Sometimes we lose perspective in the health care debate, somaybe it would help to look at how other countries have addressedhealth care delivery and funding. This month we take a look atIsrael and Switzerland. >>

There was a time in the United States—in the 1990s—when healthmaintenance organizations were the biggest thing in health care.Many hospitals and private practices were moving toward an HMOmodel of care, and it seemed as though the U.S. health careindustry as a whole would shift to an HMO-driven system—which ishow health care is deployed in Israel, a country that's been usingHMOs as major care providers (and, later, the country's primarycare provider) since before the state's inception.

The most obvious benefit of an HMO system is the coordination ofcare the organizations facilitate. There is a sophisticated levelof communication that takes place between hospitals and practices;patient information is shared among care providers, so the surgeonin the hospital knows exactly what a patient's primary careprovider has done for him or her in terms of tests and medicationprescribed, and clinicians also have access to the patient's healthhistory.

For a variety of reasons, HMOs did not become the savior of theU.S. health care system some predicted—although Kaiser Permanenteremains a popular provider.

In Israel, labor unions established HMOs before the Israelistate was founded in 1948. The membership-based organizationsbecame increasingly important as Israel implemented mandatoryemployer-provided health care for all working citizens in 1973; in1995, the National Health Insurance Law in Israel madeparticipation in one of the four Israeli HMOs compulsory for allIsraeli citizens.

A progressive health care fund was set up through Israel'ssocial security organization, the National Insurance Institute; theIsraeli HMOs are overseen by the state, and Israeli citizens havethe option of switching from one HMO to another once a year.

The National Insurance Institute collects and distributes fundsto the HMOs based on the number of citizens covered by each planand myriad other factors, including age distribution. Through thesefunds, every Israeli citizen is guaranteed health care—and like inSwitzerland, supplementary health care plans also can be purchased,but directly from the HMO instead of through a private carrier.

Today in the United States, the Patient Protection andAffordable Care Act is attempting to address the lack of carecoordination that's developed in the American health care system byproviding incentives for medical practices and hospitals to adoptnew procedures and technologies that lend themselves to increasedcoordination. It's also doing this by creating provisions foraccountable care organizations, coordinated groups of health careproviders that provide care for specific populations of patientsand are accountable for the quality, cost and outcomes of thatcare.

The ACO component of the PPACA is tied to Medicare; PPACA hasauthorized the Centers for Medicare and Medicaid Services to createwhat's known as the Medicare Shared Savings Program.

There are some good reasons why PPACA might have gone the routeof establishing an ACO program instead of treading the HMO pathlike Israel has done—one of them being sheer size.

“The pure volume and diversity of our constituency plays a role,including impoverished people, the elderly and other people livingin rural and suburban areas. This makes any kind of universalhealth care difficult,” says Cyrus Chowdhury, chief executiveofficer and managing director of consulting firm CBPartners. “Andculturally, we're so big on choice and difference—that kind ofmentality is what drives Americans, and that's why I don't think aconsistent benefits structure would really work across the entireAmerican population.”

Furthermore, Chowdhury adds, although the structure of the HMOsin Israel and the United States might be consistent, how Israelfunds their health care is very different.

“They don't rely 100 percent on employer and individualcontributions to pay for the benefits,” he notes. “The governmentis providing the majority of funding to HMOs. So it's not reallyfair to say that Israelis have a private program with HMOs.”

And in terms of highly specialized care, Israel does have tooutsource some of its health care. Certain rare diseases mightrequire patients to travel overseas to treat theirconditions—particularly to Asia, where many countries have highlyspecialized medical infrastructures through their medical tourismindustries.

“The way their system is set up, you can still pursuespecialized medical care in Korea or Malaysia,” Chowdhury notes.“You have to pay for your own flight, but your care will besubsidized through your HMO in Israel.”