New Zealand and Denmark healthcare observations made from an American perspective

Measurements of the quality of care and the satisfaction with healthcare in New Zealand far exceed those measured in the U.S. Yet, Kiwis only spend 1/3 as much per person, per year, for healthcare.

The key reason for the differences in the healthcare systems are that most physicians in NZ are generalists, and nearly all Kiwis have access to a primary care physician. However, there is choice where New Zealanders can see whatever type of physician they prefer to see. They see their primary care physicians by choice, not force.

It is my opinion, U.S, attempts to turn primary care physicians into gatekeepers, instead of gateways to care has severely damaged healthcare. Limiting patient choices has also caused damage to Canadian and UK healthcare systems.

There are wiser means to ration care than those chosen in the U.S., Canada and the U.K.

In America, social and political hypocrisy regarding the mechanisms we have chosen for rationing care is reaching such a level of intolerability, that change is inevitable.Rationing here is primarily by making it inconvenient or cost-prohibitive.

In NZ, patients pay 60% of the bill directly to the generalists, and there is a simple and clear path to collect the other 40% without the expensive, payment-denial games that U.S. patients and their physicians have to play. So, Kiwis spend less than 10% for administrative costs, where Americans pay around 30% just to manage the flow of the money in the system.

More than 20% of what Americans pay for healthcare does not purchase any healthcare. Most of the world, including New Zealanders, find this almost inconceivable.

In the U.S., a "GP" is the name generally used to refer to a physician who has not trained in a residency to specialize in general practice. In contrast, In NZ, most physicians who are referred to as a GP have completed the equivalent of a residency program after graduation from medical school.

GP physicians in NZ experience, on average, a greater annual income than U.S. generalist physicians (i.e. Family Practice, Pediatrics, and Internal Medicine).

Almost all generalist medical records in NZ are electronic, and more than 90% are near paperless. In contrast, in the U.S. less than 10% are paperless. There is little faxing of medical reports to and from generalist physicians in NZ. Almost all reports are transferred electronically as free text documents via HealthLink. Less than 10% of documents are able to be transferred electronically in the U.S.

Yet, in NZ, some other types of interoperability of information is in its infancy. For example, Kiwis do not have electronic prescribing.

My prediction.. The obstacles to more interoperability, everywhere, are primarily political, and I predict initiatives such as Open Health Data Exchange Projects ( i.e. Google Health, Microsoft HealthVault, and projects via professional organizations) will bypass these obstacles in the near future. In the end, the power of technology and the Internet will superceed governmental inaction and industry cartels.

Also, see - http://e-caremanagement.com/birth-an...-network-phin/

Kiwis do have some particularly innovative physician performance and decision support systems in place. The Cornerstone system from the College of General Practitioners and the Best Practices Program are great models for other nations to consider.

NZ is experiencing a significant migration of generalist physicians to the UK (and young physicians into specialties) where salaries are even greater. As their percentage of generalist physicians fall, they fear escalation of healthcare costs and decreased quality and satisfaction. In so many words, they are "attempting to reverse this trend before it becomes like the situation as it is in the U.S."

Denmark has the best healthcare outcomes and satisfaction data, and is having less problems maintaining the availability of primary care physicians. Danes are spending approximately 1/2 as much as the U.S. for healthcare. Primary care specialists have the same income as other types of specialists in that nation. It It is important to note that patients there also have a choice as to what type of physician they see and virtually all prefer to initially see their primary physician.

The vast majority of primary care physicians in Denmark and New Zealand own their own practices and opperate as independent businesses directly accountable to those they serve (i.e. patients).

I wish to extend my great appreciation to Harbour Health and the many gracious New Zealanders who recently extended their hospitality. Some of the trip activities are listed below.

IPAC Conference Participation:[1]

http://www.ipac.org.nz/conferences/ipac_conference_2008

Physician Leadership, Practice Readiness for Change, Change Mgmt

The emphasis on change has been identified by TransforMED as an essential ingredient to the success of their model.    Dr Oates and David Garrett will outline the focus of a facilitated change process for the TransforMED model of care.  In this session they will discuss learnings on Physician Leadership, Team work including the “huddle”, practice readiness and the facilitation  role in the change process. To assist conference participants with these areas there are two articles in the conference handbook which outline TransforMED research on Physician Leadership excellence and Practice Readiness required for their new model.

Practice Metrics, QI and Collaborative Learning

A fundamental focus of the TransforMED facilitated practices is continuous quality improvement processes within each of the practices. Metrics to evaluate the efficiency and effectiveness of practice operations, the quality of care and the outcomes of care as well as the risk associated in the delivery of care are being developed and implemented at intervals. TranforMED's pursuit of the development of a "dashboard" of indicators for use by practices fulfills some of the primary expectations of this project:  to use data-based decision making, best practices, and good quality information to assist practitioners and their staff to optimize the way they practice family medicine. Learn also how TransforMED have adopted a collaborative learning model as a framework for learning, sharing experiences and understanding the data to effectively improve patient care and business performance.

