Tireless triage: How Israeli community medicine prevents Omicron swamping system
The healthcare providers that delivered Israel’s turbo-speed vaccination drive a year ago are now enabling the country to face mass infection without a health system meltdown
Nathan Jeffay is The Times of Israel's health and science correspondent
There has never been illness in Israel on such a scale. With 1 in 20 citizens currently confirmed infected by the coronavirus, and 10 percent of medical staff out sick, what is enabling hospitals to take it in their stride?
Meltdown on the wards has been prevented by the reduced ability of Omicron to cause serious illness, hand-in-hand with the effect of new antiviral pills that are prescribed to the elderly and the high level of vaccinations, both of which reduce deterioration.
But there is another often-overlooked factor. Israel has one of the strongest community medicine infrastructures in the world.
We often talk about hospitals as the “frontline” against the coronavirus. Really, they are the last line of defense, which normally come into the picture only after healthcare providers — or HMOs — have tried everything possible to get patients fully recovered at home.
The HMOs had a stint in the spotlight when they achieved turbo speed in Israel’s initial vaccination campaign, but have since attracted limited attention. Yet today they act as the ultimate in triage, keeping patients out of hospital unless absolutely necessary, while giving them a range of services at home which are keeping Israel’s fatality rates modest despite high infection levels.
Regardless of income level, every Israeli is a member of one of four HMOs, as part of the state’s National Insurance program, and most basic services are free at the point of care. The HMOs have huge networks of clinics, including in kibbutzim and other outlying communities, and in response to the pandemic, also offer telemedicine and online medical services. They boast sophisticated digital record-keeping — a strength that helped make Israel become a world leader in vaccine effectiveness stats.
“The HMOs are the frontline in the defense against the threat of the coronavirus, and the doctors and nurses in the community definitely join the ranks of the hospital staff as soldiers in this war,” said Dr. Tanya Cardash, head of the Jerusalem region for Maccabi Healthcare Services.
“Hospitals are playing a vital role in the management of those who are in a serious condition but the vast majority of Omicron patients are being managed by their primary care physicians in the community,” Cardash said.
In fact, just a small change in the proportion of patients that HMOs are able to keep at home would quickly cause a domino effect that could push hospitals beyond their limits — or require emergency steps like military reinforcements.
Dr. Doron Dushnitzky, head of the coronavirus department at the Leumit HMO, told The Times of Israel that the organization was functioning, but was heading toward the edge of its capabilities.
“We’re at ninety-something percent of what we can manage, and if it goes higher and hits the maximum capabilities of our employees, things could become too much,” Dushnitzky said.
“If we see that red flag, we will take emergency measures, for example calling in the army [for reinforcements]. There are plans for emergency measures that haven’t yet been put in place,” he said.
HMO staff are working many extra hours to provide consultations to all the newly-diagnosed people who are inundating booking systems, as well as providing ongoing care to many who are struggling to shake the virus and who could well end up in hospital if not given intense oversight.
In the current wave, HMOs also have a new responsibility they didn’t have in the past: delivering the new antiviral pills to elderly or at-risk patients who are diagnosed with the virus.
“At the Maccabi [HMO] we have set up a special team that supports the primary care doctors in treating coronavirus patients in their homes, including delivery of antiviral medications given to high-risk patients,” Cardash said.
Meanwhile, Leumit’s Dushnitzky said the HMO was also dealing with a wave of flu infections.
“We’re facing not only the coronavirus but also lots of flu at the same time, which causes a comorbidity effect and increases the workload. Altogether, the situation pushes our abilities to the limit in all areas, from representatives who give answers to people by phone to family physicians who are overwhelmed by patients,” he said.
“A lot of doctors, nurses and other employees are very exhausted in the last few weeks, but we’ll continue working to the maximum,” he said.
Intense HMO activity during the Omicron wave reflects an ever-increasing community focus in the coronavirus fight, according to epidemiologist Nadav Davidovitch, a Ben-Gurion University professor and leader of Israel’s doctor’s union.
“Israel has very high infection rates but we are doing well in terms of mortality and one of the main reasons is the community healthcare, which ensures health provision from not-for-profit health funds which actually provide the entire COVID treatment for 98 percent of people who test positive,” Davidovitch said.
“As the pandemic has evolved, HMOs have found more and more innovative ways to keep patients away from hospitals, and they have become an important component in the pandemic response in an increasing range of levels,” he added.
Health policy expert Prof. Alex Weinreb, research director at the Taub Center, told The Times of Israel that the pandemic performance of HMOs highlights the role they play in normal times.
“The strong community-based health system is one of the ways we’re able to maintain public health — measured by our high life expectancy — enabling us to spend so much less of our GDP on health,” he said.
