Why Beijing's war on hospital ticket scalpers is doomed to fail: top cardiologist says jail sentences won't fix supply & demand problem

by MICHAEL WOODHEAD
This week a Beijing court sentenced 15 hospital ticket scalpers to prison sentences varying from 19 months to two years in jail. It's all part of a very public crackdown on the practice of 'entrepreneurs' buying up the hospital clinic reservation numbers (guahao, 挂号) that are needed to gain access to see a doctor. Typically, these hospital tickets cost 20 yuan at the front desk but are bought up and sold for ten or more times their face value by scalpers (piao fanzi, 票贩子) who operate in gangs around the foyers of public hospitals.

In theory, China's hospital clinics operate on a first come, first served basis. Whoever is prepared to queue up early at the hospital ticket window in the morning gets the tickets. In practice, the scalper gangs either send their agents to stand in line and book an appointment - or they have inside connections with hospital staff to procure the tickets through the back door. The corrupt practice has been going on for years, but made headlines in January when a video emerged showing a young rural migrant woman ranting about the scalpers at a Beijing obstetrics hospital. The video went viral on China's social media channels and there was soon public pressure for 'something to be done'.



As in the past, the hospitals and the Beijing health department announced yet another "get tough" campaign on scalpers. They sent in the PSB to round up the usual suspects. They also issued a series of "Five Musts" measures that included real name registration procedures and an end to collusion between hospital staff and scalpers. And as usual, an example has been made of a few offenders in the media. The Party has listened to the masses and taken action. Never mind that the 15 offenders sent to jail weren't actually scalpers, but fraudsters. They had hired hospital rooms in which they used bogus doctors to swindle unsuspecting out-of-towners into jumping the queue and paying for dodgy TCM treatments.

But even if the authorities had enacted a serious and enduring action against hospital ticket scalpers, it still would not make any difference, according to one leading cardiologist.

Professor Yang Qing, has worked at the cardiology department at the Sichuan University Huaxi Hospital for 20 years. He says the problem is not due to the scalpers, who are only the symptoms of a monopolistic system. Professor Yang says it is important also not to blame doctors, who are also constrained by the system.

According to Professor Yang, every day his hospital cardiology clinic in Chengdu is besieged by patients from far and wide, seeking a consultation. Patients come not only from Chengdu, but also from across the province and even from overseas. A typical clinic has 20 allocated slots to see patients with an average consult duration of 6 minutes - but most will actually fit in 30 patients by running over time. Every day at the front desk he is mobbed by people saying: "Professor Yang can you add an extra place for me?" Some are very deserving patients who have traveled a long distance to see him - even renting rooms near the hospital. Others are former patients who want continuity of care and to be followed up by the same treating doctor. And there are also 'insiders' - acquaintances, connections and people who work in the hospital who seek an appointment with him.

Professor Yang says the demand for 'tickets' is inexhaustible and he only has a finite amount of time in a working day. On a typical day he works right through an after noon clinic without a break even to go to the bathroom. He is supposed to finish at 5pm, but usually does not actually finish until at least 6pm. If there is a chance he will add a few extra places, but he says he feels bad for not being able to accept all the requests. And his colleagues all feel the same way. They are not heartless, but they have other responsibilities and things to do - not to mention family life. Professor Yang says that in addition to attending to patients in the outpatient clinic he must also do surgery, supervise junior staff, take part in research and write reports. He must attend medical conferences and teach students.

Professor Yang says that the demand for hospital tickets is high, but the price is low and does not reflect the 'economic value' of the doctors' skill and experience. The scalpers are simply selling the doctor's appointment at a price the market is prepared to pay, he says. And the 'profit' is going to criminal gangs instead of to the hospitals.

Professor Yang says that what the scalpers do is an unsatisfactory and unfair situation, but he believes it is inevitable under a monopoly system. It would be unrealistic to expect them to be stamped out - and even if all the ticket scalpers were removed there would still be an imbalance between supply and demand of medical appointments, he says.

"When a resource is scarce, and when everyone wants to have this resource, the authorities' fight against ticket brokers is meaningless," he says.


Professor Yang says that in theory a system that guarantees low prices is good because it makes treatment affordable for everyone. However, in practice he says low prices enforced within a monopoly lead to low quality care and also to the 'detestable' practice of scalping.
 
Professor Yang's solution is a free market one - free up the doctors to set their own prices and let them manage their own patients. In this way, there will be competition between doctors that will keep prices low and affordable while raising levels of service and quality, he believes.

[Editor's note: Given that they have been given prominent place in the state media, Professor Yang's pro-market comments are presumably endorsed by the government and China's minister for health. It's notable that the learned professor suggests a new model based on the US free market healthcare system, and makes no mention of other more successful models such as the gatekeeper' system of Britain's NHS. 

