost operational efficiency or quality objectives.

In our lecture, we will briefly review the general hospital sector in Israel (ownership, market share, revenue mix, etc.). Additionally, we will discuss the major sustainability issues in funding hospitals, sweep the historical development process of budgeting, and discuss the reimbursement patterns between Sick Funds and general hospitals in Israel. 16 International Workshop Report

Budget of the General Hospitals of Clalit's Health Services: Evolution of the Process Mr. Eli Cohen

Clalit is the leading health organization in Israel; Clalit operates as health maintenance organization and operates 8 general hospitals, 5 special hospitals and hospitals that specialize in pediatrics. There are also 1,452 different community clinics, including professional secondary clinics, all over the country.

The budgeting process of Clalit's general hospitals is an ongoing process, which began in the year 2000 and continues until today. During this period, three different budget models were applied, as each model was the basis for development of the next model, designed to address the disadvantages of the previous model.

The following is a summary of the evolution process:

Years Model Disadvantages Advantages 2000 Historical › Simple › Distributive injustice budget › lack of transparency 2003- Preliminary › Objective › Information problems 2004 model › Transparent › To-large budget transfers between hospitals 2008- Subsidy › Equitable › No streamlining of 2010 model › Transparent solution deviating hospitals for exceptional › Disregarding business departments (small, environment inner-outputs etc.) › Perpetuation of small departments › Problems of information system 2013- Output model › Incentives for › Complex and difficult to Present operative efficiency understand and increasing output › Exogenous processing › Use of objective and of information from comparable indices information systems › Restrain the budget (calculating the weighted transfers between the output) years Hospital Budgeting 17

Below are principal conclusions from the process's evolution: 1. Information systems, Information systems, Information systems. 2. There is a need to drilldown to the pricing level as a basis for budget (information systems). 3. There is a need for clinical policy that will determine which outputs are more desirable than others. 4. Managerial responsibility. 5. There is a need for small complementary models - nursing schools, periphery wages. 6. There is no perfect model.

Future Plans: Integrating "departmental-budget" system that produces pricing and the pricing system will serve as a basis for budgeting. 18 International Workshop Report

General Sick Fund Hospital Budget - Soroka Medical Center

Dr. Ehud Davidson

Soroka Medical Center's budget, as part of the hospital division of Clalit budget, is based on the weighted productivities model. The aim of this model is to increase total productivities, and to increase the operational efficiency of Clalit hospitals.

Hospital management level: We act according to an overall and approved efficiency plan, which includes income targets and cutting expenses targets. We emphasize utilization and operating room productivity. We set targets for increasing annual productivity for the clinical departments, and we respond on-lime to the daily productivity reports we get.

Department level: Hospital departments act according to approved annual working plans. The plan includes chapters of quality, patient experience productivity and an economic chapter. The economic chapter includes report of fulfilling productivity goals and report about expenses control. Lately an organization department budget project was imitated. Its aim is to expose performance data for each department, and to present comparative options among similar departments in Clalit hospitals.

At the end of this presentation several examples for the concept "economics at the service of quality of medicine" are presented. Hospital Budgeting 19

NHS Hospital Funding - Towards Internalization of the Budget Constraint

Dr. Donald Franklin

The NHS funding system for hospitals aims to achieve dynamic incentives for efficiency whilst avoiding the risk of skimping. The current payment system largely treats need as exogenous, and attempts to reward efficiency in meeting that need. The starting point is an allocation of resources to local purchasers (Clinical Commissioning Groups, CCGs, groups of primary care physicians and others who act in the English system like local insurance funds) that is proportional to need (estimated using a Person Based Resource Allocation model based on age/gender/medical history). To balance local hospitals’ monopolistic pricing power, CCGs are supported by regulation of prices.

The NHS National Tariff Payment System sets administrative prices for nearly 2,000 Health Resource Groups (HRGs). These prices are derived from historic average cost (averaged across all NHS providers), to reward efficiency. The pricing system is under continuous development.

First, a number of services are currently outside the scope of the mandatory tariff, such as mental health, critical care, burns, a fair chunk of outpatient services, high cost drugs and devices, discrete rehabilitation - pricing of these services is negotiated locally. Growth in expenditure on locally priced services has been faster than elsewhere - perhaps due to imbalance in local negotiating power. Hence there is a programme to expand the scope of currencies and of Tariff: to include more services, fewer exclusions. Second, medicine moves on, costlier alternatives within an HRG are sometimes better value for patients, so grouping is refined (now on HRG4+) and/or enhanced “best practice tariffs” are introduced.

Third, and more fundamentally, it is recognized that under Tariff providers lack incentive to pre-empt need, which is after all actually partly endogenous.

So work is in progress to develop new population/year-of-care/pathway currencies, concatenating HRG defined spells with other care.

Implementation might require “New Models of Care”, perhaps even involving some integration across the purchaser/provider divide. 20 International Workshop Report

Hospital Budgeting in Germany - Negotiations within a Tight Regulatory Framework

Dr. Alexander Geissler

The financing of German hospitals follows the principal of ‘duality’ introduced with the Hospital Financing Act (KHG) in 1972. This means that hospitals are financed from two different sources: investments in infrastructure are covered directly by state budgets, while operating costs are reimbursed by sickness funds and private health insurance through a DRG-based payment system.

Each of the 16 state governments is responsible for maintaining hospital infrastructure. The main instruments used to do so are the so-called ‘hospital plans’, which are set by the state governments. They specify hospital capacity and the range of services across all hospitals within a state, as well as within individual hospitals.

