S7E20: Evaluating Health Systems

Hạ: Hello, dear listeners. This is Hạ in the virtual studio, and you are here for another episode of "Bundle of Hers." Yay. And with me in the virtual studio today, I have a very special guest and it's a guest that we all know very well. It's Siale. Woo-hoo. Say hi, Siale.

Siale: Hi, everyone.

Hạ: Before, what was it? Episode . . . I don't remember the numbers, but you had heard her a few weeks prior and you were like, "Oh, love Siale. Guess we only get a taste of her for one episode only per season." But we lied. She's back. We loved her so much we asked her to come back. Maybe you'll be more . . . You know how in TV shows there's the recurring guest stars? Maybe you're like a recurring guest star.

Siale: But yeah, I'm happy to be back. Thanks for having me back.

Hạ: Yeah. And the reason why we're having Siale back is if you all remember a few episodes back, we were talking with Siale a bit about health policy and briefly about her time with Tonga. That conversation was really great and we covered a lot of ground.

But the big hope this time is to continue having conversation about a different aspect of public and population health. And who better to have that conversation with than the person who studied public and population health?

For this episode, the topic that we really want to talk about is actually focusing on health systems. And the significance about wanting to focus on health systems is because . . .

I guess before I state this, I should give the disclaimer that the views that are expressed in this episode are our personal views and do not reflect the views of the institutions that we belong to or the institutions that this podcast is associated with.

In addition, I wanted to give a second fun disclaimer, and it's that Siale has in her room a cute little child, her son. So you might be hearing kid noises throughout this room, because he is 2 and he is ready to show the world who he is.

Now that I put that disclaimer, I want to say that healthcare is a human right and it is something that is critical for us to be able to function and to meet our basic needs. And all to say is that along those lines, I think the concept of universal healthcare is a very important concept to consider and something very much important to think about in terms of health policy. It comes and is really connected to the whole topic about health systems.

And the reason why this is significant for our topic of exploration and discovery is . . . I don't know about you, Siale, and I'd love to hear your thoughts about it, but for me, I felt that when I started in medicine, I was a pretty hopeful, passionate person about really making change.

As I've continued throughout medicine, I've begun to realize a lot of the nuances about what it means to be able to provide care for my patients, and I've realized that it is very much ingrained in the way that our health systems function.

And so it's something that I keep wanting to learn and it's something that I keep discovering and reflecting about. I'd love to hear about your thoughts.

Siale: Yeah, I felt like I entered medicine and still feel the same, that healthcare is an essential right that belongs to everyone. And it's unfortunate that we have so many systems all across the world that don't align with that thought.

And so I think some of the reason that I started to dive into health systems and trying to understand them is because of this fundamental belief that I think everyone deserves healthcare, and I think understanding the systems and then what comes with that.

And so one of the things I love about being Tongan is that in Tonga, they believe that healthcare is a right, and everyone has healthcare and the government pays for it. But that does come with some drawbacks in how they function.

I think most people that are probably listening, they all agree with the view that healthcare is a right. And I think being able to understand the system and what the drawbacks of various systems are, so when you talk health policy with someone or when you propose an idea to legislatures or people who sit at the table, you understand what the drawbacks are, because that's what they're always going to refer to when you bring these ideas to them. What's the downside? What's the cost? Which is usually the downside. I think it's important to keep having these conversations.

Hạ: And I think to take it a step back first too, for instance, for me, before I even started thinking about medicine or even before I entered medical school and did population health, my understanding of when people talked about health systems was very skewed.

I think it's helpful to give that framework for people to understand what we're talking about when we think about health systems. And I'd love to hear what you've learned. How do you approach it or how would you explain it to most people?

Siale: I guess it's going to be different depending on what level you're talking about, but I think to step back, what is the U.S. healthcare system and what is the structure of it? I don't think I really even understood that as a medical student until I had more time to dive in.

So the U.S. healthcare system has two parts to it. It has both a public part and a private part. And what public versus private means is who is paying for it?

So public refers to the government pays for it. In the U.S., that's only given to people who are above the age of 65 or people who fall below a certain income level.

The other part of it, the private system, which we're all familiar with, that's private healthcare insurance. That's insurance that you get from your employer. And that's often determined by how much money you make. How good of a job you have really will determine how good of healthcare coverage you have.

And so when you refer to systems, it just sounds like it's money, but the reason it's all related is because it will tell you what type of care patients can and can't receive depending on the type of healthcare they have.

And that impacts what sounds like money, but it's all interconnected about what resources are available to them, where they can seek care, and the bill that they're left with afterwards and what ends up happening in the big picture.

Hạ: That's something that I feel really deeply because a lot of times, for instance, we can think about it as high-level care for certain specialties, like cancer. A lot of times, what we'll hear a lot of people talk about is, "Oh, we need to file to your insurance for prior authorization and to get that approval." So waiting for insurances to give approval to start care can sometimes pause care. Or if the insurance doesn't approve it, this means that what medications we're able to prescribe to you will differ.