The kind of problems that Professor Yang describes do not occur in the UK  because that country (like many others) has an efficient primary care gatekeeper system that ensure that patients do not go straight to hospital. To see a hospital specialist, patients in countries such as the UK and Australia must first go to see a community-based general practitioner, who decides if and where they should be referred. This means that patients with minor illness and chronic disease can be managed in the community' rather than clogging up the overloaded hospital system. It also means that patients are sent to the most appropriate specialist. 

Of course the system isn't perfect because financial restraints mean that public hospital patients often have to wait months for an appointment to see the doctor. In countries such as Australia, patients can jump this queue if they have private health insurance (but they still need a GP referral) But if any patient needs urgent care, they can receive it. 

Interestingly, China is pursuing both these options. It is loosening the monopoly of public (actually state-owned for-profit monopoly) hospitals. China is also moving towards a community/family doctor system. However the progress is glacial because of the entrenched financial interests of local governments [and managers] in their local hospital monopoly. So is the solution to hospital scalpers a crackdown, free-market healthcare or a gatekeeper system? You decide ...]

China is crazy for medical apps

The latest medical app craze in China is iBaby, developed by an entrepreneur from Harbin to provide antenatal, childbirth and childcare advice to Chinese women. The creator Lu Guotao featured on a recent Apprentice-style TV show on which he demonstrated how his app can link women up to advice via video and online help from obstetricians. Lu turned down offers from investors and went it alone to market the app, which he says now has tens of thousands of users in 31 provinces. Lu says he has had 10,000 obstetricians sign up to provide medical advice online via the app. The one stop platform for pregnancy advice also links women up with local clinics and offers links with merchandisers for pregnancy wares.

Lu says he was already a successful businessman when his wife became pregnant, but they were so busy attending to their work that she lost the baby through a miscarriage. Lu turned his grief into an energetic mission to help avoid such incidents again, by providing accessible information, advice and contacts for prospective parents.

He says the huge success of the app is not surprising given China's move towards relaxing the one child policy and also the opening up of the healthcare system to private investment and more flexibility in doctor roles.

The app has received backing from national obstetric experts including Professor Liu Xinghui, director of the West China Second Hospital, Sichuan University, Chengdu. Professor Liu offers weekly online lectures via the app. She says women can access a wide range of obstetric experience via the app.

Doctor defamed online by spurned patient

A well respected ophthalmologist at a Chengdu hospital was slandered online by a patient who claimed that he was unethical and had discriminated against her daughter. In an 'exposure' on an online forum, the female patient said her daughter had been refused treatment by a Professor Liu, who discriminated against her because she was a single mother and yet he consented to treat other patients who were less deserving than her. On a popular social media site the woman said the professor had no ethics and she warned that he discriminated against common local people. The post stirred up a lot of angry debate about the ethics of the doctor.
However, when reporter from Sichuan Online followed up at the hospital he heard a very different story. The staff said the woman was impolite and demanded treatment despite not having registered at the hospital. Also she had no medical records and her case was not urgent. A patient from Yunnan was seen instead as their case was urgent and because they faced extra expenses if the case was delayed until the following morning.
Professor Liu said he personally intervened after the woman  argued with nurses. He said it was reasonable in a busy clinic to ask the woman to return when she had her medical records. The other case was more deserving. A security camera recorded the woman acting aggressively and knocking over billboards and items on a table in rage.
However, this story was not told online, and the social media site was led to believe that Professor Liu was an arrogant and uncaring doctor with no ethics. His name has been blackened. Nurses and staff at the hospital said he was a caring and hard-working doctor who often stayed until 9pm at night to ensure that all patients in the waiting room were treated.

China needs to act on overuse of intravenous infusions - BMJ

[Pic: www.news.cn]

Action is needed to reduce China’s massive overuse of intravenous infusions for inappropriate indications, according to an article in the BMJ this week.
The timid steps taken so far by the Chinese government have done little to dent the widespread misuse of IV infusions, with as many as ten billion courses – or eight per person per year – being given, says Yuan Sanying of the West China Hospital, Sichuan University, Chengdu.
She says the government has recognised the problem and has acted to reduce financial incentives for prescribing infusions. However, there is still enormous pressure on doctors to set up IV infusions and the practice continues in most hospitals. Many hospitals even have dedicated infusion rooms, she notes.
Ms Yuan, who works as a nurse in the Department of Liver Surgery, says hospitals look like ‘infusion forests’ during cold weather spells as patients are treated with infusions for common respiratory ailments. And yet doctors acknowledge that most patients don’t need IV medication and could be better treated with oral remedies and rest.
The use of infusions is a major burden on hospital staff, with nurses reporting being overworked and diverted from other tasks as they spend half their working day setting up IV infusions. The Ministry of health has responded by monitoring the number of infusions and by banning some hospitals and doctors from earning commissions from the use of infusions. However, inappropriate is still driven by pressure from patients who believe that they will recover faster if they have an infusion. Doctors and nurses who refuse to provide infusions face getting into disputes with patients and their families, she says. Yuan Sanying says financial restrictions should be extended to all hospitals. She also recommends a public education campaign, similar to the ones that have discouraged the public from using antibiotics for viral illnesses.

