News & Analysis
Medical News & Perspectives ......p1105 Global Health ................................p1109
Israeli Physician Salman Zarka, MD:
Caring for Syrian Patients Is Our Duty
The JAMA Forum...........................p1107
Value-Based Purchasing: Time for Reboot
or Time to Move On?
Medical News & Perspectives
Israeli Physician Salman Zarka, MD:
Caring for Syrian Patients Is Our Duty
Jennifer Abbasi
S
ix years after the start of a devastat-
ing civil war, more than 6 million
Syrians are displaced within their own
country, according to a report from the
United Nations and international partners.
More than 4.8 million Syrian refugees have
fled to Turkey, Lebanon, Jordan, Iraq, and
Egypt, while more than 880 000 have
sought asylum in Europe. Although US Presi-
dent Donald J. Trump signed an Executive
Order suspending entry to Syrian refugees
this January, by the end of 2016, more than
18 000 Syrian refugeesroughly half of
them children younger than 14 yearswere
already being hosted in cities across the
United States, according to State Depart-
ment data.
But not all the Syrians who left their
country in recent years are looking for asy-
lum. Some are seeking medical treatment
they can no longer obtain in their home-
land. Half of Syrias public hospitals and
health care centers are either closed or are
only partially functioning, the World Health
Organization has said. Physicians for
Human Rights reports that, facing deliber-
ate attacks, more than half of the coun-
trys 30 000 physicians have fled.
Faced with a decimated health care sys-
tem, wounded civilians from Syria first be-
gan to arrive on Israels northern border
seeking medical assistance in early 2013. At
the time, Salman Zarka, MD, MPH, MA, was
a colonel in the Israeli Defense Forces (IDF)
and had previously served as medical com-
mander of the northern arena in Israel. Under
his watch, the IDF opened a military field
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hospital to provide medical support to those
Syrians who came seeking it.
Since then, Zarka said, Israeli health
care personnel at an IDF aid station on the
border, the now-closed military field hospi-
tal, and civilian hospitals have provided
medical care to roughly 2500 Syrians.
Most come from Syrias southern region,
close to the Israeli border. In a New Years
speech in December, Israeli Prime Minister
Benjamin Netanyahu pledged to expand
medical treatment to civilians from the
more distant ravaged city of Aleppo. Israel
does not host Syrian refugees; the patients
return to their country after receiving
treatment, Zarka said.
Now retired from the military, Zarka is
general director of Ziv Medical Center in
the city of Safed. The staff of Ziv, Israels
northern-most civilian medical center, has
treated more than 800 Syrian patients.
Zarka said that although many Israelis
and Syrians view each other as the enemy
due to 3 wars and protracted tensions be-
tween the nations, he believes its part of his
mission to provide medical care to those who
need it. This is my duty, he said. I chose to
be a physician because I believe in that.
On a recent visit to the United States,
Zarka spoke with JAMA about the chal-
lenges of treating Syrian civilians and why he
believes medicine could be a key to peace in
the region. The following is an edited ver-
sion of the interview.
JAMA: How many Syrians does your hos-
pital see on a daily or weekly basis?
(Reprinted) JAMA March 21, 2017 Volume 317, Number 11
Administration...............................p1110
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DR ZARKA: Usually we have about 10 to 20
Syrian wounded at our hospital.
JAMA: What type of care are they coming
to your hospital seeking?
DR ZARKA: We have treated children,
women, very young, and very old, with
multiorgan system problemsmostly very
serious war injuries. Others were sick. We
already have 19 new babies that were
delivered at Ziv.
JAMA: What types of war wounds are com-
mon?
DR ZARKA: Most of them have orthopedic
problems because of bombardments. We
had some children who have played with
mines. We had some people with very trau-
matic amputation of limbs. We have neuro-
surgery problems. We have very compli-
cated chest and abdomen injuries. Firing
[injuries]. I can remember in one case [a
man] was fired with a bullet in this bone.
[He points to his jaw.] Another bullet in the
chest. And he also was near a grenade, so
he had a big problem with the abdomen,
with bleeding from the liver, with bleeding
from the intestine. So this man, in order
to save his life, we needed to operate on
him again and again. Mostly the Syrian
wounded suffer from a bacteria very resis-
tant to antibiotics, and this is made more
complicated with sepsis disease.
JAMA: In terms of the people who are sick...
