USA to New Zealand: A Journey into Socialized Healthcare
We moved to New Zealand in July of 2014, after about 15 years of my wife Erin and I seeking the right place to raise our three boys and practice medicine. I am an emergency medicine physician with a PhD in microbiology and immunology, and Erin is an internal medicine doctor with a focus in non-invasive cardiology. I spent many years in academic medicine, including research in Brazil, developing a residency program in Kathmandu, and now in a teaching hospital in Northland. I climbed the academic ladder and found it did not meet my imagination of what I wanted out of a career. I particularly found it difficult to be in a big city and to be indoors, working in the ER or a lab bench. I was missing the beauty of the world around me. That pretty much excluded most of the East Coast for me-- working in places with opportunities like the CDC or NIH were not going to work in terms of the need to be around natural beauty like big mountains, green trees, and the waves on the ocean. It seems sort of superficial when I think of it, but those things do give me joy and replenish me. I find that working in these non-natural places takes more from my soul than it gives back. I do find meaning in working with patients, but I found the systems in the United States to be causing me moral injury. In the simplest sense, this means it was not filling my soul and I was not bouncing back from the challenges of the day. I could feel my resilience was weakening.
There is plenty of natural beauty in the US, and God knows we explored and camped and hiked and climbed and skied the most beautiful places with our children. While we would never tire of the beauty of North America, there is a special concentration of beauty here in New Zealand on these two islands. From the majestic Kauri, to point breaks like Raglan, or the Southern Alps where Edmund Hillary cut his teeth, there is something here for everybody. When we have the time to explore it, Erin and I have both been recharged by new Zealand’s natural beauty.
Something else that is indigenous to New Zealand and crucial to understand is the nature of the people here. These are South Pacific Islanders, with all of the rugged individualism, ingenuity, resourcefulness, utilitarianism, and kindness that would make them perfect members of the Wild West of the United States, but there is something uniquely practical and prudent about their relationship to each other and the world around them. There is a famous saying that sort of summed it up when we first got here: “you don’t want to be a tall poppy in New Zealand”. You don’t want to act or try to rise above the community around you, not without bringing them up with you. This concept represents a crucial difference in how I think healthcare systems differ between the United States and New Zealand.
In the US, particularly in private hospitals, the focus on medicine or healthcare for profit seems to have required American doctors and oftentimes specialists to engage in a “deal made with the devil” (to borrow a phrase). In post-World War II United States, the insurance market grew up and was largely provided by employers. It worked in a pinch to provide those services in the 50’s and 60’s. I am afraid it has evolved into something that does not help the average person, and particularly not those who cannot afford private insurance: often those who are young, partially/under-employed, or self-employed. Because the cost of private insurance keeps a lot of people out of the marketplace in the US, their only fallback is to rely on a Federal rule that is effectively the safety net for those people in those situations. The Emergency Medicine Treatment and Active Labor Act has turned into that defacto safety net. It is the only portion of socialized medicine that I recognize as an emergency physician daily in the United States, whereby any condition needs to be evaluated with a screening evaluation and stabilized before transfer or discharge from the hospital.
To illustrate, here is a case: a theoretical one, but as many physicians do we can create cases as the amalgam of real episodes of care that we have been involved in. Imagine a thirty year old father of two who has fallen out of a tree he was trimming and broke his femur, and arrives in the ER. He was underemployed, as he worked seasonal jobs for the ski area in winter and a rafting guide in summer. This was springtime and he fell three metres out of a tree, resulting in a closed femur fracture. He refused the ambulance and had his friend drive him into the hospital because he knew it was going to be a very expensive injury. Looking up from the gurney in pain, he pleads with me not to do the other imaging I think is necessary. Because he was in so much pain, I can’t clear his neck. He had brief loss of consciousness, and it was impossible to tell whether he had abdominal trauma because of all the distracting pain from his femur. After pain medication and putting him in traction, he considers everything we were doing (x-rays, bloodwork, ortho referrals) and wants to know how much each thing costs. I thought it was fair for him to ask, but I had no access to the information. Although I had asked for the “charge master” to be made available to us, it was only the purview of administration. Since he did not have insurance and did not have the advantage of their own collective bargaining for their own bills, he was going to have to pay full retail price. I would estimate $10-15,000 for the hospital visit and ultimate orthopedic care.
I often think about the other entities in the room at that time, affecting the management, documentation, and care provided in the US. In the case of the man and the tree, his wife is in the room. She listens as I describe all the possible injuries he could have that I might be missing. I do this in the presence of a nurse, who writes the conversation into her note. There is a counter-signed document I gave to him about his declining care. I try to do this with respect and empathy, but at the same time, there are other forces acting at this point. It is not just the insurance company or lack thereof. The hospital administration and billing office in our own facility would also be scrutinizing the care and his ability to pay. There would be the constant specter of legal action if I were to miss an injury, or if he were not entirely competent or capable of making his decision because of either his injuries or the pain medication I had given him. In these instances, I would have to face the medical legal system in the US, which has grown up as an ecology around these situations. It derives its income oftentimes from litigating honest mistakes that are made or by seemingly having oversight into what the standards of care are in each situation under retrospective analysis and the threat of a lawsuit. This places physicians’ livelihood and professional standing in the limelight to be scrutinized. Even when nothing has been done wrong, physicians settle to not go through the stress and embarrassment of a malpractice case. There is also the real harm happening to uninsured/underinsured people in the US, or even people with insurance who cannot bear the burden of medical debt. Medical debt has become one of the largest causes of bankruptcy in the US. My colleagues and patients in New Zealand cannot believe this to be true. Here is why.