Long-term infrastructural assets require a case-by-case grant application by each individual hospital. State governments distinguish between grants for construction of hospitals and initial procurement or replacement of other assets. According to the KHG, a hospital acquires a legal claim to subsidy only as long as it is included in the ‘hospital plan’ of the respective state. Inclusion in the hospital plan also means that flat-rate grants for short-term assets (3-15 years' economic life) can be granted. In practice, infrastructural hospital investments are mainly determined by the budgetary situation of the states and by political considerations.

Reimbursement of operating costs is, to a certain extent, limited by volume and case- mix related budgets, which are negotiated annually between every hospital accredited in the hospital plan and the sickness funds. If a hospital treats more cases than negotiated, the DRG-based reimbursement rate is reduced by a certain percentage. The annually updated G-DRG system applies to all hospitals, irrespective of ownership status, and all patients (except rehab and psychiatric care), regardless of whether or not they are members of the SHI system, have private health insurance, or are self- funding patients. DRGs cover all clinical departments with the exception of institutions or facilities providing psychiatric care, psychosomatic medicine, or psychotherapy services. Hospital Budgeting 21

The Experience of A Public Hospital - Shaare Zedek Medical Center

Prof. Jonathan Halevy

Only a few public-private hospitals exist in Israel: Hadassah, Laniado, Mayanei Hayeshua and three hospitals in . This lecture will discuss Shaare Zedek Medical Center as a case study.

The corporate structure of a public-private hospital (public, because it is a non-profit and develops its services according to the needs of the community; and private, due to the fact that it is owned by a non-public entity) includes a Board of Directors and various committees which supervise the hospital management in financial, administrative, and to a certain degree, even medical aspects.

The hospital's budget is derived from a work plan drafted by the Director General approximately two months before the beginning of the calendar year. This work plan is based on the activities of the previous year combined with a projected forecast (based on justified premises) for additional activities in the upcoming year in various areas, including development-based new activities (such as opening new departments and units, construction, etc.).

The sources of income of a public hospital are similar to those of government hospitals and HMO hospitals and are based on services purchased by HMO's, the National Insurance Institute, the Ministry of Defense and private purchase. However, the purchasing power and advantage of size is negatively dissimilar, effecting the interactions with insurance companies and other providers.

If the situation in Israel is such that no sophisticated market exists in the hospital system due to the small number of players and parties with strong purchasing power or supply power, this is all the more extreme in the case of an individual public hospital such as Shaare Zedek or Hadassah. Indeed, the rates of discounts awarded to HMO's in both of the largest public hospitals in are higher than in the rest of the system.

Also in terms of expenses there exists a unique factor which negatively impacts the public hospital: while salary expenses are an expense common to the entire system and are dictated by collective agreements, expenses such as professional liability insurance as well as a significant part of retirement pension budgets are a further 22 International Workshop Report

burden on public hospitals. This is in addition to the lack of negotiating power and the interactions with the insurance companies. Furthermore, the public hospital must also independently contend with depreciation and capital expenses without any significant government support.

The advantages and disadvantages of private medical services (SHARAP) will be discussed in the lecture; however, I will mention briefly that its contribution to the hospital's income is an insignificant 1% of the total revenue.

That public hospitals are discriminated against in the present budget policy vis-à-vis government hospitals and HMO's is evidenced by the fact that most of the government hospitals and HMO's have requested - and received - supplementary governmental funds to their budget in order to continue functioning. In contrast, over the past few years most of the public-private hospitals have suffered a complete collapse or have needed to implement an emergency recovery plan (Bikur Cholim, Hadassah, Laniado).

Conclusion: The current budget model, which is based on historical data and its development and on the recent use of exogenous models for the financial reality of the hospital system in Israel, poses a threat to the existence of public "incorporated" hospitals in general, and, in particular, to large academic public hospitals which are intensively involved in emergency activities, teaching, and research. Hospital Budgeting 23

Hospital Financing in OECD Countries

Ms. Valérie Paris

This presentation will provide an overview of the organisation and financing of hospital care in OECD countries (share of public and private supply, hospital spending by financing agent, share of hospital spending in total health spending, etc.).

Then, it will describe how hospitals are paid and how budgets or/and unit prices are set.

Finally, it will describe tools employed by OECD countries to remain within budget constraints and explore some of the consequences (e.g. waiting times, hospital debt). 24 International Workshop Report

Ministry of Health - Hospital Budgeting

Mr. Vadim Perman

The public hospital system in Israel1 struggles in a challenging economic environment. On the one hand, the system is an array of profound professional achievements and a source of national pride, but on the other hand, the system suffers severe financial difficulties, and its current exist is in an environment of great uncertainty and lack of resources. In present time, the public health system status, makes the decision makers face immediate challenges regarding long waiting times for exams and surgeries, insufficient investment in infrastructure development, signs of financial instability and the public's expectation for high standard of treatment.

The public health system is a fairly closed economic environment that contains four HMO's which are the main bulk of procurement of the public hospital services. The system composed of three major groups of players: Hospitals of Clalit Health Services, Government hospitals and Public hospital. Each group has a different DNA of management structure and operation interface.

The economic environment where the HMO's and hospitals operate is supervised and planned by the ministry of health and the ministries finance, both at the micro and macro aspects. Namely, the inter-ministry committee of prices (health), establishes and approves the maximum-rates-catalog for surgical procedures and all medical services, while the legislature determines in law the consumption ceilings (Cap) which define the scope of the procurement of every HMO from each hospital and the rules in case of deviation from the specified scope (floor, ceiling, Alpha).