I feel it's really interesting because, for me, I'm currently at a residency program that's multi-site and I really appreciate it because it means I rotate at a county hospital, which is affiliated with the San Francisco Department of Public Health, and then I've rotated at our academic hospital that's affiliated with the academic institution that I'm a part of.

I've also rotated at a hospital that's . . . basically, it's the Kaiser Network, which is this network of its own insurance and everything like that. It's this whole system of special care within its own insurance system.

And it's so interesting seeing how we care for patients differs. It can be the exact same diagnosis, but what we do for them and even what they get when they're in the hospital and when they leave the hospital is vastly different. When we talk about health inequities, it is affected by what healthcare systems exist and what people can navigate through.

Siale: Yeah, I feel like I'm in a place very similar to Hạ, but my residency program is also a multi-hospital system. So we also have a county hospital, and most of those patients are on public health insurance like Medicaid. And then we have an academic center. And then we also have the VA hospital. For those listening, the VA is the special hospital system that we have for veterans and the government pays for their care.

Just briefings that I've noticed, when I am at the county hospital on wards, what I can offer to patients is very different to what I can offer patients if they're at the academic center. The resources that are available, it doesn't really have anything to do with the skill level of the physicians because a lot of our docs, they bounce back and forth between the county hospital and the academic center.

For example, today we were talking about stress test echoes and we were talking about the different things, like what testing is even available. And we were saying, "Here at our hospital, the county hospital, this is what's available. And then all these other fancy tests exist, but we can't offer that to patients here. That's only available at the academic center."

And so it really does drive . . . it can impact the decisions of what tests we order and really the care that we provide. And as much as we try to do the best that we can, it's still that you're on the wards and what type of anticoagulation plan they're going to have is really dependent on the health insurance they have. And that's unfortunate when really the question should be, "What's going to be the most optimal treatments for this patient?"

Hạ: Yeah. I find it just so frustrating because we talk about evidence-based medicine and we're taught to think about what's optimal. And then at the end of the day, we can't really make those decisions because of what access to the system that the patient has. I find it really does drive health inequities and it keeps perpetuating it.

Siale: It's unfortunate. Yeah, I feel like when patients are preparing to leave the hospital, pharmacy always has to be like, "Let me do some prior auths to figure out can they even take these medications when they leave the hospital." And you're just like, "I wish that wasn't the case." Then we end up being like, "Well, this is not the ideal thing, but this is what they can get with the insurance that they have." As a provider, it kind of feels icky.

And I think, again, this has always been the reinforcement of, "This is why I need to understand the system," because at the end of the day, I want patients to go home with the best thing that is available to them. So what do I need to understand to be able to address that?

Hạ: And I think it's just hard because I think for most medical students or most providers, unless you actively choose to, for instance, get a master's in public health or to learn about public policy or things like that, you aren't given the tools to really understand it. Then you end up as a resident and suddenly you're navigating it while working, what, 80-plus-hour weeks. And it's really hard. It's frustrating, and I sometimes wish our system itself could be simplified.

I've seen other health systems that aren't this way. I remember my personal experience. I once had to go to the emergency department in France. And in the U.S. with the pretty solid insurance I had at that time, it was maybe $200. My actual bill was thousands of dollars for this visit. And then in France, I wasn't insured and it only cost me $40 for this emergency visit. I was just sitting there and I was like, "What is this? I don't understand."

And what's wild is I feel like multiple people, whenever I tell this story, they're like, "Oh, yeah, I've had this exact experience in this other country where a similar thing happened."

Siale: Yeah. So Tonga is an inverse of the U.S. I would say that the U.S. is primarily a private system, so we pay a lot of our healthcare through private sector. But Tonga is the opposite where the government pays for it. There is the option for those who have money to pay privately, meaning they can pay directly to physicians at their clinic or whatever.

It was funny because they're like, "Oh, if you get sick, it's okay. You can just go and you don't have to worry about the bill. The government is going to foot it," even though I'm not a Tongan citizen officially.

And so it's interesting to think about how people approach going to the doctor differently or to the hospital, because they know that someone else is going to be paying the bill.

What ends up happening, though, is because the government is paying for everything . . . There's not this unlimited budget, so the government has to say . . . For diabetes, for instance, they don't have the money for even stuff that we would consider to be a part of basic diabetes care. Everyone there just does insulin and we don't really have the choices to use other drugs. I think there are a lot of barriers that come with that.

But I guess all this to say is because the government pays it and they don't have this unlimited budget, it means they have to be very restricted in what they can and can't give people. And so if patients want something that's outside of that, then they're going to have to pay for it out of pocket.