New Zealanders recognized that the medical legal system, which seems permanent in the US, was not adding to the quality of care of patients that were injured either in accidents or in what was called medical misadventure (now called treatment injuries). This is possible to a different extent in a socialized healthcare system where everyone has a stake in how it functions and how the costs are controlled. For example, I have taken care of patients in New Zealand who have fallen from trees or roofs, whose injuries paralleled the previously offered case. That patient would have no problem accepting the local ambulance, largely funded by donations from corporations and private funding, to bring him safely to the hospital and to provide all of the necessary care that the specialists seeing him feel is warranted. Given that several of those other actors are no longer in the room, there is no reason to worry about a legal system that is looking to earn money off of any errors or non-errors in a medical emergency. In a brilliant series of acts from the 70’s into the early 90’s, the New Zealand legislature brought into being several organizations you’ll need to understand to see how this patient would be cared for and why it is so different from the United States.
The current healthcare system, actually a mix of public and private services, came into being from the Social Security Act of 1938 in New Zealand. The creation of the Accident Compensation Corporation, or the ACC, in the 1970’s, covers the costs of treatment for cases deemed accidents, including treatment injuries (which we would consider malpractice cases in the US). This is done for all people legally in New Zealand, including tourists. The costs are recovered through levies on employers, employees, petrol and vehicle registration, and contributions from the regular tax pool. Because of this funding, there is no need to create a medical legal system to sue doctors for treatment cases that go poorly, which as we all know, happen regardless of the quality of care in many cases, and are rightfully considered in New Zealand to be no-fault events so that there is no directly responsible party. That is where the ACC takes over. So, whether this patient fell out of a tree on his own or someone else’s property, whether employed or volunteering, or even if he was jumping off a cliff into water and broke his thigh, it would all be covered under the ACC as long as he is in New Zealand legally as a resident or tourist. This funding also helps organize and pay for rehabilitation to get this person back to work or back on their feet again.
Beyond that, there is an organization here that handles all prescription medications in the country, called Pharmac. Therefore, if an individual needs any medication, it will largely be subsidized. This is greatly different from that we see in the United States, where pharmaceutical company pricing is driving the cost of medicine out of reach for many people with chronic conditions as well. Generally, nobody will be in the room determining whether patient satisfaction is met or if their pain score is adequately controlled. Because this gap is filled in New Zealand, the use of opioids in these situations is rarely subjected to the issues that have driven their overuse in the United States, such as over-prescribing to satisfy the customer in the process. If I want to hand a patient a controlled substance, I would have to hand-write a separate prescription, which is in triplicate and is watched closely by the pharmacy board. I have been here for six years and I have probably prescribed two dozen prescriptions stronger than the usual Codeine or Tramadol used to cover someone’s pain. There does not seem to be a significant number of people complaining of having their pain under-treated and not under control. I almost never see drug-seeking behaviour in this system.
There is also an equitable and seemingly effective method to complain about services provided by hospitals and specialists called the Health and Disability Commission. The HDC has systems of reporting serious events as a way of ongoing quality assurance and system improvement since 1994. Per the Woodhouse report, which led to the Compensation Act, the consumer could not sue healthcare providers. This movement has developed into a fairly robust review system (albeit one that is public and can be quite distressing to physicians brought under its scrutiny). There seems to be a reasonable method of resolving claims for treatment injury and for policing providers and the quality of care. In our case of the young man from the tree, he would generally be given quality assessment, imaging, and care, through the public system, and if his injuries allow it, he could be discharged and cared for in private under the ACC as well. In the case of a broken femur, he certainly would get rapid, high-quality care in this system with appropriate referral to recuperate, all under the ACC. He would not be subject to excessive costs for care, he would not face bankruptcy, he would likely be covered until back to work, and if he was employed would receive up to 80%of his income for that time. There is a robust system of social work that can provide for home care in the event that an injured person needs temporary services in-home for things like bathing, dressing, and meal preparation until they are back on their feet and able to do it themselves.
The final organization I would be remiss to not mention, would be our specialists’ union: the Association of Salaried Medical Specialists. They collectively bargain for contracts for specialists in NZ, including all of the regular medical specialists and dentists, but not general practitioners. American physicians have been considered administrators or independent contractors, and therefore exempt from the protections a union may provide employees. As the model of physician employment in the US has changed, this definition has failed to modernize. For so many reasons, the American medical system seems wed to systems derived in the 50’s and a certain unwillingness to look at successful models which have kept other entities out of the physician- patient relationship.
Through these connected systems, we manage our payment system being equitable and fair across the regions. The New Zealand system is not perfect, but it fills many of the gaps in United States healthcare that inhibit patient care. Gaps that COVID19 has exploited to reveal glaring weaknesses. New Zealand chose to eradicate the SARS CoV2 virus avoiding that stress test of the healthcare system, in a way not possible in the United States.
This post was transcribed and edited by L. Esther Hibbs, Managing Editor, from a voice memo created by the author. If you would be interested in creating content this way, please email esther@epijournal.com .