Moreover, in parallel to the public hospitals system, there are private suppliers which are direct and indirect competitors in the ambulatory and elective surgeries market while using a shared main resource (the doctors), but operate under a very different regulatory rules. And so, the private system is not bound to prices inspection and not to the law of consumption ceiling.

In addition, in recent years, the public hospital market is characterized by recovery plans2 and direct money transfers from the Government (subsidies), in increasing rate,

1. Public Hospital, in its definition in “Pkudat Haam” operates emergency department 24/7 2. Hadassa, Bikur Holim Hospital Budgeting 25

to all system players, including HMO and hospitals, in some cases, without proper logic method at the stand of source distributing, not among the different markets and not among the different sectors.

This presentation will focus on the, resources flows within the health system, and the economic as well as planning challenges they are create. We will address and examine the anomalies and other issues that arise from the present structure of the system, and its ability to maintain the current status as long-term equilibrium. 26 International Workshop Report

Rambam Government Hospital Prof. Shimon Reisner

Governmental hospitals are operational units of the Ministry of Health. The Israeli government determines hospital's budgets, the maximal price list of the various services and the accounting method between the hospitals and the HMO’s. Revenue targets, salary and operational budgets of the governmental hospitals are determined by the Ministries of Health and Finance based on historical figures, totally unrelated to hospitals needs and the regulatory requirements issued by the Ministry of Health itself.

Human resources standards in governmental hospitals are archaic based on a committee report from the mid 70 's. Entire areas of medicine that have developed in recent years and essential support services such as computer and IT are not regulated at all. In order to provide the required services, the hospitals often employ personnel at the expense of Health Corporations that is adjacent to the hospital. As a result, the salary budgets in governmental hospitals do not reflect at all the actual salary expenses.

More than a decade ago, the Ministry of Health made an attempt to refine the operating budgets of government hospitals using a model which incorporated the individual characteristics of each hospital. Since the funding of the model was based on the principle of 0 sum game, it resulted in worsening the conditions of some of the hospitals. Since then, the operations budgets of the hospitals are updated using an "autopilot" system with on-purpose erosion of regulation controlled update mechanisms. Consequently, the operations budgets are not sufficient to address the essential needs and all hospitals experience yearly budget crisis that interferes with their routine activity.

One of the main reasons for deep deficits of hospitals is inadequate pricing of medical services. Medical Services Prices List of the Ministry of Health does not reflect the full costs of the hospitals since it was based on outdated pricing principles without reference to many significant cost components.

Current Cap mechanism significantly increased the obligatory discounts granted by low to the HMO’s whereas increasing the budget deficit of the hospitals.

Government hospitals have almost no budgets for the renewal of equipment and Hospital Budgeting 27

maintenance of buildings and therefore in these aspects the hospitals are almost totally dependent on donations.

The new initiative of the Ministry of Health to establish a prospective and approved budget at the beginning of the fiscal is too little and too late for the chronically starved governmental hospital system. 28 International Workshop Report

Establishment of the Division of Government Medical Centers

Dr. Orly Weinstein

In 2015, the Israeli government decided to establish the Division of government medical centers (GMCs). The decision was a result of multiple assessments of the health system’s functioning made over many years, which underlined the importance of forming a body to manage and monitor GMCs.

The Division is responsible for all the GMCs - the general ones, the psychiatric and the geriatric ones. All hospital functions will be under the responsibility of the Division, including medical, academic and research, budgets, human resources, purchasing, safety, quality, data bases, etc.

The Division will deal with the policy of all the according to the directives of the CEO of the Health Ministry, will help and supervise the implementation of the policy.

The Division's aim is to advance the medical centers, to pursue constant improvement in the professionalism and quality of medical care provided in them, to improve work processes whilst streamlining and maximizing resources, to take advantage of the great size and wide scope of the centers to promote medicine, mutual learning, strengthening and improved efficiency. The goal is to develop processes that will create synergy and added value, leading the GMCs to be strong organizations of excellence.

Moreover, the Division will promote processes of standardization in core areas- for example, information systems and digitization, in order to promote management abilities, medical care, economic strength, human capital and transparency; in the purchasing area, development of standardization and regulation, etc.

The Division's main areas of responsibility are: • Defining strategy and the operational doctrine of in the GMCs, and their implementation. • Mapping out the existing processes and practices in the GMCs, and improving them. • Formulating operative plans for the promotion of the GMCs.

We envision the Division as a powerful body that can significantly impact on activity in the medical, financial, logistic and human resources fields in the GMCs, as powerful and significant organizations. Hospital Budgeting 29

Mr. Nisim Alon

CEO, Leumit Health Service, one of the four Health Service organizations in Israel. Leumit's market share is 9% and it has branches covering all Israel.

Prior to his current position, Mr. Alon served in Leumit in various positions: Acting CEO, Deputy CEO and VP Human Resources, COO, Tel-Aviv District Director and Jerusalem District Director. In addition, at the outset of his career in health services organizations he was Branch Director in Meohedet HMO in Jerusalem.

Mr. Alon holds an MBA from the Hebrew University in Jerusalem, and a BA in Political Science and Criminology from Bar-Ilan University in . He is a graduate of the IDF Command and Staff College.

Mr. Alon lecturers in the Health Systems Administration Department in Hadassah and Peres Academic College.

