More thisses and thats

I'm having a hard time compiling my thoughts into a coherent written form.  There is so much that is new and interesting and I'm just trying to figure it all out.  I'm still having a hard time coping with the change in seasons, including the daylight, the weather, and the fact that we are starting to give influenza vaccines for the upcoming winter season.  It's all a bit disorienting.

I've had a couple of days of work in which I've seen some patients and started figuring out the nuances of the healthcare system here.  I've also met the students with whom I will be working this year.  They are a select group of 5th year medical students (in a 6 year programme) who are doing all of their clinical rotations (or attachments) in a rural community. I am to be the coordinator of this particular site (Balclutha).  They are four very bright and motivated students who are meant to be responsible for their own curriculum.  Of course, right off, I feel like I'm in a bit over my head.  Afterall, this is a new country, a new curriculum, a new job...what makes me think I can do something like this?  Well, I guess that's the point...I DON'T but clearly someone does and, as I posted here, I am just following the directions and the path laid out in front of me.

I'll try to summarise my understanding of how the New Zealand Healthcare system works.  First off, there is a Minister of Health and a Ministry of Health which allocate government funds to various aspects of healthcare.  Generally speaking, there are District Health Boards and local Primary Health Organisations.  Primary care is the basis of all health care here and, as my colleagues at The Robert Graham Center for Policy Studies in Family Medicine and Primary Care have elucidated, communities and societies which are centered around PRIMARY healthcare are healthier societies with better outcomes and more efficient, cost-effective healthcare.  The Primary Health Organisations provide government subsidised care to their members.  The members are people who are eligible for the government benefits who enroll in that PHO.  They can then receive care from any General Practice doctor in that PHO at a discounted fee.  Now, when I say "discounted," I'm talking about a fee for an average consultation (say, 15 minutes) that FULL PRICE would cost about $50, far less than a similar consultation/visit in the US.  The interesting thing, though, is that doctors in the PHO are often in private practise.  They set their own fees and they get paid by a combination of government money allocated to the PHO (on a sort of capitation system) and patient co-pays.  Other services, such as hospitalisation, nursing home care, home health care, physiotherapy/rehab, etc are also government subsidised to varying degrees.  They are also VERY well coordinated by the GP(s)...very much like a Patient Centered Medical Home.

In addition to PHOs, which are funded by the government (through taxes) and the Ministry of Health and District Health Boards, there is a separate Accident Compensation scheme.  This is funded by petrol taxes, automobile registration taxes, and income and sales taxes.  It covers ANYONE in New Zealand, whether visting, traveling through, or permanent resident or citizen, who gets injured in an accident.  The definition of such an injury is fairly strict; it has to include a definite time and place and event that caused it.  However, if that happens, all the funds for treating that injury come out of a separate pot and the fees are 100% subsidised.

Then there is private insurance.  Anyone who needs specialty care has two options:  go through the public system, which often requires long waits to see a specialist for non-emergent problems, or go through the private system.  Many employers provide insurance and many people have their own insurance, but almost half of New Zealanders have no health insurance other than what they are entitled to through public subsidies.  So, there is a two-tiered system. The wealthy and well-insured can get their knee scoped faster than the others.  However, the key word is "faster."  Everyone who needs it will get their knee scoped or their gall bladder removed, it's just that some will wait longer than others.

I think the sticking point when it comes down to trying to garner support from the average American for such a system is the definition of "emergency."  Today I saw someone who had a problem that could have threatened the viability of an important body part.  I phoned up the surgical resident in Dunedin (about an hour's drive away) and he was VERY polite and told me to send the patient up right away.  I printed out a note from the electronic record and sent the patient to the hospital.  If he needs surgery, he will get it immediately.  HOWEVER, if a person has a gallstone, for example, this USUALLY does not have to be handled emergently.  There are signs and symptoms to indicate when it becomes an emergency but absent those, a strict low fat diet is usually sufficient to keep the symptoms under control until surgery can be done.  No, a person will not "die waiting" for their procedures.  If the problem becomes life-threatening, they move to the head of the line and get right in.  If they die, in the meantime, it's likely from something else that had nothing to do with the problem they were waiting to have fixed.

So, that's the basic idea.  In addition, I've made a few other interesting observations.  First, people do not expect antibiotics for their colds!  Yes, they still come to the doctor for colds but they are more than happy to be told it's nothing more serious and that they don't need antibiotics.  Second, people are not allowed to sue doctors.  That, of course, would NEVER go over in the US.  Patients who are injured through "medical misadventures" (I LOVE that term) are covered under the Accident Compensation plan.  They have all of their medical bills covered and, I believe, their lost income as well.  Doctors may be disciplined by the Medical Council and have their licences or practising certificates suspended for their "misadventures."  Doctors don't "get away" with irresponsible practises and patients get well compensated for their injuries. However, you don't have people getting wealthy from malpractise suits and you don't have doctors afraid to practise good, rational medicine because of fear of lawsuits.  It means that the doctor-patient relationship can be one of mutual trust, rather than suspicion.

Another interesting observation is about tests, especially screening tests.  Screening for things like cervical, breast, and colon cancer are done according to rational evidence-based guidelines.  Did you know that in most cases, it is not necessary to have a pap smear EVERY year?  And the breast cancer screening?  Don't get me started on that one!  It would seem that, at least at my clinic, there is an ongoing effort to use the technology available to track appropriate screening indicators and health outcomes.  It appears to me that they do better than many practises I've been involved with in the US.  BUT they don't do it by over-testing.  So, while we are busy trying to get people to have mammograms, blood tests, and CT scans they don't need, they are actually getting people in for smoking cessation, nutritional education, and cardiovascular risk screening and finding that it actually makes a difference.

One last thought before I put this post and myself to bed for the night.  Healthcare providers in New Zealand are almost universally committed to working to erase disparities in access and outcomes.  As in most other countries, the indigenous people (the Maori) have higher mortality rates from preventable causes, such as diabetes, hypertension, and heart disease.  There are programmes that EVERYONE has bought into to work to eliminate these disparities.  It's fascinating.  I've spent a lot of time listening to discussions about WHETHER there are health disparities along racial and ethnic lines in the US, as well as philosophical discussions about WHY these disparities exist and WHETHER we have an obligation to try to eliminate them.  While we're still arguing about these questions, New Zealanders are actually tackling the problem.

I don't want to imply that this is a perfect system.  I don't think such a thing exists.  AND, as I describe the New Zealand healthcare system, I note many places where Americans just simply would not accept such conditions.  However, the system seems to work pretty well for most people.  I will be interested to see, over the coming months, what the problems and pitfalls are and how they get solved.

Meanwhile, I am enjoying Hokey Pokey icecream, a flavour which I will describe in a future post.