Medicine in New Zealand
01.07.2016 - 24.09.2016 4 °C
NOTE: Below is my impression of the Medical System in New Zealand. I have tried to write with as little jargon as possible for the non-doctors in the crowd. However, please email me if you have taken the time to read this blog and would like a more clear explanation.
One of the reasons I decided to spend a year in New Zealand was the opportunity to work in a medical system with universal healthcare. While living in Idaho, I spent a lot of hours outside of work promoting Medicaid expansion. Through the Idaho Medical Association, I attended many mixers and social events with congressmen. Medicaid expansion should by no means be considered as an effort to gain universal healthcare in the US. But at nearly every event, I was asked questions about socialized medicine and its "failures." Though I have read a lot on the healthcare systems in Canada and the United Kingdom, I never felt convincing in my response. Looking across the world, I noted New Zealand and Australia as models of successful mixed pay systems; medical systems that include both healthcare paid for by the government and healthcare paid for through insurance or by the patient. I believe that if the US ever reconstructed their medical system, a mixed payer system including both public and private options would make Americans most happy. New Zealand and Australia have health care systems that include both a public health system that is partially funded for all residents by the government as well as a private system that allows individuals to buy insurance or pay out of pocket for faster and/or more advanced medical care. Classically American, as with any product or service, the US will always feel entitled to an option for those with more money to pay for faster and more advanced services. Overall, my goal was to better understand how to reduce the cost of healthcare in the US. Though a small country and not as comparable to the US, I chose New Zealand because the total cost expenditure per resident of the country per year was the lowest. For example, per the World Health Organization in 2013 the US spent $9523 per capita on health care expenditures. In Australia, the cost was $3866 per capita and in New Zealand the cost was $3328.
The public medical system in New Zealand is built on a capitated model. New Zealand is broken up into health districts. Each district gets a annual lump sum of money to care for the people registered in each district. The sum of money is estimated based on age of population, average income and historical data. The money from the government covers anywhere from 50%-99% of health care costs of the patient. The remaining expense is covered by the individual patient. For example, at my clinic, it costs $115 to see a doctor for a regular visit. We get $75 from the government and then each registered patient then pays $40 to the clinic to see the doctor. The out of pocket expense for all services from labs to doctor visits and procedures like mole removals are listed as you walk into my clinic; similar to walking into a fast food restaurant and observing the cost of food items on a menu overhead. Cost of services are adjusted each year depending on the governments health care budget. Overall, it is extremely refreshing to have cost transparency. When a patient asks, I can tell them for certain their expense when pursing any medical procedure. This includes the cost of a night in the hospital and a hip replacement!
The public system also incentivizes preventive medicine. Clinics that demonstrate high rates of cervical cancer screening, mammography referrals, counseling for obesity or tobacco use cessation as well as improvements in blood pressure or diabetes markers get extra incentive funding from the government. All these markers are monitored in the single electronic medical record used by the majority of clinics. This makes mining of this data incredibly easy. Unlike working in the US with more electronic medical records than one can count and poor interface communication, using one primary electronic medical system that communicates fairly easy with the hospital electronic medical record makes being a doctor surprisingly more easy.
There are a few of the ways the public medical system in New Zealand limits costs.
First, annually New Zealand selects a drug formulary for the year. Patients in New Zealand have access to about 1/8 of the amount of prescriptions when compared the the US. 70% of the drugs on this formulary are subsidized. Therefore, if only subsidized prescriptions are chosen, a patient can get up to 10 prescriptions per month for $5. As a provider, this makes my life much easier because I need to know the actions, sides affects, and interactions of a much smaller pool of medications. Also, though lagging behind ~ 3-5 years, the medications on the formulary are mainly generic options and go through a pretty strict review process being chosen based on patient outcome standards. Meaning, only medicines with research to support improved health in patients are included on the formulary. The downside, if you have a rare disease or cancer, the options for new and innovation treatment pretty much do not exist.