DR ZARKA: Some of them unfortunately
have cancer disease. We treated a girl,
1105
 News & Analysis
Dr Salman Zarka is the general director of Ziv Medical Center, whose staff has treated hundreds of wounded
Syrian civilians.
14 years old, with a big cancer disease of
the uterus who was hospitalized at Ziv for
about 4 months. She was treated with che-
motherapy, by surgery, and after 4 months
she got back to Syria. Three weeks ago, we
had a 10-year-old girl with diabetes mellitus
that came to the border with a really life-
threatening situation. And we treated her
and provided her insulin for 6 months to get
back to Syria. And I want to believe after 6
months she will come get back close to the
border, and we can continue helping her if
they have no facility at their country.
JAMA: What are the biggest challenges
you face in treating Syrian civilians at your
hospital?
DR ZARKA: Money may be the first one.
Its really a big debate: Do we have to pro-
vide medical support to our enemy? Syria
is our sworn enemy [because] of many
wars between the 2 countries. Ziv Medi-
cal Center is a small to moderate govern-
mental hospital. Its the only one at this
area, at the north of Israel, and we need to
support first of all our citizens. We provide
medical suppor t to about 400 000
people living in that area. So sometimes
they ask: Why him? What about us? Some
of our community is the Druse community
that I belong to. And the Druse community
sometimes feels that we are providing
medical support to the enemies of the
Syrian Druse.
The other issue When you are treat-
ing Syrians, mostly they have no documen-
1106 JAMA March 21, 2017 Volume 317, Number 11 (Reprinted)
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tation about what happened, no patient
files, and you need to lean just on the data
that they give you. Its really very problem-
atic. Its not the Western standard.
When youre treating Syrians, [they
are] mostly alone. They have no family
[with them]. These patients have only Ziv
staff to provide medical support, to pro-
vide social support, to provide other needs
like equipment, like clothes.
We decided that well treat the Syrians
as if they were Israelis. We decided we have
only one standard of treatment at Ziv hos-
pital. When the patient gets into the emer-
gency room, whether hes Israeli or Syrian,
well provide him our best.
JAMA: Who is paying for the care that
theyre receiving?
DR ZARKA: Most of the payment is from
the Israeli government. They pay Ziv hos-
pital in order to provide medical support
to the Syrians. But sometimes we need
more. And most of this is philanthropic
from the north of Israel or from the good
Jewish community or others all over
the world.
JAMA: You mentioned that you are Druse.
What does this mean and how does it
affect your perspective on treating patients
from Syria?
DR ZARKA: Druse is a small community
living in Israel, especially at the north of
Israel, in several villages. The Druse commu-
nity is more known in the Mediterranean
area, in Lebanon and in Syria. We believe
in one God. We believe in reincarnation.
As I said, there is a big debatenot just
a Druse debateabout providing med-
ical support to the Syrians. But really
Im providing medical support to all of
the northern residents of Israel. Druse,
Jewish, Muslims, Christians, all of them.
And all of them are reflected in my staff at
Ziv hospital.
JAMA: What are the biggest challenges
Syrians face in obtaining health care in
Israel?
DR ZARKA: Especially when [the crisis]
started, its not easy for them to come to
their enemy asking for help. When it
started I met a Syrian wounded [man] that
used to be a Major in the Assad regime.
[He] was shot at Damascus. He lost his leg
and after about 3 weeks, when I met him, I
asked, Why now? Why you didnt come
before? He said, I want to be honest. I
was educated that you are the devil. When
I came here I really looked for the tails of
your people. Or the big ears.
I think the other issue is they are
lonely at my hospital. So I hired a social
worker speaking Arabic.
JAMA: What particular cultural issues
should US physicians be aware of if theyre
treating Syrian refugees here?
DR ZARKA: I think treating refugees
is very complicated and very challeng-
ing. These days we are talking about
tradition-related medicine. You know,
health is part of tradition. Its part of reli-
gions. Its part of [a] way of life. And it dif-
fers for people all over the world. When
Western people have a cancer disease,
they will go every place searching for
treatment. Sometimes a more traditional
community behaves different. They think
that this cancer disease is part of their des-
tiny, something that God sent. And they
need not struggle against it.
JAMA: Why is it important for you to be in-
volved in the care of Syrians?
DR ZARKA: For me, as a physician, its
really very clear. I swore to provide med-
ical support. Maybe when this started, I
thought, This is my enemy. But during the
Ziv Medical Center
last 3 years I really feel that I, my military
staff, and my Ziv staff, we are very lucky for
the opportunity to provide medical support
to these people in their time of need. I think
jama.com

medicine really could be a bridge between
people, can connect people, and maybe in
my vision at Ziv hospital, maybe there is
better future for all the children of the area.