He is a Board member of the Israel Health National Council, and served as the CEO of the Israel Diabetes Association, 1993-1994.

Between 1976-1988, he served in the IDF in Command and Staff positions in large combat and command units, after which he served for 11 years in reserve duty. Rank - Lt. Col. (Res). 30 International Workshop Report

Prof. Alik Aviram

Scientific Director, The Israel National Institute for Health Policy Research, since 2002.

Medical Director, Maccabi Health Services (1996-2002). Director, Assuta Hospital & CEO of Assuta Medical Centers (1987-1996).

Specialist in Medical Administration (1987). Associate Director-General, Hadassah Medical Organization (1986/87). Acting Director, Tel-Aviv Sorasky Medical Center (1985/6). Director of Rokach ("Hadassah") Hospital, Tel-Aviv Medical Center (1976-1985). Head, Department of Nephrology, Tel-Aviv Medical Center (1972-1985). Senior Lecturer in Internal Medicine, the Hebrew University, (1971). Chief Resident & Senior Physician, Nephrological Service, Hadassah, Jerusalem (1969-1972).

NIH Research Fellow, UC San Francisco (1968/69). Resident in Internal Medicine and Nephrology, Hadassah, Jerusalem (1961-1966). Hospital Budgeting 31

Mr. Moshe Bar Siman Tov

Director General, Israeli Ministry of Health since July 2015. August 2014 - June 2015 - Economic Attaché (Israeli Ministry of Finance), Embassy of Israel, Washington, D.C., USA. Head of Ministry of Finance’s Economic Delegation to the United States. July 2014 - February 2010 - Deputy Budget Director, Israeli Ministry of Finance (from November 2013 - Senior Deputy Director). June 2008 - February 2010 - Healthcare coordinator at the Budget Division, Israeli Ministry of Finance. June 2006 - June 2008 - Social Affairs and National Insurance Coordinator at the Budget Division, Israeli Ministry of Finance. June 2006 - September 2003 - Referent for Employment and Social Affairs in the Budget Division, Ministry of Finance.

Education: 1999-2002 - BA in Economics and Business Administration from the Hebrew University of Jerusalem. 2002-2004 - MA in Economics and Business Administration, specializing in finance, the Hebrew University of Jerusalem. 32 International Workshop Report

Dr. Yitzhak Berlovitz

Certified Pediatrician and expert in Medical Management. He holds a Master’s degree in Management of Medical Organizations, Tel-Aviv University.

2006-Present Director, WMC. 2000-2006 Associate Director General, Ministry of Health as well as Director of Medical Affairs, Ministry of Health. 1993-2000 Director of Medical Affairs, Ministry of Health as well as a member of the committee drafting the National Health Insurance Law of 1995. 1998 Founder of The Israeli Association of Medical Management. Hospital Budgeting 33

Prof. Gabi Bin Nun

His career began working as an economist in the Ministry of Health. He worked in various key positions his last being the Deputy Director General for Health Economics and Health Insurance.

Gabi was one of the architects and designers of Israel’s National Health Insurance Law (1995) and since then has played a central role in its implementation and evaluation.

Since 2008, Gabi has been an Associate Professor in the Department of Health Systems Management at the Faculty of Business and Management at Ben-Gurion University of the Negev in Israel. The courses taught by Gabi include: Public Financing and Health Economics in the MHA Program, and The Israeli Health Care System in the MEMS program.

Gabi holds a B.A degree in Economics and Political Science from the Hebrew University in Jerusalem, and a Master degree in Public Management from the Heller School in Brandeis University, Boston, USA.

He is one of the founders and a board member of the Israel National Institute for Health Policy Research. Between 1998 till 2014 he was a board member of the National Health Council. Between 1998 till 2008 he was a member of the National Drugs and Technologies Prioritization Board, a board member of “ELCA” (Senior Management Training Institute for the Social Services JDC Israel), a board member of Brookdale- Meyers-JDC Institute, Jerusalem, Israel, and a board member of the Gertner Research Institute, Tel-Hashomer, Israel.

In 2014, he was nominated as a member in the Advisory Committee for the Strengthening of the Public Health System in Israel (The ‘Garman Committee’).

His research focus is in the field of health policy, health economics and health care systems. He has published books and many articles in these fields. 34 International Workshop Report

Dr. Yair Birnbaum

Chief Medical Officer, Clalit Health Services (Largest HMO in Israel).

He completed his Medical degree at the School of Medicine, the Hebrew University-Hadassah and a residency in Pediatrics at the Shaare Zedek Medical Center.

He also received an MA degree in Public Administration from Harvard University in 1999 and completed a residency in Medical Management.

Prior to joining Clalit he served as head of the Medical Division of Maccabi Health Care Services (Second largest HMO in Israel).

Previous positions included the following: Associate Director General and Head of Medical Services of the Hadassah Medical Organization, Director of the Hadassah Ein- Kerem Medical Center, Associate Medical Director of Maccabi Health Care Services and Deputy Director General of Shaare Zedek Medical Center in Jerusalem.

In addition to medical training, Dr. Birnbaum is also an ordained Orthodox Rabbi who wrote his thesis on “The Status of the Physician in Jewish Sources”. Hospital Budgeting 35

Dr. Shuli Brammli-Greenberg

Senior Researcher, Myers-JDC-Brookdale Institute and the Head of the Health Systems Management program (MHA) at the School of Public Health, University in Israel. She holds a PhD in Health Economics.

