Nearly 200 Chilean emergency physicians gather at Clinica Las Condes for the first national conference addressing growing demand for improvements in patient flow, medical quality, and standards of emergency care for the newly-sanctioned medical specialty.’ Visible in the front are Dr. Erwin Buckel, chief of emergency service at Clinica Las Condes (far left) and conference co-host Dr.Jose Luis Santelices (far right).
Is the growing divide between private and public care in Chile a harbinger for America’s future?
A few months before the Chilean Society of Emergency Medicine (SOCHIMU) sponsored the nation’s first course on emergency department management, emergency medicine – known as Urgencia – was recognized as Chile’s 38th medical specialty by the nation’s Comptroller General. The government endorsement came along with a 30% increase in compensation above primary care levels, a welcome boost for the dozens of new graduates coming out of universities around Santiago.
Unlike Canada, the United Kingdom, or US, where ED visits average around 400 visits per thousand residents per year, there are slightly more than 1,000 visits per thousand per year in Chile. Given these numbers, and given the years I’ve spent debating with US policy makers and payers about whether American ED utilization is appropriate, I arrived to speak at the Chilean conference ready to warn my new colleagues that their system was unsustainable. The first thing I discovered was that in terms of global standards for healthcare outcomes and costs, Chileans have no apologies to make to gringos. World Health Organization metrics for infant mortality, life expectancy, and preventable mortality show the ‘long thin country’ to be on par with America. Most compelling, Chile achieves comparable medical outcomes for 7.5% of its Gross Domestic Product, while our own system expends 17.9%, based on 2009 WHO data. Perhaps the most important comparison is that both countries have fairly even splits between health care spending in the public and private sectors, unlike most every other country in the Americas, or systems of care in the developed world. The second – far less heartening – observation was that disparities in emergency care in Chile are painful reminders of problems we have long faced in the US that may be worsened by the enactment of the Affordable Care Act.
How the Chilean System Works
As a result of government programs enacted since the Pinochet era, Chile offers universal coverage to its citizens through a 7% payroll tax; free to those over 60. Higher income Chileans can choose from a variety of health insurance programs in the private sector, known as Isapre, many sponsored by integrated delivery systems like Clinica Las Condes, Clinica Alemana, or Clinica Santa Maria. Patient care in Isapre, which accounts for half of all health expenditures in Chile, covers only 17% of the population, offering the latest treatments and technologies seen in advanced countries. Hernan Acuna, Chief of Urgencia at Las Condes, is rightfully proud of his 50-bed department, with tens of thousands of patients per month from the affluent Las Condes district usually waiting less than 30 minutes to see emergency physicians, with pediatricians, orthopedists, ophthalmologists, and dentists also on duty. Urgencia, like the rest of the private medical center, operates with a familiar US-brand of electronic health record. On the roof, a helicopter stands by for skiers injured on the Andean slopes above Santiago, or traffic accident victims on the busy road to the port of Valparaiso.
Like the US, the other half of Chilean health expenditures are in the public sector, where disparities in care are often stark. According to the Organization for Economic Cooperation and Development, Chile’s average net adjusted disposable household income in 2009 was $11,039. For the vast majority of Chileans, the 7% percent withheld only qualify them for the public insurance tier known as Fonasa, which has many of the same attributes and unmet needs of US Medicaid. The same is true of health benefits for the unemployed or medically indigent. In a country where only public facilities are called ‘hospitals’, longer wait times, inferior outcomes, and dysfunction seem as bad or worse than those threatening US safety net facilities. In both countries, questions remain about whether lower-income patients with government insurance are best served in the private sector or public hospitals. Low government payments per capita from Fonasa to public hospitals are further weakened by the influence of strong unions of health workers over progressive political parties. And physicians who practice in both public and private sectors can game a health care system where critical care and many specialized services are often not available in public hospitals, yet command higher payments from Fonasa when rendered in private clinics. SOCHIMU Vice President Santelices sees a conundrum: “If we don’t find strategies to attract specialists in EM to implement our model in public hospitals (where the really sick people are) I think that the main objective of our specialty will be lost.”
In a nation with barely one physician per thousand Chileans (compared to 2.4 per thousand in the US), and very high levels of patient demand for Urgencia, the potential EM workforce requirements are daunting. Application of Camargo’s workforce model to Chile implies that nearly one third of the nation’s 17,000 physicians need to be EM residency trained. But, as in the early days of EM in the US, the vast majority of physicians in Urgencia today were trained in primary care or surgical specialties. And, as in the US, the actual demand for EM trained specialists is likely to be tied to how the government, private payers, and other medical specialties address the very different needs of primary care and acute care in an evolving Chilean system.
As the term implies, in both public and private sectors Urgencia includes a large amount of care that in other developed countries would be provided in ambulatory care clinics in medical centers or free-standing urgent care clinics. The same appears to be true for pediatric care and geriatric care.
Beacon of Hope or Cautionary Tale?
Is Chile a New World harbinger of government-run, universal healthcare? One of the realities of ‘universal’ systems in Europe that is seldom heard in America’s partisan healthcare debates is that nearly the entire EU operates under healthcare models that result in tiered systems, where high-income patients can pay to get private, concierge-level care. As Oregon Governor Kitzhaber, an emergency physician, has pointed out, there is a direct parallel in the American education system. All families pay to support the public system, yet wealthier parents happily pay extra for private schools.
The potential dilemma for Chile’s acute care system is whether the government will continue to pay higher rates for time-sensitive care in the private sector for lower-income patients with meager public coverage. In health care systems within democracies, it is always easier for governments to reduce payments to providers than reduce access to health services to patients who are also voters. This paradigm is already familiar to American physicians. US emergency departments will likely see more and more patients sponsored by government programs that pay less and less. Since employers and the private insurance industry are also rapidly shifting risk and share of costs to beneficiaries, higher income consumers will have stronger incentives to seek more and more urgent care outside hospital settings. Texas appears to be leading the charge in developing a functional two-tier ED system, with more affluent patients choosing to use freestanding EDs and high-end urgent care clinics. This may well compound the payer mix problems within the public system, including many non-profit hospitals in communities too heavily weighted towards Medicare and Medicaid.
To their guest, the friendly debates between Drs. Acuna and Santelices dramatize many of the tensions between health care tiers, social classes, and EM practice models. When asked what the most important thing gringo readers of EPM should know about the status of their new specialty in Chile, their points of view were complementary, and pertinent across the Americas:
JLS: “This is a scenario in development, a good place for fellows in public policy, international emergency medicine, and public health to come and develop their ideas. We have the financial resources, we have the needs (no doubt), and we have the support of the authorities.”
HA: “I think it is very important to understand that nothing is for sure yet in Chile. The most important part of our story is still to be written and we have a great opportunity to write it in the best possible way.”
Dr. Wesley Fields is the Founding Chair of the Emergency Medicine Action Fund (EMAF) and an Assistant Clinical Professor of emergency medicine at UC Irvine Medical Center.