Future of Family Medicine; TransforMED

The Future of Family Medicine – A Collaborative Project of the Family Medicine Community
At this breakfast, free to all delegates, Dr Oates and Mr Garrett will be speaking about their Future of Family Medicine collaborative project.  "Recognising growing frustration among family physicians, confusion among the public about the role of family physicians, and continuing inequities and inefficiencies in the US health care system, the leadership of 7 national family medicine organisations initiated the Future of Family Medicine (FFM) project in 2002.  The goal of the project was to transform and renew the specialty of family medicine to meet the needs of people and society in a changing environment."  In this session Dr Oates and Mr Garrett will outline the history, the system changes and the new model. 

David V. Garrett, MHA - In his role with TransforMED as a Practice Enhancement Facilitator, David assists family practices with implementing the TransforMED Model of Care.  He has been one of three facilitators implementing this model at 18 practices around the United States of America as part of the TransforMED National Demonstration Project which began in July of 2006.  TransforMED's facilitators are completing this project to create specific changes in family practices and to assess the effectiveness of the methods used for doing so. David's professional career has been a progression of healthcare management positions which have allowed him to experience the delivery of healthcare in various settings. He has significant experience in the healthcare insurance industry, clinic operations, healthcare facility design and efficiency, and healthcare financial management. David is also very skilled in human resources and information technology management. David is a native of Cincinnati, Ohio and a graduate of Ohio University with a BS in Zoology / Pre-Physical Therapy.  He also holds a Masters in Healthcare Administration from Ohio University.

Randall Oates, M.D., is a family physician and a member of the AAFP. He founded and continues to be the President of a software company called SOAPware, Inc., whose primary product is SOAPware, a low cost electronic health record (EHR) system that has more installed physician practices than any other brand or product in the US. In fact, SOAPware is used in 6,000 clinics in 50 states and 22 foreign countries. He is widely respected within the field for his dedication to the ongoing development of health information technology designed for the needs of small medical practices in family medicine and primary care.  Dr Oates has also been focused on assisting medical practices transition from older to newer models.  He has been very much a part of the whole change management process at literally thousands of practices.   

Press Interview with North Shore Times Advertiser in New Zealand: 
http://www.stuff.co.nz/auckland/4495620a6016.html

Opinions:

It is of increasing fascination to see the nations having the greatest success in healthcare are generally those that focus on empowering the relationship between the patient and their primary physician deserving of their trust. I was able to observe this in Denmark in January, 2007 and in New Zealand in April, 2008.

Unfortunately, the opposite approach has been chosen in the U.S.  At least for the past 2 decades, U.S. healthcare policies have intentionally and consistently been designed to interfere, in some fashion, with the doctor-patient relationship. The body of evidence and my personal experience continue to validate healthcare reform does not have to be complicated if the desire is to actually do what is in the patient's best interest based on the evidence of highest satisfaction and quality. http://www.pcpcc.net/content/evidence-quality

In the U.S., we continue to chose flawed approaches (primarily via choosing payer interference with doctor-patient relationships), and we appear to be choosing to express frustrated amazement that we continue to get the same results of uncontrolled costs, poor outcome performance and low satisfaction.

"Insanity: doing the same thing over and over again and expecting different results." - Albert Einstein (attributed))

If the discussion in the U.S. continues to be focused on who pays for the product rather than focusing on the product, itself, expect more of the same.

Is it not disturbing to see the political process continuing to ignore the facts and advocate that someone other than patients and their physicians can resolve this challenge?

Again, there are alternatives. Many nations have (and are) choosing to be more rational, and they are enjoying the consequences of wiser choices. I advocate it is time for patients in the U.S. to demand a different type of product, and it is time for physicians to step up to the challenge. It will only be from the grassroots that the errors of past choices will be corrected.

In all nations, patients and the physicians deserving of their trust must embrace the evidence, work together to educate, and create mechanisms to facilitate the needed transformation. Don't expect governments or medical-industrial complexes to offer responsible reforms, because the evidence is overwhelming that they are unable to manage that responsibility. Their input and collaboration are crucial, but they must be under the final control of patients (and the patient's primary advocates), and not the other way around.

Also, see my comments at http://www.healthcareitnews.com/story.cms?id=7782  

Healthcare is not a setting where either predominantly government-controlled or predominantly free market approaches succeed. The successes appear to be directly proportional to the degree to which informed patients and their trustworthy physician advocates are empowered to make the decisions within the system. That is, success requires that third parties such as government or corporations can't be making the decisions for individuals.

Will we ever learn from past errors, or are we doomed to more of the same?

Who is to blame if we don't succeed in transforming healthcare?

What will be the consequences if we don't transform healthcare?

Best,

Randall Oates, M.D.

Also, see…

Comments regarding 2007 Denmark observations- http://healthnex.typepad.com/web_log...althcare-.html

Comments from 2006 in attached document -  Randall Oates Opening Statement for US House Caucus 7-26-06

U.S. Playing Catch Up in Health Care IT - http://www.eweek.com/c/a/Infrastruct...lth-Care-IT/2/