Second, through the public medical system, there can be wait lists or requirements for certain criteria to be met prior to seeing specialists or having a procedure. Wait times can be anywhere from 1 week to 6 months. It is up to the GP to treat the patient accordingly during the wait period. Interestingly, I have noticed that roughly a third of the referrals I send are cancelled because this original medical complaint or injury has resolved with treatment by myself or the problem resolved without any intervention while the patient has been waiting to be evaluated by the specialist. Maybe there is something to "tincture of time." On the other hand, I do not agree with some of the criteria requirements for procedures. For example, one area that New Zealand has horrible outcomes is in the area of colon cancer. The criteria to get a subsidized colonoscopy is very strict excluding many individuals with risk factors for the cancer. Also, these criteria can change depending on funding available. For example, in the beginning of the fiscal year more hip replacements may be offered compared to the end of the year. There are criteria for many other referrals for subsidized procedures; hip/knee replacements, long term contraception options, weight loss surgery, osteoporosis screening, and substance abuse rehabilitation to name a few. The downside is that while waiting to see the specialist or while waiting for the needed procedure, the medical problem can progress beyond repair. One particular patient I see regularly developed heart failure from a bad heart valve. Though she eventually got a new heart valve, her heart had experienced so much damage she only marginally improved post repair. Whereas, she would now have a normal heart if the valve was replaced as soon as the defect was found. These stories are common and make the wait times hard to understand for the patient at times.
One area of the New Zealand medical system that is surprisingly functional is their Accident Care Coverage (ACC). This program is similar to worker compensation in the US but much more broad and stream lined. If you get hurt in New Zealand, a claim is submitted by the first doctor you see. The claim covers 85% of doctor visits, imaging, hospital care, physiotherapy, acupuncture, counseling, massage and other non-traditional treatment modalities. More impressively, they cover up to 90% of lost wages starting at 2 weeks post-injury if the patient cannot return to work. The claim is more likely to be accepted the sooner it is submitted after the injury. Therefore, most Kiwi's see a doctor for any injury as soon as it occurs no matter how big or small. This allows them to claim ACC if the injury remains debilitating. Under ACC, the return to work rate at 2 weeks is very high. In addition, ACC also covers non-residents. So, lets say you were visiting from Germany and decided to go skiing. If you had no traveler's insurance and fractured your ankle, New Zealand would pay a portion of your medical expenses. This is amazingly nice of New Zealand to cover travelers to their country and likely reduces liability on New Zealand adventure activity retailers. However, this is a hot point of debate in the governments health care budget.
The private system in New Zealand is quite simple. The majority of doctors that provide care in the public system maintain a part of their schedule for private patients. Paying out of pocket or through purchased insurance often allows the patient to schedule an appointment with a specialist or for a procedure within a few days. Controversially, if there is high demand for a procedure, patients that pay privately are moved to the top of the wait list. I have never seen a patient wait longer than 2 weeks for an appointment if they have requested private medical services. Unlike Australia that has completely independent private hospitals and clinics, with a few exceptions in New Zealand, the private medical services are mainly provided in the same hospitals and clinics as the public system.
Currently, I am working at Twizel Medical Centre. I am one of two general practitioners at the clinic and our clinic is designated as one of the three most remote clinics in New Zealand. We are the only doctors for 100km in all directions and the closest hospital is 165km away. We do not have an x-ray. Any labs that are completed must be sent away and the results do not return for 24 hours. Minus having to learn a few new names for medications, getting frustrated with the spelling of diagnosis based on the British Medical System and observing the dramatic differences of opinion between my partner physician and our medical center's new management, my day to day patient care is really not that different from the US. I can see anywhere from 15-36 patients per day; greater than a half of patient visits are urgent care same day appointments. This is because of the ACC system and because I am working in a high tourist area.
The most anxiety provoking and learning point of my job in New Zealand has come from taking PRIME (Primary Response in Medical Emergency) call. In New Zealand, all but very urban areas depend on volunteer Fire Fighter and Ambulance staff. Because of this, the staff has very little training and there are no EMTs or paramedics in rural areas. If there is a bad accident, car wreck, or medical emergency like a heart attack, stroke or seizure, the local PRIME doctor or nurse practitioner is called to attend. We are then responsible for stabilizing the patients and getting them to the closest hospital. I have learned a lot about where helicopters can land, how to put in IV lines on the side of the road, not to lift with my back, and to think twice about entering a patient's home alone.
As I enter my last two months of working in New Zealand, I have come to a few conclusions. Overall, no health care system is fair or perfect. However, I think I would rather have a model where patients have to wait for medical services than where patients have no access medical services or must declare bankruptcy if they get injured or develop a serious illness; which happens often in the US. It is hard to observe patients on a daily basis that could potentially get better medication or treatment in the US. However, with a limited pool of money, how can you argue for the treatment for one patient when the same amount of money could potentially help 50-100 other people live healthier longer lives? Also, after never fully understanding the workers compensation system for accidents at work in the US, I am incredibly impressed by the ACC system for its ability to keep patient off long term pain medication and return patients to work fast. I have appreciated my time working in New Zealand and am sure it will make me a better and more understanding Family Doctor and political advocate when I return to the US.