In recent years, her research has focused on economic aspects of patient/doctor/ policymaker behavior and decision-making in health and health insurance markets.

During her career as an applied researcher, Shuli's main efforts have been to disseminate new knowledge and methods to assist leaders of the health care system to make informed decisions. She works closely with senior officials in the Ministries of Health and Finance and was a member of the Public Committee to Strengthen the Public Health System, led by then-Minister of Health Yael German.

Her main areas of research in the last five years have been included: willingness to pay for the right to choose in health system, integration of public and private financing, compensation models in health systems, health insurance, disparities in the use of health system by different population groups, and waiting times as shadow prices.

Shuli is also the Principal Investigator of the on-going assessment of the Israel's National Health Insurance Law and the 1995 reform of the health system. 36 International Workshop Report

Mr. Eli Cohen

Deputy Director, Head of Finance division, and Chief Risk Officer, Clalit Health Services.

Clalit provides health services to 4.3 million members in 1400 community clinics and in 14 hospitals.

The Finance division is responsible for planning and managing of $7B annual budget distributed between 30 institutions.

The Institute includes: hospitals, districts, logistics division and central units.

Finance division has about 80 employers working in five departments: Accountancy, Finance, Budgets, Business Development and Assets Arrangement, in the recent years the division has established and managed the risk management of Clalit. Hospital Budgeting 37

Dr. Ehud Davidson

CEO, Soroka Medical Center and Head of the Southern Region of Clalit Health Services.

Ehud Davidson is a graduate of the Sackler School of Medicine of the University. He completed residency in Internal Medicine at . His current position is CEO of the main and only hospital for the entire Negev region-Soroka Medical Center, as well as the Head of the Southern Region of Israel's biggest Health Organization- Clalit.

Dr. Davidson serves as senior lecturer at the Faculty of Health Services of the Ben Gurion University of the Negev. Dr. Davidson served in several field armored units of the IDF including armored division' and he is Lieut Col (res) of the IDF.

His previous positions include: Head of Wartime Emergency Services at Clalit Headquarters, Medical Manager of the Dan District at Clalit, Director of the Northern District of Clalit, CEO of Meir Medical Center, Director at Dikla Insurance Company, Deputy Director General and Head of the Hospital Division of Clalit. 38 International Workshop Report

Dr. Donald Franklin

Worked as a Senior Economic Adviser in the UK’s Government Economic Service for some twenty-five years, both at H M Treasury, and latterly at the Department of Health (DH).

He is currently seconded to NHS England as Head of Incentives within the department that contracts directly for some £15bn of specialized care.

Previously, he has developed policy appraisal methodology in HM Treasury and went on to establish the DH’s policy appraisal system.

He is chair of the Inter-Departmental Group on Value of Life and Health (developing valuation methodology for cost benefit analysis). Acting for DH, he has been a founder member and Treasurer of the Middle East and North Africa Health Policy Forum. Prior to joining H M Treasury, he served as Chief Economist to Schroders PLC.

He was educated at King’s College Cambridge and the London School of Economics, and received his PhD from University College London in 2000.

In 2008 University of Wales Press published his philosophical monograph Groups in Conflict: Equality versus Community.

In a private capacity, he chairs The Jerusalem Interest-free Microfinance Fund Limited, a UK charity fostering inter-communal welfare through microfinance in Jerusalem. Hospital Budgeting 39

Dr. Alexander Geissler

Senior Research Fellow at the Department of Health Care Management at the Berlin University of Technology.

His research focuses on incentives and payment methods for hospitals and their impact on quality and efficiency of service delivery.

He is part of the coordinating team of the EuroDRG consortium and occasional consultant for different governmental and international organizations.

He published articles in scientific and professional journals as well as book chapters on different topics like hospital payment methodologies, medical resource utilization and hospital management and quality.

Moreover, he is engaged in teaching activities for Berlin's Economics, Medicine and Public Health students.

Alexander studied Economics and Engineering at the Berlin University of Technology with an emphasis on health economics, health care management and logistics and graduated in 2008. He received a doctoral degree in economics in 2013 from the Berlin University of Technology. 40 International Workshop Report

Prof. Jonathan Halevy

Graduated summa cum laude from the Sackler Faculty of Medicine of Tel-Aviv University in 1973.

Following four years of military service, he completed his residency in the Rabin (Beilinson) Medical Center, attaining board specialization in internal medicine. After a two-year fellowship in Gastroenterology in Yale, Prof. Halevy served briefly as acting Head of an Internal Medicine Department in Beilinson before being appointed Director-General of Shaare Zedek Medical Center, Jerusalem in 1988, a position he continues to hold.

Inaugurated in 1902, Shaare Zedek is today the largest medical facility in central Jerusalem, treating 85,000 inpatients, 650,000 outpatients and receiving 16,000 births in its 850-bed campus in 2015.

Following amalgamation with Bikur Holim Hospital in January 2013, Shaare Zedek now operates on two sites within Jerusalem and has a total of close to 1000 inpatient beds.

In addition to the demands of heading Shaare Zedek and one of its Internal Medicine units, Prof. Halevy has held a wide range of public positions: Director Representing the Public at Tefachot Mortgage Bank (1995-2000), Chairman of the Israel Transplant Center (2000-2006), Member of the Executive Board of Bar-Ilan University (2004- 2007), Chairman, Council of Higher Education Committee to evaluate the need for a fifth medical school in Israel (2007). From 1993-2003 he served as Chairman of the Medical Risk Management Forum of the Medical Risk Management Company Ltd., Israel and since 2006 has been a member of the Council of National Service. Prof. Halevy also served as Chairman of the Public Committee of the National List of Health Services (2013-2015).

