Sunday, August 30, 2009

Health care in New Zealand

I’ve gotten a unique glimpse of health care in New Zealand by attending this conference. One of the faculty members, Timothy Fleming, M.D., spends half of each year practicing and teaching in Seattle and the other half practicing and teaching in New Zealand. By some accounts New Zealand might be considered a model single payer system---comparable “hard clinical outcomes” but at markedly reduced cost compared to the U.S. Fleming, who eschews simplistic statements about which system is “better”, offered some examples from his perspective as a cardiologist of how costs are cut:

Brand name drugs require administrative approval and may take weeks to obtain.

There’s no one to read your images for you. You do it yourself and there are no extra fees.

In the U.S. if you have atrial fibrillation of uncertain duration and want cardioversion you can get a TEE to be sure there are no atrial appendage thrombi and get shocked that same day. A TEE (or a TOE as they call it) to enable prompt cardioversion is unheard of in New Zealand. You take your coumadin and wait 3-4 weeks.

In the U.S., influenced by the legacy of CAST, doctors generally avoid prescribing flecainide to help patients maintain sinus rhythm after conversion from atrial fibrillation without first performing imaging studies to rule out structural heart disease. In New Zealand flecainide tends to be a drug of first choice without regard to structural heart disease. That saves a lot of imaging studies. Fleming tends to think the outcomes are just as good, and the difference in practice is driven largely by differences in malpractice concerns.

This week we ran into a nice older couple from New Zealand taking a bus tour of the National Parks. They seemed satisfied with their healthcare system. He didn’t seem to mind the long wait for his CABG, knowing all the while that had he suddenly clutched his chest and collapsed on the street he would be moved to the front of the line. Tongue in cheek he suspected that some patients game the system by feigning cardiac emergencies.

But people in New Zealand are generally community minded. They appreciate the benefits of community support and are willing to put the medical commons above the individual. Their single payer system would never be accepted in the U.S., a society based on individualism. We are a society of different values, but to say we are inherently more selfish would be preposterous.


Prashanth Nuggehalli Srinivas said...

Nice post. Solidarity, after all, is a culture that can take generations! The recent trends towards marketisation of health care has crushed this important value in public health. Something that will always evade health systems is the nature of equity and quality of health care becoming mutually exclusive....and these two dimensions sometimes competing with each other!

medicine girl said...

Thanks for sharing Dr. Fleming's insight into the NZ system.

With respect to health care consumption, I think it is fair to characterize U.S. citizens as more selfish than New Zealanders.

Many Americans care about others, but true to our roots of individualism, our health care system promotes a selfish (by definition) focus not supported by a single payer system like that of NZ. Here in the States, each individual negotiates with an insurance company to gain health care resources. This system does not equip patients to meaningfully consider that health care resources are finite: by using a resource, someone else will be deprived.

Even if some individuals realize health care is limited, they cannot determine their own relative need. In addition, they are aware that there is no system in place to fairly distribute health care resources according to need (so why sacrifice?). A single payer system, however imperfectly, accomplishes both of these goals on behalf of each health care consumer, freeing them to behave less selfishly without any effective change in behavior.