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Thursday, May 31, 2012

Healthcare Systems and International Mobility

I've had the pleasure of knowing three different healthcare systems in my time:  U.S., France and Japan.  All have been outstanding  I'm a skilled IT worker and I was legal resident of all three countries so I never had any problem with payment.  I was always covered under either private insurance through my employer or a national healthcare system.  Sounds simple and straightforward, right?  Not exactly.  For people who are highly mobile and move from one country to another there are some special challenges that are not necessarily taken into account by healthcare providers and networks in any country.   Here are a few thoughts about things I've noted over the years that sidesteps the question of which healthcare system is best and focusses instead on how well these systems work for highly mobile international migrants :

Relationships:  Once you get beyond the question of how it will be paid for and get inserted into whatever system exists in the host country, there is the important task of finding a doctor you like and building a relationship based on (one hopes) trust.  This doesn't happen overnight.  Leaving the country means leaving that relationship behind and having to build new ones in the new country.  I know that my own impressions of the different healthcare systems I've used are heavily colored by the doctors who treated me.  I still miss my ob/gyn in Seattle and have never found one as good or who I liked and trusted so much.  Same for my dentist in Tokyo.  I was very lucky to find a GP here in Versailles who is, for me, the very best I've found yet.  But building those relationships takes time and can involve a certain amount of trial and error.  I've talked to a number of migrants who rely for years on drop-in clinics and emergency services because they just haven't found someone they like and trust enough to become a regular patient.  This can translate into a situation where migrants don't get preventative care:  standard tests, immunizations and the like.

Continuity:  Having to rebuild relationships with healthcare practitioners means a lack of continuity in care.  All too often medical records  don't follow or have to be translated.  Immunization records, for example, have to be interpreted in the light of whatever the practice is in the host country.  There are similarities between the immunizations given to children in the U.S. and France but it's just different enough that the new doctor has to struggle to fit one system into another and determine what needs to happen next to comply with the host country's standard immunization schedules.  For adults the onus is on them to keep track of things and provide the new doctor with enough information about care received elsewhere so that he or she can pick up where the last doctor left off.  In the stress of moving and the adjustment to a new location, this is not usually a top priority, but can come back to haunt the migrant when he or she is asked by the new doctor, "So when was your last tetanus shot?"

Learning Curve:  The systems are very different from one country to another and a migrant has to spend some time learning how it all works in the destination country.  The processes are very different and you have to learn what forms to file, who to talk to or call, what to do in case of an emergency, what options are available and so on.  I know very few migrants who've actually researched the health systems of the new country or took the time to read all the terms and conditions for private insurance.  A lot of the information on-line, or provided through pamphlets and the like, all too often assumes some basic knowledge of how things generally work here which may be radically different from they worked over there.  It can be overwhelming for a new arrival and tends to be put off until he/she simply has no choice.  It comes down to "learning by doing" which can be very frustrating and very hard for someone who needs the access but isn't feeling that well and is not in an optimum frame of mind to assimilate new information.

Culture:  Aside from the basic protocols which are usually pretty similar between developed nations, the doctor/patient relationship varies radically according to the culture.  In some places doctors are remote paternalistic figures (gurus) and they don't like to be questioned by patients and would be very offended if a migrant sought a second opinion.  In other places, a migrant may be inundated with information by a doctor with a very informal familiar style.  This is not a statement about which is style is better, it's about the impact of that style on a migrant who is accustomed to something else and has different expectations and needs.  It can be very destabilizing and be an important barrier to building trust between the doctor and the patient when they are operating under two different cultural codes.  Adaptation is necessary and ideally should come from both sides.

Language:  On top of the cultural issues there is the issue of language.  To get and provide good care the doctor and patient have to be able to communicate.  Where the two don't share a common language this is a real problem.  One solution for the patient is to actively seek out a multi-lingual doctor.  This is easiest in big metropolitan areas and almost impossible in rural areas.  Sometimes the migrant actually waits until he/she has a basic command of the language before seeking any healthcare outside of an emergency.  It's simply too frustrating for both parties.  The cultural and language barriers can also be deadly.  I know one woman married to a Frenchman who was diagnosed with cancer after a few years here who became so frustrated and so depressed during her treatment that she ended up in the psychiatric ward.  Because of the communication problems the healthcare professionals simply didn't see the deterioration of her mental state until it was too late. Given how important morale is to successfully treating conditions like her, this was something that very much threatened her survival.

All of the above has a real impact on access to healthcare and the ability of any system to provide the kind of preventative care needed to avoid costly life-threatening situations.  The extent of the impact varies according to the migrant (socio-economic status, language ability, cultural knowledge and other variables) but anyone who is highly mobile will most likely encounter one or more of these difficulties. There is no one solution to all of them but I would like to propose that, instead of arguing about which system is "better," we might want to turn our attention for a few moments to the global arena and think about how we could make these systems work together to provide the best possible care for the mobile international migrant.


Shirl and Rowan said...

Hi, Victoria. I loved your posts on health today. You really think through these issues in a very incisive way. I have always said it is not the insurance company (we have an HMO in the US); it is the individual doctors who listen to you and advocate for you who really make the difference. Best with your Big Adventure with health.
Shirl and Rowan

Christophe said...


I also like your discussions on healthcare from the perspective of immigrants. You have some very good points. All of them valid and very true. I've experience some of them.
I would just add that sometimes, within a system, other "forces" may make you switch providers and start the process all over again, which is frustrating. 2 examples that I've experienced:

- I used recommendations to find a good dentist that I was comfortable with, but was later dropped from my plan. While I could continue to go see her, the financial hit was not worth it, and I chose to change.

- Similarly, I found a GP that I loved, but to try to reduce heathcare cost, my company opened an onsite clinic in our complex and offered huge incentives for people to switch (very low copay, convenience, etc). Unfortunately, I don't find the onsite doctor to be as good than my old one.
Also, my healthcare history is not that long, but I would have like to transfer my files, and the cost would have been close to $100. Ridiculous. I hate the fact that clinic and hospitals thinks your health records are theirs and make you pay a lot of money to get what belongs to you.

I haven't kept up with changes in France since I moved here, but I think they now require you to choose a main provider, to prevent people from trying to get multiple opinions.

Great post. Thank you.

Best wishes.


Victoria FERAUGE said...


Thanks for the great comment which brought back a lot of memories for me. You are absolutely right about the other forces. I recall getting that official list of doctors from the insurance company when we were in the U.S. and the panic I felt as I searched for my daughters' pediatrician on the list. Fortunately, she was there.

Yes France does now ask that you choose a "medecin traitant." It's not required but the co-pay is higher and I just found out that it impacts the Affections de Longue Durée (ALD). If anyone other than the medecin traitant makes the request it has to be renewed every 6 months.

All the best,