Jonathan Halevy is a very active teacher and lecturer and a Clinical Associate Professor at the Hebrew University-Hadassah Medical School. The author of more than 100 medical articles and papers, he has published three books in his fields of special interest: "Key Facts in Gastroenterology" (1986), "The Doctor-Patient relationship" (2003) and "Complementary and Alternative Medicine - The Facts" (2005). Hospital Budgeting 41

Prof. Avi Israeli

Chief Scientist of the Ministry of Health, and the Head of the Health Policy, Health Care Management and Health Economics Dept. at the Faculty of Medicine, the Hebrew University- Hadassah.

Prior to this he was the Director General of the Israel Ministry of Health (2003-2009) and the Director - General of Hadassah Medical Organization (1998 -2001).

He holds the Chair of Dr. Julien Rozan Professorship of Family Medicine and Health Promotion Chair at the Hebrew University-Hadassah Medical School, Jerusalem (since 1996) and teaches there regularly.

Prof. Israeli chaired the national committee to update the Israeli national standard basket of health services.

Prof. Israeli received his Medical degree from the School of Medicine, the Hebrew University-Hadassah. He completed residencies in Internal Medicine and in Health- Care Management at Hadassah University Hospital and has certifications in both specialties.

He received his Master's Degree in Public Health from the Sloan School of Management at MIT, Boston.

His scientific activities are related to applied, methodological and theoretical research in the fields of health policy, health care management, and the epidemiological, economic, social and cultural basis for decision-making.

His publications deal with translation of academic knowledge and inputs from the field into policy setting and decision-making processes.

Two additional key research foci are rationing/priority setting and comparative health care systems. 42 International Workshop Report

Mr. Nir Kaidar

Senior Deputy Director General for Strategic and Economic Planning, Ministry of Health.

In this role, Nir is responsible for the strategic planning of the Israeli Health System and leads the Long Term Care reform in Israel.

Nir is working in the Ministry of Health since 2006 and took a leading part in the dental reform in 2010.

Nir lives in Jerusalem and holds a MA in Public Policy from the Hebrew University of Jerusalem, a MA in Social Sciences and Humanitarian Affairs from La-Sapienza University , and a BA in PPE from the Hebrew University of Jerusalem.

Hospital Budgeting 43

Prof. Orly Manor

Chairwoman of the Board of Directors, The Israel National Institute for Health Policy Research and is a Professor of Biostatistics at the Braun School of Public Health and Community Medicine of the Hebrew University-Hadassah Medical Organization in Jerusalem. Prof. Manor is a former Director of the School.

Prof. Manor received her first and second degrees in Statistics from the Hebrew University and her PhD in Statistics from Stockholm University.

Currently Prof. Manor leads the Israel National Program for Quality Indicators in Community Healthcare.

Prof. Manor is the founder of the Israel Longitudinal Mortality Studies.

Prof. Manor’s research interests include health inequalities, the developmental origin of adult disease and quality of care.

In 2012, Prof. Manor was the recipient of the Hebrew University Rector’s award for outstanding faculty member. 44 International Workshop Report

Prof. Shlomo Mor-Yosef

Director General of Bituach Leumi, National Insurance Institute of Israel.

Prof. Mor-Yosef is the former Chairman of the Board of the Israel National Institute for Health Policy Research from 2008-2014.

In 2011, Prof. Mor-Yosef completed his tenure as Director General of the Hadassah Medical Organization (HMO) in Jerusalem. His eleven years as Director General were the crowning glory of his 38 years at Hadassah, from his first year of medical school until 2011, with just a few brief exceptions.

Prof. Mor-Yosef graduated from the Hebrew University-Hadassah Medical School in 1980, completing his Obstetrics and Gynecology specialization at Hadassah. He served as a senior physician in the Department of Obstetrics and Gynecology at Hadassah with special focus on cervical cancer.

From 1988-1989, Prof. Mor-Yosef completed a subspecialty in Gynecological Oncology at Queen Elizabeth Hospital, Gateshead, England.

In 1990, Prof. Mor-Yosef assumed the position of Deputy Director of the Hadassah Ein-Kerem Hospital, following which he studied at the Harvard University JFK School of Government, where he received his Master’s Degree in Public Administration. In 1994, he assumed the post of Deputy Director General of HMO and then served as Director of Hadassah Ein-Kerem. Prior to assuming his post as Director General of HMO, Prof. Mor-Yosef served as Director General of the Soroka Medical Center of the Negev.

Prof. Mor-Yosef has authored more than 100 scientific publications and has served on the faculty of several universities and boards of various organizations and companies.

From 2001-2012, Prof. Mor-Yosef served as Chairman of Hadasit, HMO’s Technology Transfer Company. Among his present responsibilities, Prof. Mor-Yosef serves as Chairman of the Public Committee for Fertility and Birth appointed by the Director General of the Ministry of Health to recommend legislation in the field of fertility and birth in Israel; and Member of the Master Plan for Transportation Committee of the Association for Planning, Development & Urban Preservation - Jerusalem. Hospital Budgeting 45

Ms. Valérie Paris

Senior Policy Analyst, Health Division, Organisation for Economic Co-Operation and Development (OECD).

Valérie Paris joined the OECD Secretariat in September 2005 to contribute to the work undertaken by the Health Division.

