There were two interesting articles published in the United States that highlighted the important differences I’ve noticed after a year in practice in New Zealand.
Both articles are worth reading, as they highlight problems that a growing majority of US physicians bemoan and feel powerless to correct, and that will impact you as patients.
The first article, an opinion piece published in the NY Times entitled “The Business of HealthCare Depends on Exploiting Doctors and Nurses“, highlights the effect that the “corporatization” of medicine and attempts at improving the efficiency of healthcare delivery has had on the morale and welfare of US healthcare workers. Particularly noteworthy is the % rise in non-practicing health care administrators who are being hired to address the increased complexity of both quality measures and payment models laid out by CMS (Center for Medicare Services, the federal government).
The second article, “The Worst Patients in the World” published in the Atlantic by author and new-best-friend-to-physicians David Freedman, boldly declares that American patients are at least partly to blame for our nation’s rising healthcare costs, which are anticipated to reach 20% of GDP by 2025 (comparable countries average about half that). Specifically:
- The author points out the role we as individuals have in determining our own health outcomes, and what he perceives as a failure to meet our end of the bargain as Americans.
- He also describes the lack of controls (financial or otherwise) for US doctors to “do less” when patients demand more in our healthcare system, including in some cases futile end-of-life care. American patients and families don’t feel the cost or appreciate the potential downside of “more” care, and doctors have little incentive to get in the way (and disincentive in the form of medical malpractice risk).
It is this lack of autonomy, of being told what to do by non-clinicians and patients alike often in direct conflict with their medical training and experience, that has led doctors and nurses to the feelings of hopelessness that characterize professional “burnout”.
How does this differ from New Zealand?
For starters, medicine is not viewed as a business in the way we think about medicine in the United States. Doctors are salaried employees of the NZ health system- pay is less than in the States but sufficient given the adjusted cost of living here.
Healthcare is a service provided to its citizens akin to the public school system. (Imagine the outrage if the milk industry was making billions of dollars off their support role of the US public school system!)
To be sure, there is a private healthcare sector for patients who wish to pay more for more personalized care. And hospitals and clinics do incorporate business best practices, measuring outcomes to improve efficiencies around the delivery of care.
But in the end, it’s more of a zero sum game:
- Citizens pay taxes (top bracket of 33%, not crazy) and some small co-pays for some services and medications.
- The NZ government provides healthcare, to include affordable medications and when appropriate specialty services.
Contrast this with the United States, where United Healthcare, the sixth-largest publicly traded company in the US, a company whose primary business is essentially collecting premiums from individuals, assessing and managing risk, and making payments to hospitals and providers… reported a $3.9 billion PROFIT in Q1 of 2019 alone.
How does having a company that does not see patients making this kind of money help the health of the American people they purportedly serve?
A second difference between NZ and the US is that in NZ it is the doctors and nurses who are forming health policy and making medical decisions about care. This, in conjunction with the low risk of being sued for malpractice in NZ, means that doctors have the ability and autonomy to decide what is appropriate medical care for patients. They get to decide what is the best medicine and who needs the available resources the most.
The cultural differences of individual patients is tougher to quantify. Generalizations about a “typical” Kiwi versus a “typical” American patient are not helpful as there will always be exceptions. What I can do is describe my observations based on a year of ED (emergency department) practice here in Gisborne.
- I can count the number of “difficult patients” (as described in the Freedman article) I’ve had in one year here in Gisborne on one hand. In the US, it’s typically 1 or 2 a shift.
- There seems to be more reasonable shared expectations between doctors and people here; an understanding that there are health problems that we just can’t fix today, and tests and that will just have to wait to be completed.
- There are social problems that we as a healthcare system can’t manage ourselves, particularly around the care of elderly family members.
- Kiwis generally assume that you are giving your best effort and accept the outcome. (Which is surprising to me in some ways, given the potential lack of trust that one could expect as a foreign doctor.) This is often not the case in the ED back home.
It can’t be cost alone that drives this difference. In fact, Kiwis have every incentive to demand “more care” given the cost to them (“free”). Yet in general, they largely don’t.
They are not dependent on the healthcare system or any system for that matter outside of the family unit. They are largely self-sufficient, respectful, and proud. They wait their turn.
Contrast this with the American patient described in the Freedman article.
But honestly, who’s to blame American patients for wanting a higher level of service given the rising cost of insurance premiums and high deductibles? When everything else in American life has become on demand, why shouldn’t healthcare?
Asking Americans to become more like Kiwis is akin to asking a dog to act more like a cat. Our cultural norms have been formed over many years and many shared experiences; we are who we are, for better or worse. What could change however is how we collectively choose to view health and the role of medicine in our society.
I frankly don’t see a way to change the US “system” until our government accepts that free market forces alone will not get us a fair and equitable system of high quality healthcare.
There has to be reins placed on the business of medicine if we wish to change the current direction of healthcare delivery in the United States.
And doctors need to quit complaining about “moral injury” and burnout and take back control. We’ve defined the problem- the next step is to advocate for solutions. The alternative is that more will leave the profession and/or be replaced by underprepared, less experienced cheaper alternatives as per standard business practices. Americans will suffer the consequences.
I’m grateful for having had the opportunity to live and practice medicine here in New Zealand. It has put so much about our lives in the United States into perspective. Despite what you might think from this blog, I’m genuinely optimistic about the next phase of my professional life and the opportunities that will await me back home in a new company. I’m really not sure though what rock bottom will look like for our US healthcare system – we are already there by most objective standards, and the costs are continuing to climb.
Like many aspects of American life, the social contract that exists between the people and those that govern appears frayed.
American exceptionalism is, in my opinion, getting in our way of us moving towards a more rational system of healthcare. But we’ll get there- we always have, eventually.