The Healthcare Start-Up Nation

Online First - Editorial
David B. Nash, MD, MBA
Gary M. Owens, MD

Author Affiliations
How does a tiny nation of less than 9 million people that is surrounded by its sworn political enemies and is in existence for only 71 years find a way to provide healthcare to all its citizens at a fraction of the cost of the United States and have a far better life expectancy and infant mortality than our country? It’s an interesting question indeed! Perhaps the answer lies in part in what Senor and Singer called in their 2009 book the “start-up nation” mentality of Israel.1 I’m going to tackle this question based on my recent whirlwind visit to Israel as part of an academic mission for Thomas Jefferson University.

Readers of my editorials know that my work at Jefferson College over the past 30 years has taken me to Australia, Germany, Great Britain, India, Japan, Malaysia, and now Israel. During that recent whistle-stop tour of 5 major Israeli academic centers, I had a glimpse of the start-up nation. In their book, Senor and Singer outlined the unique culture of Israel, given its compulsory military service and focus on new technology.1 From this unusual mixture emerges an entrepreneurial class forged by military conflict and sharpened by academic prowess. After a quick overview, I will provide some observations about several of the organizations I had the privilege of visiting in person.

According to the State of Israel’s Ministry of Health, Israel’s healthcare system is characterized by a universal healthcare coverage, with a community-based orientation and a focus on preventive services.2 In 2013, Israel spent approximately 7.5% of its gross domestic product (GDP) on healthcare compared with the Organisation for Economic Co-operation and Development (OECD) average of 8.9%; at that same time, the United States spent 16.4% of its GDP on healthcare.3 The life expectancy at birth in Israel exceeds the OECD mean (82.1 years vs 80.6 years, respectively), and infant mortality in Israel is lower than the OECD average (2.7 vs 3.6 per 1000 live births, respectively).4

Historically, Israel has had 4 large HMOs, with universal coverage as a core national goal. In the past decade, Israel has focused on creating the Ofek System, which is a national electronic medical ­record (EMR) information exchange platform.5 In a nutshell, every single citizen is included in this national ­online, readily accessible EMR system, which is the envy of many other nations, including our own.

I had the privilege of meeting Gabriel Chodick, PhD, MHA, MSc, an associate professor at the School of Public Health at Tel Aviv University in Israel, and Unit Head of Epidemiology and Database Research at Maccabitech. Maccabitech was founded in 1999 by Varda Shalev, MD, MPH, as an offshoot of Israel’s Maccabi Healthcare Services, the second largest of the country’s 4 HMOs.5 Maccabitech is a 2.5-million-person, readily accessible healthcare data engine that enables predictive analytics, artificial intelligence, and population health intelligence to thrive in a country essentially the size of New Jersey. Here’s the punchline: Maccibitech is an incredible amalgam of everything we have strived to create in the United States.

There is nothing quite like the database at Maccabitech in the United States. In a recent issue of Harvard Business Review Case Studies, Kominers and Knoop provided a detailed account of the capabilities of medical data in Israel.6 Although I cannot adequately summarize this comprehensive article, I can reassure our readers that Maccabitech is on to something that most integrated delivery systems in the United States are still dreaming about.

I visited another hotbed of innovation in healthcare at the Sheba Medical Center at Tel HaShomer near Tel Aviv. Sheba is the largest medical center in Israel and the leading medical complex in the Middle East, with 1700 beds, serving 430,000 inpatients and 1.5 million outpatients annually.7 I spent time with Eyal Zim­lichman, MD, MSc, Deputy Director General, Chief Medical Officer, and Chief Innovation Officer at Sheba. Dr Zimlichman is a physician, healthcare executive, and researcher who is focused on assessing and improving healthcare quality and value, patient engagement, and patient safety—my kind of guy!

Dr Zimlichman is also the leader of what Sheba calls ARC, which stands for Accelerate, Redesign, and Collaborate.8 Dr Zimlichman shared with me that ARC is so successful on the Sheba campus, that there are detailed plans to export a comparable model to integrated delivery systems in the United States later this year.

ARC has a highly developed research program, with a special focus on digital health. Its research priorities include sensors and wearable devices, surgical innovation, precision medicine, big data, and telehealth. With what ARC refers to as an “open innovation campus” strategy, it welcomes start-ups and has streamlined its processes to ensure a quicker turnaround.8

ARC’s attributes include fast-track lanes for start-ups, increased transparency, full data access, and facilitated pilot implementation.8 In other words, ARC is the innovation engine for Israel’s largest healthcare delivery system.

In summary, Maccabitech and ARC are emblematic of the unique start-up culture that currently pervades Israeli society, and they represent 2 outstanding examples of the role that healthcare plays in this story.

As our College of Population Health learns more about these fantastic organizations, and as we build our academic bridges to these institutions, I am hopeful that we could import some of their tools into our own great city of Philadelphia. I’m looking forward to this important endeavor.

As always, I am interested in your views. You can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

David B. Nash, MD, MBA is Editor-in-Chief, American Health & Drug Benefits, and Founding Dean Emeritus, Jefferson College of Population Health, Philadelphia, PA.

References

  1. Senor D, Singer S. Start-Up Nation: The Story of Israel’s Economic Miracle. New York, NY: Twelve; 2009.
  2. State of Israel Ministry of Health. About the Ministry. www.health.gov.il/English/About/Pages/default.aspx. Accessed May 24, 2019.
  3. Organisation for Economic Co-operation and Development. OECD Health Statistics 2015. July 7, 2015. www.oecd.org/els/health-systems/Country-Note-­ISRAEL-OECD-Health-Statistics-2015.pdf. Accessed May 24, 2019.
  4. Organisation for Economic Co-operation and Development. Health at a Glance 2017: OECD Indicators. 2017. www.oecd-ilibrary.org/docserver/health_glance-2017-en.pdf?expires=1559052805&id=id&accname=guest&checksum=2A466D962CD16131981A5EB69938D35B. Accessed May 24, 2019.
  5. Israeli Ministry of Health. Solution for Viewing Imaging Tests for Health Information Exchange. August 27, 2015. www.health.gov.il/Services/Tenders/Documents/com15_2015.pdf. Accessed May 24, 2019.
  6. Kominers SD, Knoop CI. Maccabitech: the promise of Israel’s healthcare data. Harvard Business School Case 819-032. February 2019.
  7. Sheba Medical Center Tel HaShomer. Sheba Hospital in Israel facts and figures. www.shebaonline.org/about-us/. Accessed May 24, 2019.
  8. The ARC Sheba Innovation Center. https://arc.sheba.co.il. Accessed May 24, 2019.
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