Since then, she has contributed to several projects on health systems’ characteristics and performance, providers’ payments and on pharmaceutical policies.

Previously, she was researcher at the French Institute of Research and Information on Health Economics (IRDES), a non-for-profit organization.

She participated in research projects on pharmaceutical policies, physicians’ payment schemes, health accounts and comparative analysis of health systems.

She holds a Master’s degree in Economics, Statistics and Econometrics from the University of Paris 1-Sorbonne (1990). 46 International Workshop Report

Mr. Vadim Perman

Manager of the Pricing Department of the Planning, Budgeting and Pricing Division of the Israel Ministry of Health since 2012.

Vadim is responsible for the Financial Supervision of the Hospital Sector (FSH) Department, which was established in order to improve the economic and financial monitoring of the Public Hospitals, and to take part in policy formulation process at the Ministry of Health.

In his role of Manager, Vadim has been accountable for the pricing process of hospital services including technology assessment as well as setting maximum prices for prescription medicines.

Vadim graduated with a MA in Economics and MBA from the Hebrew University, Jerusalem.

He is actively participating research in the field of economic incentives driven by prices (DRG) in the Israeli health system. Hospital Budgeting 47

Prof. Shimon Reisner

Associate Director, Rambam Medical Center, Haifa, Israel.

Professor Shimon Reisner is a graduate of the Sackler Faculty of Medicine at Tel-Aviv University. He completed MHA degree at the University of Haifa and is Israeli Board Certified in Health Administration.

Prof. Reisner obtained clinical training in Cardiology at Rambam Medical Center in Haifa and at the University of Rochester Medical Center in New York. Until 2004 he headed the Noninvasive Cardiology Unit at Rambam Medical Center. In 2005, he joined the executive staff of Rambam serving as the first Head of R&D department and later as the Associate Director of the hospital.

He is a Retired Colonel from the Medical Corps and is very experienced in medical management under emergency conditions.

Professor Reisner's main research and clinical interests are in the fields of novel methods in cardiac imaging, valvular heart disease and cardiomyopathies. Since 2009, he has been teaching and organizing the Health Administration course at the Technion. 48 International Workshop Report

Dr. Bruce Rosen

Director, Smokler Center for Health Policy Research - a division of the Myers-JDC-Brookdale Institute.

His recent research foci have included the Israeli mental health reform, efforts to monitor and improve the quality of care, health information exchanges, and the cross-national flow of health policy innovations.

An important component of his work involves promoting linkages between research and health policy development.

Dr. Rosen is the lead author of the European Observatory's country report for Israel and The Commonwealth Fund's profile of the Israeli health care system. He recently co-edited a World Scientific book entitled "Accountability and Responsibility in Health Care: Issues in Addressing an Emerging Global Challenge", which combined conceptual contributions from leading international scholars with local reports on how eight different health systems are addressing the accountability/responsibility challenge.

Dr. Rosen is also co-editor of the Israel Journal of Health Policy Research, which seeks to promote intensive intellectual interactions between scholars from Israel and their counterparts from around the world.

As someone who spent the first half of his life in the U.S. and the second half in Israel, Dr. Rosen has always enjoyed facilitating cross-national learning opportunities between the two countries. In recent years, he has come to see that he can also be helpful in creating bridges with health systems in other countries as well.

Dr. Rosen holds a B.A. in Economics from Harvard College and a Doctorate in Health Policy from the Harvard School of Public Health. Hospital Budgeting 49

Prof. Joshua Shemer

Full professor of Internal Medicine at the Sackler Faculty of Medicine at Tel-Aviv University, Chairman of the Board of Assuta Israel, the country’s largest private hospital network. He is also Director of the Israeli Center for Technology Assessment in Health Care (ICTAHC) at the Gertner Institute, which is a research unit serving the Israeli Ministry of Health.

A graduate of the Hebrew University and Hadassah School of Medicine, he is a foremost specialist in medical technology management and serves in that capacity as a faculty member at the Tel-Aviv University Business School.

Over the years, Professor Shemer has served as Surgeon General of the IDF, Director General of Israel’s Ministry of Health, and CEO of Maccabi HMO. He has led a number of national reform committees and has been an active participant in more than a hundred scientific meetings both in Israel and abroad.

A prolific writer and editor, he has published extensively in prominent professional publications, authored numerous chapters and 6 books on trauma, terror, health reform and technology assessment. 50 International Workshop Report

Dr. Orly Weinstein

EDUCATION 1984-1991: MD, Hadassah Medical School, the Hebrew University. 2003-2005: MHA, Ben-Gurion University of the Negev. License to Practice Medicine, Ministry of Health, Israel. Board certification in Ophthalmic Diseases and Medical Administration, Ministry of Health.

EMPLOYMENT 01/2016-present: Head, Division of Government Medical Centers, Ministry of Health. 03/2011-01/2016: Deputy CEO, Soroka University Medical Center. 09/2010-03/2011: Medical Assistant to the General Director, Ministry of Health (intern in medical management). 2006-2010: Commander of the Southern Region, IDF Medical Facility. 2005-2007: Manager of the Ophthalmology Clinic, Soroka University Medical Center. 2005-2006: Senior Ophthalmologist, Soroka University Medical Center. 2002-2004: IDF (Medical Doctor).