And so I think that's the downside of . . . It's so great that the government pays for it and I wish everywhere could be like that, but because of the strained resources, they can only offer people so much.

So then it still leads to this inequity because the people who can afford to pay for the higher-end stuff, they will be able to pay for it, but the other people who don't won't.

It was interesting when I went there, I went around . . . The pharmacies there, a lot of them, you don't really need a prescription. As long as you can pay for it, you can get it. My aunt had cellulitis, and so I just went up and I was like, "These are the antibiotics I want." And they didn't ask me any questions. I just paid the $4 for it and they just gave me the antibiotics. I felt kind of sketchy about it because I was like, "I'm just a medical student."

But I had other patients too that came into the hospital and they've been taking steroids. They've been taking prednisone for their gout for years, and they were having all these side effects. And I think that's the other downside. Because it was not well regulated, people end up taking things that could actually be really harmful for them.

But I did a lot of exploring at the pharmacies. There are a lot of different private pharmacies in Tonga, just because I was curious. And one of the pharmacies is actually run by basically a nonprofit organization from New Zealand. They would subsidize medications, more expensive meds. The one that keeps coming to my mind is a DOAC for anticoagulation.

Hạ: For listeners who don't know the acronyms, DOAC is direct oral anticoagulant. And the direct is . . . I'm trying to remember how it is. It acts on a factor . . . It just acts in a specific part of the pathway to do coagulation.

Siale: Thank you. Sorry. This is too much residency and I forget I'm a real person and this is not sounding like it. But I think some common drugs that people may have heard of is something like Eliquis, or apixaban.

And so a lot of patients couldn't afford that in Tonga, so they would have to take Warfarin, which is a much cheaper drug. But the thing about Warfarin is that you have to have a lot more monitoring. So you need to go in for, essentially, weekly blood tests, and that can be a really big burden on people.

So they end up having all these patients on Warfarin and then things get out of whack and then they come in bleeding because they haven't been monitored. I'm sorry. I'm getting off track.

The pharmacy was telling me for people who can't afford their medications, they can give it to them for a very subsidized rate or for free, but the problem is they're giving medications from New Zealand that people have returned.

So in New Zealand, people can return prescriptions. They can be partially open or whatever. And so what New Zealand does is they take all these medications that people have returned and then they send them to places like Tonga. But then people being able to continue these drugs is all on the contingency that they continue to get these drugs from New Zealand. And you can't predict what people are and are not going to return, so then the question is "Should they even be started on this if I can't guarantee them a supply or if they can't guarantee to pay for it?"

I felt internally conflicted about that situation, or just the pharmacy situation in general. I think it's great that we can offer universal healthcare, but in a place like Tonga where you have very limited resources, government has to make tough calls. They can only offer so much. And then because of that, we still get these health inequities and then weird things happening like this in the pharmacies.

And so I think that's something that I learned from that trip, was there's a lot more than just giving everyone universal healthcare. You have to be able to see the problems before they even arise. And some of that, I just don't know how you predict those things.

Hạ: It is that thing where I feel like whenever I'm trying to imagine an ideal state or trying to imagine . . . because as we've established, healthcare is a human right . . . how we are able to ensure that people are able to reach that, I always feel really stuck. Because even in systems that we talk about that seem so much better than the system that we know of, there's a lot of complexity to it and inequities still ring quite clearly.

And I've just been thinking a lot about . . . I'm currently in a medical education pathway and we talk a lot about curriculum design. But when they talk about curriculum design, they always talk about predicting and thinking about, "What's an ideal state? What are people's needs? What are barriers that we anticipate seeing? What are the other stakeholders involved in it?"

And I feel like with curriculum, it feels a bit more tangible to do it, but when I try to apply that into thinking about the greater healthcare scheme, I just feel so overwhelmed because I really don't know.

As I keep looking at different health systems, like the National Health Service and the UK health system, and then I hear people who operate in it and they go, "These are the negatives of this system," it's just so hard because there hasn't been a solution that really targets the inequities and really gets across and makes sure that everyone is able to achieve that basic human right.

Siale: So a lot of my year when I took my year away from medicine was comparing different parts of different healthcare systems. And that's really what I took away, is, "Maybe this country does this better than the U.S. Maybe they can regulate prescription drug pricing, but then they'd have more primary care doctors."

But there's always this other problem, like you said. It takes two years to see a sub-specialist, and there's no incentivizing for people to continue their schooling because they're paid the same as the primary care doctors and often just experience the opposite edge of the pendulum of the problem.

And so I don't have anything really insightful to say other than other countries do some things much better than us and there are some things that we do better.

Because of our strengths . . . the U.S.'s big strength is we are innovators. We have the greatest technology. We have the best of everything when it comes to techniques and blah, blah, blah when providing patient care. But with that comes we have the greatest health inequities. And I think that's something we as a country decided to sacrifice, which is really unfortunate.

