Giving priority to medical tourists over Israelis, operating on those tourists in the morning while the doctors are on the public payroll, financial irregularities in the management of medical tourism agents, are among the findings of an official report from the audit unit in the accountant general’s division of the Finance Ministry in Israel. The report covers five large state-owned hospitals during 2013 and the first quarter of 2014. Health corporations are the bodies that run the additional operations at the hospitals in the afternoons after services to the public have ended, and this includes medical tourism. The five hospitals: Sheba Medical Center at Tel Hashomer; Ichilov Hospital in Tel Aviv; Rambam Medical Center in Haifa; Assaf Harofeh Hospital in Tzrifin; and Wolfson Medical Center in Holon. The revenue of these five hospitals from medical tourism in 2013 was 347 million shekels, states the report. The report estimates that by including other large private hospitals such as the two Hadassah medical centers and Shaare Zedek Medical Center in Jerusalem, as well as Assouta Medical Center in Tel Aviv, the total revenue of the medical tourism market in Israel in 2013 is more than 600 million shekels (£102 million). Of the five hospitals, Ichilov took in by far the most money at 155.4 million shekels, with Sheba earning 129 million shekels. The rest earned much smaller sums. The accountant general’s report was presented to the health ministry’s German Committee which is studying potential reforms in the health care system. The committee is scheduled to vote soon on its recommendations. The report is scathing about the way hospitals tried to hide what they are earning from medical tourism: ’Hospitals did not fully cooperate even after the intervention of the director general of the Health Ministry and his order to cooperate with the audit team. Hospitals either refused to provide documents outright or provided some, but refused to allow them to be removed from the hospital or photocopied — something which made it difficult to conduct the work of the audit.” All five hospitals are state owned and state run. The audit says that medical tourists are given priority over Israelis — at the latter’s expense. This violates ministry regulations that ban giving such tourists priority in making appointments, as well as requiring that such appointments for the tourists do not lengthen waiting times for Israeli patients. In practice, the medical tourists go through a separate procedure and wait much less time and in most cases receive appointments on the dates they ask for. The agency studied the question by examining the patients’ files — and found that medical tourists had priority in all the hospitals, and often wait only a few days, while Israelis can wait months. In cases in which the waiting time for Israelis is unreasonable according to the National Health Law, medical tourism should be stopped, says the report. Hospitals are reluctant to talk about medical tourism but when they do, the big defence is that money earned goes to improve health care for the public. The report could not conform this and as the Health Ministry has no supervision over the use of the funds it is not clear where the money goes. Regulations state that medical tourists must be charged the standard rates for Israelis, and are not allowed to choose their doctors in return for payment. In practice neither rule is followed. At Wolfson and Assaf Harofeh, payments to doctors were the result of negotiations between management and the doctors, and in almost all cases the payments were much higher than what is allowed. The health ministry now bans the practice of charging medical tourists higher rates. The audit recommends banning medical tourism agents from being able to approach doctors directly and suggests that they should have to work through the hospital medical tourism departments. The report also found that doctors were being paid for medical tourism procedures at the same time that they were being paid for being on duty in the morning hours on their regular jobs providing services in the public health care system. Other hospital facilities such as laboratories and imaging departments also worked for medical tourism clients during the hours they were supposed to be doing public work only. The report highlights that medical tourism agents are completely unregulated, as are their fees, and there is no transparency. There are no tenders or rules, and no price lists; and in some cases these agents get free offices inside the hospitals and often present themselves as being representatives of the hospitals. Another problem is that in a number of cases the hospitals have been stuck with bad debts as the tourists leave the country owing money that often cannot be collected.Overall the report is an indictment of how medical tourism agencies and state hospitals can misuse medical tourism, with strong suggestions that agents and doctors get most of the financial benefit.