Maybe we suffer enough with war. Maybe
we can dream about a better future. We
have started talking about establishing a
bigger clinic near our border [with Syria].
The JAMA Forum
Value-Based Purchasing: Time for Reboot
or Time to Move On?
Ashish K. Jha, MD, MPH
T
hese are difficult days for those of
us who have advocated for pay-
for-performance (P4P) as a policy
tool to improve health care quality. The
idea behind P4P has always been simple:
physicians and hospitals should be finan-
cially rewarded for providing high-quality
care and financially penalized for provid-
ing low-quality care. Although this idea has
been around for some time, it gained
national traction over the past decade, as
policy makers pushed toward paying for
value and not just volume.
What began as experiments with P4P
in the early 2000s became a major policy
focus with the passage of the Affordable
Care Act (ACA). Six years after the ACAs
passage, the evidence on P4P in general is
largely mixed, and the evidence on Hospital
Value-Based Purchasing (VBP), the national
hospital P4P program, is discouraging.
The early studies on P4P found that
these programs had little effect on quality
but provided bonuses primarily to those who
were already doing well. A key study found
that the largest hospital-based P4P pro-
Aubrey LaMedica/Harvard T.H. Chan School of Public Health
gram known as the Premier Hospital Qual-
ity Incentive Demonstration, had no effect
on patient outcomes. This program pro-
vided bonuses and penalties of up to 2% of
total Medicare payments to hospitals
based on their performance on a series of
quality metrics. However, there has been
the mounting evidenceeven in multiple
meta-analysesthat P4P programs were
having little effect across a range of clinical
services, from quality of ambulatory care
to rates of breast cancer screening. Despite
this, Congress created multiple P4P pro-
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And then we can connect with videoconfer-
ence between Ziv and this clinic. Dreaming
to change the area you need to think out of
the box.
JAMA: Do you have any other messages for
physicians who might be thinking about
treating refugees?
grams within the ACA to incentivize better
care. Although some, like the Hospital
Readmission Reduction Program, appear
to have had modest effects, the national
VBP effort is not.
The Evidence Around VBP
When VBP was created, it was structured
largely on existing P4P models that al-
ready had been found to be largely inef-
fective. To reward or penalize hospitals,
the program made 2% of overall Medicare
payments contingent upon performance
on a complex set of measures, includ-
ing process measures, mortality rates for
targeted conditions, patient experience,
and even efficiency. Two recent studies Ashish K. Jha, MD, MPH
have illuminated the VBPs effects on
patient outcomes.
The first comprehensive study, pub-
lished in early 2016, found that 3 years
after the initiation of the program, it had
no impact on patient outcomes. Before
the program began, mortality rates for the
targeted conditions (acute myocardial
infarction, congestive heart failure, and
pneumonia) were collectively declining at
approximately 0.13% per quarter (or about
half a percentage point per year). After
the VBP incentives kicked in, mortality
reductions actually slowed, to 0.03%
per quarter. Comparisons of hospitals par-
ticipating in the program with control hos-
pitals or targeted conditions with nonin-
centivized conditions provided a similar
picture. Instead of accelerating improve-
ments in patient outcomes, VBP incen-
tives appeared to have no effect or possi-
bly even a detrimental one.
(Reprinted) JAMA March 21, 2017 Volume 317, Number 11
News & Analysis
DR ZARKA: I think all of us swore to save
life and really to make life better for all kinds
of people. I think we can do it. And I think
usually physicians are not just physicians.
They are leaders in order to change this
world. I want to hope so.
Note: The print version excludes source references.
Please go online to jama.com.
Value-based purchasing efforts fo-
cused on more than just mortality. Another
key metric incentivized by the program is
patient experience. So has it improved
patient experience in US hospitals? The
answer is no, according to a recently
published study. Before it was established,
the proportion of patients rating their hos-
pital highly was increasing by approxi-
mately 1.5% per year. After VBP was estab-
lished, that increase slowed to 0.6% per
year. Again, comparing the effects with
those at non-VBP hospitals did not im-
prove the picture.
Why Is Hospital VBP Failing?
Those of us who have been advocates of
P4P have argued that VBP as designed was
destined to fail because key principles of
what makes good P4P programs have not
been met. As I noted in a JAMA Viewpoint
1107