PROFESSIONAL AND ACADEMIC ACTIVITIES 2013-Present: In charge of the "Hospital Management" course, Health systems management department, Faculty of Health Sciences, Ben-Gurion University. 2006-Present: Lecturer, Faculty of Health Sciences, Ben-Gurion University. March-April 2011: Participated in the Israeli humanitarian delegation to Japan. 2009-2012: POC of the medical corps for the IDF transfer to the Negev project. 2006-2010: Chairman of the residency committee, Soroka University Medical Center. 2006-2011: Member of the national internship committee. Peer Reviewed Publications - 15.

AWARDS & SCHOLARSHIPS: 1996 The Dr. Matityahu Shtich Prize for Distinction in Final Medical Thesis, Hadassah Medical School, the Hebrew University. 2001 Award for best Ophthalmology Resident by the Israeli Ophthalmological Society. 2008, 2009 Awards of the Head of the Technology & Logistics Branch, IDF. 2015 Award of General Director of Ministry of Health for best Medical Logistic Project. Hospital Budgeting 51

Dr. Salman Zarka

Director General, Ziv Medical Center. Graduated from the Faculty of Medicine, Technion - Israel Institute of Technology, Haifa in 1988.

He received a Master's degree in Public Health (MPH) from the Hebrew University, Jerusalem, and an additional Master's degree in Political Science from the University of Haifa. Dr Zarka's areas of specialty are public health and medical administration.

Prior to his position at Ziv Medical Center, Dr. Zarka served as a Colonel in the I.D.F. for 25 years in a variety of positions, the last of which was commander of the Military Health Services Department.

Previous to this position, Dr. Zarka was the Head of the Medical Corps of the Northern Command and the Commander of the Military Field Hospital for the Syrian casualties in the Golan Heights. 52 International Workshop Report

List of Participants

Last Name First Name Institute eMail 1 Afek Arnon Ministry of Health [email protected] 2 Alon Nisim Leumit [email protected] 3 Asraf Yair Ministry of Health [email protected] 4 Aviram Alik NIHP [email protected] 5 Aviv Ofir Ministry of Health [email protected] 6 Bar Siman Tov Moshe Ministry of Health [email protected] 7 Ben Moshe Roei Meuhedet [email protected] 8 Berlovitz Yitzhak Wolfson Medical Center [email protected] 9 Bin Nun Gabi Ben-Gurion University [email protected] 10 Birkenfield Shlomo Clalit Health Services [email protected] 11 Birnbaum Yair Clalit Health Services [email protected] 12 Bisharat Bishara EMMS Nazareth Hospital [email protected] 13 Bitterman Haim Assuta Medical Center [email protected] 14 Blondheim Orna 'HaEmek'' Medical Center [email protected] 15 Brammli- Shuli Brookdale Institute [email protected] Greenberg 16 Cohen Eli Clalit Health Services [email protected] 17 Davidovitch Nadav Ben-Gurion University [email protected] 18 Davidson Benny Assaf Harofeh [email protected] 19 Davidson Ehud Soroka Medical Center [email protected] 20 Doron Chaim NIHP [email protected] 21 Dudkiewicz Mickey Hillel Yaffe Medical Center [email protected] 22 Ekka-Zohar Anat Ministry of Health [email protected] 23 Engel Dani Assuta Medical Center [email protected] 24 Fernandes Haim Leumit [email protected] 25 Foerster Noa Sheba Medical Center [email protected]. gov.il 26 Franklin Donald NHS England [email protected] 27 Geissler Alexander Technische Universität [email protected] Berlin 28 Geva Oren Ministry of Finance [email protected] 29 Gil Ziv Rambam Medical Center [email protected] Hospital Budgeting 53

Last Name First Name Institute eMail 30 Ginsburg Iris Ministry of Health [email protected] 31 Halevy Jonathan Shaare Zedek Medical [email protected] Center 32 Halperin Eran Beilinson Hospital [email protected] 33 Hershkovitz Hadassah Medical [email protected] Organization 34 Israeli Avi Ministry of Health [email protected] 35 Kaidar Nir Ministry of Health [email protected] 36 Kreiss Yitshak Sheba Medical Center [email protected]. gov.il 37 Litvak Ziva NIHP [email protected] 38 Manor Orly NIHP [email protected] 39 Mor-Yosef Shlomo National Insurance [email protected] Institute 40 Noy Shlomo Sheba Medical Center [email protected] 41 Oliel Zion Maccabi Healthcare [email protected] 42 Paris Valérie OECD [email protected] 43 Perman Vadim Ministry of Health [email protected] 44 Press Joseph Schneider Children's [email protected] Medical Center 45 Ralbag Ruth Shaare Zedek Medical [email protected] Center 46 Regev- Sigal Meuhedet [email protected] Rosenberg 47 Reisner Shimon Rambam Medical Center [email protected] 48 Ridnik Ran Ministry of Finance [email protected] 49 Rosen Bruce Brookdale Institute [email protected] 50 Shemer Joshua Assuta Medical Center [email protected] 51 Tal Orna Assaf Harofeh [email protected] 52 Topper Revital Ministry of Health [email protected] 53 Vurembrand Zeev Meuhedet [email protected] 54 Waitzberg Ruth Brookdale Institute [email protected] 55 Weinstein Orly Ministry of Health [email protected] 56 Yona Neta Ministry of Health [email protected] 57 Zarka Salman Ziv Medical Center [email protected] המכון הלאומי לחקר שרותי הבריאות ומדיניות הבריאות )ע"ר( The Israel National Institute for Health Policy Research

+972-3-5303516 [email protected] www.israelhpr.org.il