I think that's the big thing I learned my year away, is when you get one thing, then you just open a different can of worms. And like you said, just trying to anticipate what those things are is really what will be helpful.

And I've reflected a lot on the Tongan healthcare system and some of the things they could consider doing. But then every time, I think, "If they do that, then what's the next problem that's going to come?"

And so one of their other issues is they're losing a lot of their doctors. They don't get paid very well. The government pays them. And then they end up leaving and going abroad because they're going to get paid more. Then you think about, "Well, if you pay them more, then . . ." Or every time I think, "What if you did this?" then I'm like, "This could happen." It is really a complex thing.

But the way I think about it is trying to address it from the perspective of health inequities, because to me that's the most important thing. And like I said, some people care about technology and some people care about whatever it is, but for me, it's always approaching with "What's going to help people receive the best care that they can get and become the best that they can be?" To be honest, it's kind of discouraging sometimes, but it helps me keep fighting to look for solutions.

Hạ: I both operate in that cynicism and that optimism, but I think that's the only way you can move forward when you're in medicine in a way, is both looking for change into making things better, but then also having hope that things will get better. Keep hoping that eventually one day we'll solve health inequities.

There are so many more other things that are compounded that explain health inequities. We talk a lot about it on this podcast, thinking about things like race, sexuality, gender, socioeconomic status, which we've alluded to here in this conversation, or even where you exist in the U.S. or not.

I recognize there's just so much nuance to it, and that's why I feel the problem is really difficult to solve. But if I don't have hope, I go, "Then why am I here doing this thing, coming into medicine trying to create change?"

Siale: Yeah, I feel like it can be discouraging. I felt like the first two months of my program, I was like, "Wow, I'm learning so much. It's so cool. I'm going to be able to change so much." And then I was like, "Wait, the more I understand, actually, the more confused I am, and then the more overwhelmed that I feel."

But then you see people who have done incredible work and you think, "Maybe I can't change it on that large of a scale, but even if I tackle this . . ."

Some people work their whole career to tackle prescription drug pricing. And when we saw the cap on insulin pricing happen, even though it was only for Medicare patients, that's a step in the right direction. And then you think about how many people that helps. How many people couldn't afford their insulin and now maybe they're one step closer to being able to afford their insulin?

It inspires you that, "Even if I address just one little thing . . ." Or any time I address a problem, if I think about, "Who are the people that are the most hurt by this problem?" and if I make a policy that will focus on them, then we can figure out the rest of the things and try to anticipate it.

I definitely have moments. It's like a roller coaster. Some days you feel good. You're like, "Yeah, I think I'm addressing things." And then the next day, you're like, "Wow, I'm just a part of this bigger system that's actually really harmful to a lot of people." And it can feel really icky, especially as a resident, but I guess we just keep fighting.

Hạ: Yeah. I feel like it's that pendulum of when I start feeling good about something, the world is like, "Hold up. You're being too positive here."

Siale: Yeah. It's not even every day. It's literally every patient. You feel good one patient, and then the next patient you just get destroyed. That's just how the job goes and it sucks.

Hạ: It's there to keep you humble. And I think it's important because I think it's those moments that help us re-reflect, and then keep striving to be better and to create better worlds.

One of the things I just want to close with is thinking about . . . as we've talked about health systems, just reflecting on a personal commitment or action that we really want to consider based on this conversation.

And I think, for me, it's to continue to assess and to continue thinking about the health systems that I exist in and doing this due diligence of comparing and contrasting and thinking about it a bit more critically. I think, by being more critical, I can better realize or recognize how to ensure more equitable care as I navigate different systems, especially for the systems that don't get as many resources as they could.

And I'm curious, what would your commitment be, Siale?

Siale: I echo everything you said. And I think right now for me, at this phase in my life, I feel like I entered residency with so much passion and I'm only Month 4 and I found myself already being affected by the burnout. And then I have had experiences that I looked back later and I thought, "I could have advocated better for this patient," or, "I could have been better in this scenario." And so I think for me, it's not letting framing weigh me down that I forget the big picture of why we entered medicine.

And sometimes it might take some extra time to an already long day to make sure that people are being advocated for, and that can be really hard. But my commitment is to continue to check in. Even if I can't always address it right in the moment, to at least be able to find people who can help me address that when capacity is right. Anyway, to keep fighting.

Hạ: Yeah, I think that's really beautiful. And I hope that for the listeners, the conversation today has started for you to also think about things and to think about your own commitments too.

I always just want to put this caveat that we're talking about really complex things about health systems and stuff that I'm still learning. I'm constantly learning. And I will also say there are probably a lot of different podcasts that can break down health systems or readings and a lot of different things.

We're just all learning together, and I appreciate Siale and our listeners for learning with me today. I hope that you were able to reflect.

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