Putian hospital surgeon spills the beans on dodgy practices

by MICHAEL WOODHEAD

Dr Qiu Jianqin is a plastic surgeon turned cosmetic surgeon from Fujian province who has a few unkind things to say about Putian hospitals. In an 'exposure' aired in the Chinese media this week, Dr Qiu talks of his four years working in a Xiamen hospital run by the Putian network - and portrays it as rife with corrupt practices, overcharging, health insurance fraud and substandard clinical practices.

Before I describe these in more detail I should point out that Dr Qiu may well be an aggrieved ex-employee because he has been sacked by the hospital over claims that he was treating patients privately, in an unauthorised way, in his own premises. Dr Qiu and the hospital are now in litigation over unpaid wages, broken contracts etc etc.

The expose comes from the Southern Weekend - based in Guangzhou, which has a reputation for relatively bold investigative journalism.

Dr Qiu says he made the move to the Xiamen New Century hospital in 2011 after becoming burnt out and disillusioned working in the public hospital system. Despite being a senior plastic surgeon, (he is a representative of the Chinese Medical Association Standing Committee of Fujian plastic and cosmetic branch) Dr Qiu says his workload was excessive and the rewards small. The market reforms in the public sector meant that many burns units became more oriented towards lucrative cosmetic surgery, and gave staff commissions and quotas to generate more income for the hospital. And yet at the same time, the hospital still had an iron rice bowl mentality in which they were overstaffed by bureaucrats, says Dr Qiu. The last straw was when his assistant surgeon left over low pay, and Dr Qiu allowed himself to be lured by the promise of the New Century Hospital. He was personally invited by the manager, Su Qincan, who he said spouted a lot of hype but promised a lot of benefits and good facilities.

Su Qincan

Dr Qiu joined the New Century Hospital along with his wife, a senior nurse, but was disappointed to find that the private facility was lacking in many basic facilities such as as resuscitation equipment that are standard in public hospitals.  He wasn't aware initially that it was part of the Putian network, and he had a poor impression of that group. His negative impressions were confirmed when he found that the hospital was now what it purported to be. While claiming to have many different departments, it actually concentrated only on four areas: cosmetic medicine, STDs, obstetrics and dentistry. The other departments - required by health department regulations were 'Potemkin villages' - they were there in name only and were only staffed when health department inspectors visited, at which time they 'borrowed' clinical staff from sister hospitals. The New Century even paid 10,000-30,000 RMB to 'rent' the name plaques of several senior doctors, to make it appear as if they had many eminent consultant physicians and surgeons.

Dr Qiu found that the doctors and managers working at the hospital were unscrupulous profiteers. They would lure in patients, overdiagnose and overtreat their illnesses. In the cosmetic filed, a simple skin fold operation that would typically cost 50 RMB in a public hospital was being billed at 1000 RMB at New Century. If patients complained about costs or about botched procedures the hospital's policy was to engage them with obstructive and expensive legal actions.

The hospital also engaged in routine health insurance fraud - doing extensive cosmetic work such as liposuction and claiming it as appendix removal was one  common example. The hospital accountants became skilled at 'swiping' the health insurance cards of patients, using all their family credit balance on the card even if just one person was being treated at the hospital.

Dr Qiu said this practice was so widespread that the local health authorities must have known but they were also bribed by the hospital. The hospital managers had a well organised system of what Dr Qiu termed "Feeding Putian Cake" - taking officials out to dinner on a monthly basis and allowing them to win 'prizes' of department store spending vouchers worth 1000RMB.

Dr Qiu said that at first he believed this widespread corruption and malpractice was a passing phases as part of the transition to a market-based healthcare system - and he believed he could help improve standards and bring change from within. However, after a couple of years he realised things were getting worse, not better and he started to look for ways out of his five year contract. He was working on commission and described it as being "like forced prostitute"

His managers told his he could not leave and warned him that he would not be able to work anywhere else because his name would be blacklisted if he broke his contract. Things came to a head in 2015 when Dr Qiu kept making complaints and demands for improvements in the hospital. He was told he had been fired - along with his wife. The given reason for his sacking was that he was 'sneaking work home' - seeing patients privately without payment through the hospital. Dr Qiu disputes this. And now he has entered into a litigation with the Putian hospital and its manager Su over unpaid wages and the refusal to hand over his documents and medical licence.

