At Shanghai General Hospital, a white-gowned physician assistant runs out of the operating room and heads into the nearby waiting room, crowded with patients’ family members anxious for word on their loved ones. “Bed number 42’s family?” he bellows. “The balance in his account is too low. Please go pay the bill so we can continue the operation! Forty-two’s family?”
Holding the completion of a patient’s surgery hostage to immediate payment while he lies unconscious on the table would probably seem like a shocking breach of ethics in most countries with advanced healthcare systems. But in China, it may not be all that unusual or unseemly, even here at a respected major hospital in one of China’s most populous, affluent and sophisticated cities.
It’s not that China’s healthcare system suffers in general from low standards of care. On the contrary, the improvement of healthcare here, in a country that has only in recent decades emerged from widespread poverty, has been nothing short of remarkable. Government-financed hospital care — at least in facilities near major cities — in many cases approaches the standards of hospitals in the U.S. and other fully industrialized nations. Even state-of-the-art robotic surgery is routine in some Chinese hospitals.
But at the same time, doctors here continue to face financial and working-condition pressures that can interfere with their willingness to deliver top-notch and appropriate care to all patients. One result: Doctors at times end up making individual treatment decisions based largely on the income they and their hospitals will derive from those decisions, even when the decisions may be at odds with what would best meet patients’ medical needs.
These problems come to light in a visit to Shanghai General, more formally known as Shanghai No. 1 People’s Hospital. Comprising two enormous campuses, Shanghai General is one of the largest hospitals in Shanghai to merit an “AAA” rating — the government’s highest. The 2,500-bed hospital has a staff of nearly 3,800, which in 2015 performed some 74,000 inpatient surgeries and saw more than 3.5 million outpatient and emergency-department visits.
For many local residents, the healthcare they get at Shanghai General is not only high quality, but also affordable. For example, the hospital charges between US$1,500 and US$3,000 (RMB10,000 and RMB20,000) for breast cancer surgery, and of that fee patients pay only 20 percent (US$450 to US$800) out of pocket, with government insurance picking up the rest.
That doesn’t mean the hospital can count on prompt payment for all the care it delivers. For one thing, even the 20 percent share can be a burden for some patients. But more important, China’s government insurance scheme isn’t very geographically portable, so people who have traveled from other parts of China to work near here aren’t automatically covered at Shanghai General. “We have two million people in the greater area, but only 500,000 can get covered care here,” says Dr. Miao Zheng, head of breast, thyroid and vascular surgery at the hospital. Migrant workers in the area either don’t have medical insurance, he notes, or have medical insurance tied to their hometowns, which means they have to travel back to those towns to qualify for reimbursement. Even then, reimbursement rates are as low as 50 percent rather than the 80-percent coverage of those who are local to the Shanghai area.
In many countries, hospitals tend to set fees high enough so that the revenues from government, insurance and out-of-pocket payments cover the costs of those patients who can’t pay. But in China, fees are tightly capped by national and regional governments, and public hospitals like Shanghai General are given budgets that can’t easily be exceeded. When patient demand for care exceeds funding to pay for care, a hospital has only a few options: Try to deliver more care that pays well, try to deliver less care that doesn’t, or try to pressure strapped patients and their families to pay their bills.
That means patients with exactly the same medical needs may receive very different treatments, depending on their respective insurance coverage, and on their ability and willingness to pay out of pocket before and even during the treatment. And it can also depend on how close a particular physician, clinical department, and hospital is to exceeding their respective budgets at the time of treatment. Thus, for example, a patient showing up when a doctor’s spending is near the limit might receive less-expensive, and potentially less-effective, care than if he or she had come a few weeks earlier when budgets were less strained.
It also means that doctors may be tempted to drive up fees quoted to paying patients by pushing for more complex surgeries involving higher-priced, high-profit medical devices such as implants. Even worse, China has had problems with manufacturer and distributor kickbacks to physicians and administrators to push particular devices and drugs. The problem has been especially acute in orthopedics, where it’s relatively easy to steer a patient toward a complex procedure with an expensive implant when a less-expensive approach might have been more appropriate.
Exacerbating these problems and temptations is the fact that China doctors, and especially surgeons, tend to be more overworked than their counterparts in the U.S. and in many other countries. As a Shanghai General senior surgeon with a heavy surgery and outpatient schedule, orthopedics trauma specialist Dr. Fang Wang also must serve 24-hour emergency-department duty every five days, and still has to find time for his teaching and researching duties in the medical school affiliated with Shanghai General. He often works until 22:00.
Adding to the pressure is the infamously prickly attitude of Chinese patients toward doctors. In most cultures doctors are treated with a fair amount of respect, but in China many patients and family members strongly assert unrealistic expectations for results, and can become confrontational and even belligerent toward doctors if those results are not forthcoming. Reports of patients striking doctors are common, and occasionally news stories tell of patients murdering doctors. That’s likely rare, but it’s hard for surgeons and other physicians to ignore the stories — especially given that, as Wang notes, physicians are all too aware that a certain level of patient disappointment is warranted. “We can’t provide all the care our patients need,” he says. He adds that the gap is widened by the Chinese healthcare’s lack of recognition of, and counseling for, the emotional trauma that patients and their families often suffer. “This just leads to more stress for us, too,” he says.
Meanwhile, physician pay is lower in China than in many countries with modern healthcare systems, especially for surgeons in specialties requiring complex procedures that don’t require revenue-boosting medical devices. For example, a gynecological tumor surgery carries a total fee of US$600, which has to cover the costs of a full operating-room team for as long as several hours. A gastrointestinal surgeon, on the other hand, can add US$2,000 to the surgery fee if the procedure requires an anastomat, a device designed to join together two segments of the intestine after a middle portion has been removed. “Gynecological doctors don’t have opportunities for extra income,” says Dr. Xiaowei Xi, the director and head surgeon of Shanghai General’s department of gynecology.
In spite of all these pressures, it may only be a small percentage of doctors who indulge in unethical behavior in order to keep fees up. A more common response to the stress is to flee the field, says Zheng, the vascular surgeon, noting that the result is a talent drain that further threatens healthcare quality throughout China. To make up for the outflow, he says, medical schools are lowering standards to enroll more students, placing future healthcare quality in even more jeopardy. Swelling the ranks of medical-school students may not even solve the physician shortage, says Wang, because increasing numbers of graduates are choosing to forego practice to work in other, better-paying industries.
So far, a lack of clinical skills isn’t widely seen as a problem at better hospitals in China. “Chinese practitioners have practical skills as good as those of our Western counterparts,” says Dr. Zheng Ruan, a thoracic surgeon at Shanghai General. That’s not an uninformed claim; Ruan recently finished an observership in operating rooms in France, and many of his colleagues at the hospital have spent as long as a year in various Western hospitals.
But the workloads and budgetary pressures on Chinese physicians take a toll on what is normally a critical component of advanced healthcare systems: clinical research. It’s not a lack in quantity of research in China as much as quality, says Wang. The problem, he says, is that physicians are pushed to publish as many papers as possible in order to qualify for promotion, whereas there’s no real incentive to tackle a difficult research problem that may lead to an important breakthrough, but risks eating up years of work without a stack of published papers to show for it.
All of these problems are well-recognized by the medical community and the government, says Wang, and there’s intense interest in instituting system-wide reforms to address them. But there’s a catch: Doctors can’t take the time to participate in efforts to develop reforms unless they’re freed up from some of their overwhelming duties, but the demands of the current system won’t allow it. “Healthcare reform can’t get anywhere without the full participation of clinicians,” says Wang. “But they have to focus on the basic and immediate needs of patients.”
Still, there are some promising developments. To eliminate the pernicious incentives to prescribe more expensive drugs and medical devices that can also lead to kickbacks, more hospitals in China are turning to online procurement systems. This is an effort to eliminate the backroom, relationship-based, deal-making known as guanxi. Guanxi is endemic to Chinese culture, but in the healthcare arena it can bring unnecessarily high prices and restrict choices, all at patients’ expense. Eliminating it could be an important first step to bringing more fairness to fees.
The growth and increasing influence of private healthcare institutions is also raising the bar on healthcare in China. In addition to the growing availability of private and public-private providers, more people in China are purchasing commercial health insurance as a supplement to governmental coverage. So far such efforts have mostly served to improve care only to more affluent Chinese, even at public hospitals. Shanghai General, for example, now has a special VIP Center for those patients who can pay higher-than-government-insurance rates for healthcare, either through private insurance or out-of-pocket payments.
In the long run, the availability of higher levels of care is likely to trickle down to publicly financed healthcare. Part of that process would have to involve improving the lot of physicians at public hospitals. And that’s a development that would pay off for patients as well as doctors.
— Changhong Zhang
Changhong Zhang is a freelance healthcare writer based in Shanghai, China.