2000-year old clinical guidelines written on bamboo, found in Chengdu

Chillies for a headache and a bull's urine for jaundice: These are the latest deciphered messages of how Chinese people two millennia ago cured themselves, and their horses.
The 920 medical bamboo slips, together with other historical relics of the Western Han Dynasty (202 BC- 9 AD), were found in a subway construction site in Chengdu, capital city of southwest China's Sichuan Province.
A total of 184 bamboo slips are said to be the "guidebook" for horse vets. The remaining 736 can be categorized into nine separate medical texts covering various domains.
According to Xie Tao, a research fellow with Chengdu's archaeology institute, the books could be lost medical classics written by the successors of Bian Que, a medical pioneer from the 5th century B.C.
Two characters in one of the books have the same pronunciation as Bian Que, though in different written forms, said Wu Jiabi, of a bamboo script research institute in neighboring Hubei Province.
Bian Que was said to have invented the technique of taking the pulse and narcosis. He perhaps performed the world's earliest organ transplant, as recorded in Lie Zi, an important classic of Taoism.
The bamboo slips did not contain any sorcery, believed to indicate the separation of medicine and witchcraft and the budding of medical science.
Source: China Daily

Health official suspended in nepotism probe

Qu Songzhi of the Chengdu health department

A senior health official and wife of the dismissed deputy Party secretary of southwestern Sichuan Province has been removed from her position at the Chengdu branch of the Red Cross Society of China.
An unnamed official with Chengdu Red Cross said Qu Songzhi had not been at work since her husband Li Chuncheng was put under investigation.
Li was removed from his positions for suspected "serious discipline violations" only one month after he was also elected a non-voting member of the Chinese Communist Party's central committee during the 18th Party National Congress last November. Li is currently under investigation by the Party's discipline department.
Chengdu government officials said Qu was a hospital worker before her husband was appointed Chengdu City Party chief in 2003. She quickly gained several promotions afterwards to become a section chief in the city health bureau.
She became Party secretary of Chengdu Red Cross in 2009.
On Weibo.com, Shen Yong, who claimed he was a police officer, published six posts about Li, calling him "Li Chaicheng," meaning destroyer of cities.
In his online posts, Shen claimed that Li had "bought" his posts, and to recoup his outlay, had created a department and promoted his wife.
Li is said to be the most senior official to be investigated for corruption since Xi Jinping became the Party's leader.
Xi has launched a campaign against corruption also targeting the petty bureaucracy and infractions of low-ranking officials who are the bane of many people's everyday lives.
Source: china.org.cn

Chengdu researchers show oral insulin as effective as injected insulin

An enteric coated form of insulin was as effective as NPH insulin when given orally

by Michael Woodhead

While insulin is usually given as an injection because it is broken down and inactivated in the stomach, doctors in Sichuan  have shown that it can be effective when given orally in a special enteral formulation.
Researchers from the Department of Endocrinology and Metabolism at West China Hospital, Sichuan University, Chengdu, evaluated the pharmacodynamic and pharmacokinetic profiles of orally administered enteric insulin and compare the time–action of the oral insulin capsules with a standard insulin injection formulation, neutral protamine Hagedorn (NPH) insulin.
in their study, 12 healthy volunteers received one of three doses of oral enteric insulin (50, 100, or 200 U) or one subcutaneous injection of NPH insulin (6 U) on four separate days.
Glucose infusion rates increased after administration of either NPH or oral enteric insulin. The mean times for maximal metabolic effects for 50, 100, and 200 U of oral enteric insulin were 250, 170, and 236 minutes, respectively, compared with 243 minutes for NPH insulin. The onset of action was slower for oral enteric insulin at 50 U, 100 U  and 200 U compared with NPH insulin. The maximum glucose infusion rates for oral enteric insulin treatment were lower compared with NPH insulin, although these differences were not significant.
The researchers conclude that "oral enteric insulin capsules induced significant glucodynamic effects and exhibited a time–action profile similar to that of NPH insulin in these healthy volunteers. No detectable increases in serum insulin concentration were observed in any treatment group."
Read more: Clinical Therapeutics