Illegal vaccine fallout: clinics deserted as public lose confidence; lawyers support patients' rights; failure blamed on 'private market'

by MICHAEL WOODHEAD

The issue of the 2 million substandard vaccines distributed across China continues to make waves in the media and for the government, with some surprising developments.

In a bold move, a group of more than 40 lawyers has written an open letter to the State Council demanding that the government 'protect the public's rights to information and compensation' in regard to the health consequences of the illegal vaccines. In their letter, they pose five questions:

• How do individuals know if they have received the substandard vaccine?
• How can people find out whether the vaccine they received was effective, and if necessary the need to re-vaccinate - and who will bear the cost?
• Why were the public not informed of these risks associated with vaccination?
• Why did the vaccine quality monitoring system set up in 2006 fail in early warning?
• For those with vaccine injury, how will this be remedied?

According to Caixin, one of the authors of the letter is Guangdong lawyer and mother of a baby Wang Shengsheng. She herself got one of the suspect vaccines for hepatitis B and was shocked to discover that she may have put her baby at risk.

Wang Shengsheng says she had her baby vaccinated with both essential and non-essential vaccines on the strong recommendation of health authorities and was told they were both necessary and safe. She says she now expects full and prompt disclosure of all results from the investigation, particularly in relation to the batch numbers and locations of the affected vaccines. She says there is also a need for authorities to learn lessons from this scandal so that health consumers can be confident about future treatments and thus have the right to 'informed consent'. This freedom of information should include access to adverse event reports for individual vaccines that are derived from vaccine monitoring programs, she said.

Wang Shengsheng said China also needed a system of compensation for patients with recognised vaccine-related injuries, similar to the system already operating in the US.

Meanwhile, Chinese media outlets such as Sohu Health are reporting that parents are staying away from vaccination clinics as they have lost confidence in the safety and quality of the vaccines being offered.

Reporters who visited community health centres in Guangzhou found them almost empty, and with the few families there expressing concerns about the vaccines being used.

A doctor on duty at a clinic in Tongling said: "Usually at this time we should be full of people. But many parents do not dare vaccinate their children at this time. For the last two days we have been calling people telling them that our vaccines are safe but they are still reluctant to come. They say they are waiting for this matter to blow over."

A doctor at the Zhejiang Tonglu Street Community Health Centre told reporters that they had received dozens of calls from concerned parents asking about the quality and safety of the vaccines they had received. He said parents were still bringing in children to have the essential (Class 1, public funded) vaccines that were not part of the scandal, but use of the Class 2 (private market) vaccines had really dropped.

Doctors at other community clinics were emphasising to worried families that their region's vaccine supplies were on the 'safe list' as they were still part of the public centralised system that had always been well supervised and had not been implicated in purchase of substandard vaccines. They said they were now glad that the vaccine supply and distribution had been kept under control of the government disease control bureau and not 'relaxed' and privatised, as had been the case for many rural counties.

An opinion article in Caixin said the substandard vaccine scandal showed the stark contrast between China's successful and safe public vaccine program and the corrupt and unsafe 'private market' vaccine supply system. The article said the 2006 decision to relax controls on the sale and supply of 'optional' vaccines (Class 2) to allow a free market system had backfired with disastrous consequences for public health.

The article describes how local communicable disease control (CDC) bureaus had been encouraged to 'go to market' to generate extra funds for their own running costs. As with hospitals, these local units had been starved of funding and therefore came to rely on commissions from vaccines to boost their income. This resulted in local CDC bureaus buying the cheapest possible vaccines and charging the maximum markup to patients. It also meant that they strongly recommended non-essential vaccines to families, so that they could make extra profit.

Therefore,  any reform to prevent further substandard vaccine incidents will  need to address the "vaccine commission cash cow" phenomenon as well as ensuring the quality of the vaccine distribution system, it concludes.

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 ...]

Hospital gangster siege reveals the murky side of China's healthcare management

by MICHAEL WOODHEAD
The bizarre 22-day occupation by mobsters of a hospital in Zhengzhou, Henan, is a revealing example of the murky finances and power arrangements behind China's hospitals. 

In late December almost 100 unidentified men invaded the Zhengzhou Meixin Chinese Medicine Hospital and disrupted its operations for more than three weeks. According to Chinese media, the men  - many wearing masks - obstructed the lobby, harrassed medical staff, put up banners and drove patients away. The hospital was thus put under siege by local thugs who stayed in the building playing cards and intimidating anyone who entered.

However, this was not the result of a medical dispute by aggrieved family members of a sick patient, but an extortion attempt to try recoup huge unpaid debts owed by the hospital manager, Wang Guangyu. According to Chinese media reports, the mob had been sent in to force Wang to make good on 17 million RMB funds that he owed to a distant relative, Li Jing. Her husband had previously invested more than 40 million in the hospital via Wang Guanyu, but after the husband died last year, the funds were not repaid in full. After several rebuffs, Li Jing called in the rest of her family to put some muscle on Wang.

In any other country a dispute like this would be settled by the police and the civil courts. However in Henan, amazingly, the ringleader of the occupation gang, Guo Zhiyang, was himself the leader of the local justice department and a former senior policeman.

For someone who is supposed to be upholding the rule of law, Gui Zhiyong appears to be a pretty lawless and criminal character. During his occupation of the hospital staff were threatened by men bearing knives and poles. One pregnant member of staff was so terrorised that she went into premature labour.

The incident ended on 9 Feb after provincial media became interested. When outside journalists first visited the hospital they were rebuffed, but were able to make some reports and take pictures. When this made the news beyond Zhengzhou, the occupiers slipped away, leaving the hospital deserted.

Guo Zhiyong could not be found but he issued statements saying he had been trying in a reasonable and lawful manner to handle personal matters with family. He accused the media of slander through their portrayal of him as a gangster and said he would take appropriate action to defend his reputation.

The whole saga may be an instructive lesson for any foreign companies contemplating running a hospital in China!

[Note: this incident is also reported by a "Gloria Chan" of the SCMP . However, the article so sanitised and anodyne as to be incomprehensible. Presumably this is the SCMP's way of trying to please the Chinese government by not washing China's dirty linen in public.]

Dodgy hospital uses call centres to lure bumpkin victims

by MICHAEL WOODHEAD
A backstreet private clinic in Beijing is using call centre staff posing as doctors to lure unsuspecting victims to have expensive and often unnecessary medical procedures. In an expose, a Beijing Times reporter spoke to call centre staff for the Beijing Sande Weiye (三德伟业) clinic, who described their high-pressure sales tactics to bring patients in for high tech and often unproven treatments such as 'stem cell' technology for arthritis.

The call centre staff said they were given a script and a template to respond to phone inquiries coming from people who had been deceived by fake websites and Baidu advertisements that claimed their 'hospital' was affiliated with prestigious major hospitals in the capital. When answering calls, the sales staff said they were doctors but in reality they were unqualified and just ran through a script whose aim was to convince callers that they could jump the queue and get access to top specialists at the city hospitals. Most of the callers tended to be gullible out-of-towners who were seeking treatment in the capital rather than rely on the more basic and underfunded rural hospitals.

Sales staff told the reporter that they were pressured to get the caller's mobile, after which they would make a series of promises and phone calls to establish a relationship with the prospective customer. They were paid on commission: 2 yuan for getting a call, 20 yuan for getting a registration (ie phone number and verbal contract) with the 'network' and 60 yuan for a hospital visit. The sales person also got a cut of the treatment fees and drug fees. A successful telesales operator could make 5000 yuan in this way. The treatments offered were often high technology - such as joint replacement - and were offered regardless of whether they were really appropriate for that patient.

When the reporter visited the 'hospital' he found it to be just a standard clinic with unscrupulous doctors offering treatments that were much higher in price than the same treatment in public hospitals. A knee replacement, for example was priced at 60,000 yuan.

When the reporter informed the top three hospitals that their name (and reputation) was being hijacked to promote a bogus clinic they said they did not have the staff or resources to chase up the many such cases they heard about from complaints. They suggested the fraud be reported to the Public Security Bureau, but the PSB said they would only follow up complaint from people who had been swindled and who had evidence to show criminal behaviour. They instead suggested that the reporter called the consumer affairs bureau.

The Beijing Industry and Commerce Bureau  told reporters that any company making false propaganda, should be reported to the bureau's hotline and would be investigated, with fines and business license suspensions for offenders..

Why is there so much violence against doctors in China?

by MICHAEL WOODHEAD
As I've said many times on this site, the level of violence against medical staff in China is extraordinary. In one province, