There is no death panel. In fact, in my short time here, the Kiwis have an incredibly practical approach to their medical care...along with everything else. I suppose that living isolated here on an island selects for this trait, or breeds it. Patient preference is taken into account for most all decisions, but some things just don't happen. If you are old and have kidney failure, then you don't go on dialysis. If you can't decide your resus status yourself then the medical team may decide for you; I assure you that it is well thought out, debated and considered. The system here has a vast supply of GPs. They are out everywhere in the community, and by and large, provide thoughtful, thorough, amazing care. Primary care is hands down the most difficult thing in medicine...if you do it well (and if you don't then what is the point?).
The GPs are in the trenches, and in remote places operate with minimal resources. They can maybe do an X-ray, check a urine dip and spun hematocrit, maybe other point of care testing. They have to be able to think on their feet, because they aren't allowed to order higher level radiologic tests including CT scans and MRIs. They can't order certain blood tests, such as genetic tests or BNPs without a 'consultant' approval. They have to get a consultant's blessing to send a patient to the ER. Partly, that's because the ERs are free. Primary care has a cost, though quite nominal, to the patient. I took my six year old in just this afternoon after he languished with a sore throat and then spiked a temp to 39 C after an appropriate dose of ibuprofen. The GP five minutes down the road fit him in on a Friday afternoon no problem, thoroughly examined him, swabbed his throat for strep, talked at length with me about treatment, gave me a script AND bottles of amoxicillin and paracetamol to start us on the weekend if he got worse. The charge was $20 NZ (about $16 US).
That is how New Zealand keeps costs down. There are true gate keepers. There is a national drug formulary for medications based on expert evaluation of the literature and consensus amongst specialists. The gate keepers aren't the GPs, they are the consultants--the specialists. I'm a consultant, in both medicine and cardiology. So I get calls about ordering tests, sending patients into the hospital, as well as just simple advice. And on every single one of my 32 days working in the hospital answering calls, I have been completely humbled. As a consultant and as a gate keeper with limited data, I have to think.
The patients here are sick. I've become a bit complacent, working in a small town where we referred very sick patients out to the big city. We could order tests without much second thought most of the time and often did so more for the patient's peace of mind (which is important) than my true concern. I feel rusty. I feel challenged. And of course, that was the point. The city where we work is a referral center for the whole north of the North Island. We are in "Northland," literally. So things get funneled here, and then off to Auckland if needed for the really big stuff, like cardiac caths, bypass and valve surgery. But generally speaking, the patients here have access to basic care, they can get what they need and move up the acuity ladder if appropriate.
I've seen things this past several weeks that I've never seen in my 17 years of practice: acute rheumatic fever; an ascending aortic aneurism 10 cm in diameter (yes 10!) with horrific aortic regurgitation and a true "washing machine murmur;" I diagnosed a new Marfan's syndrome patient, and 2 Wolffe-Parkinson-White's in one day!! There has been a measles outbreak and there is a constant threat of meningococcus. Mike took care of a septic woman 36 weeks pregnant with twins. We live in the "poor" part of New Zealand, and it feels somewhat familiar. I am, however, overtrained here for opioid and alcohol addiction treatment.
There is limited access to diagnostic tests--there are 3 month long waits for routine tests, like an echocardiogram. It's debatable whether limiting something like a CT scan for a patient will save money: once you have the scanner, the cost of operating it is minimal, really. And if you end up watching a patient in the hospital for days in lieu of a CT scan...well, that will cost you real money. So no...not perfect. And as I triage the "Chest Pain" referrals according to severity...well, is there any such thing as 'routine' chest pain? Not in my previous life. Learning a new normal. There is stable chest pain...and then there are people having a heart attack and hopefully they end up in the ER like they should.
The other cost control is with salaries. All doctors are unionized and everyone essentially gets the same pay scale, with some variation from district to district. The doctors are paid fairly, based on your years of experience and whether your are a specialist or GP. That's it. Period. There is no incentive for specialists to "do," especially do unnecessarily. You do not get paid based on productivity. And the GPs are paid well--better than in the US, for the most part; and the specialists don't make exorbitant amounts of money. There is good incentive to become a GP. And you work to do the right thing...you can't really hide out in the system and not work. There is a parallel "private" system where patients can pay out of pocket for more immediate access to specialists and tests and surgeries. Those doctors can charge whatever they want. I don't know much about that side of things.... Will let you know.
We have an army of absolutely lovely, smart and earnest Registrars and House Officers from all over the British Empire and beyond who work incredibly hard doing everything to care for patients. I mean everything. Starting IVs, mixing medications. And then of course, sometimes I have to do that. And I know well how to put in a central line but those tiny little peripheral veins scare me. Though, I've managed to put several in now for the dobutamine stress echoes I'm doing.
Starting over in my career (and I'll say the same for my husband) has not been easy. It is incredibly hard to pluck oneself out of normal. Especially as a professional, where you go in and people around you--nurses, clerks, trainees--expect you to know WTF you are doing. And you don't. You don't even know where the bathroom is. You don't know what form to fill out (or even that you have to fill out a form) for the CT scan...and it's different than the regular Xray form...and different from the MRI form. And don't even get me started on the medications here...different names, different dosages and I can't find the online formulary and I can't think of the name of that ancient diuretic.... It's humbling. It's exhausting. It's at times depressing, especially if one thinks oneself competent and is hypersensitive to criticism. But...everything is in sharp relief. Moving out of complacency was what we needed. Being challenged by our patients and by our colleagues was the point. Working in an academic environment was desired. Moving away from small town politics and into a bigger system was necessary. It hasn't all been beaches and flowers...although that's here too (yay!). Nothing feels sure-footed. Nothing feels normal. I'm intimidated and I'm in awe. And every day feels like a milestone.
Really enjoy your perspective. As I suspected there are trade offs but it sounds like patient care doesn't suffer in the long run. Interesting how they have answered the question of rationing which we duck (except in Oregon Medicaid). At some point we will have to address it. Hope you keep these observations coming.
ReplyDelete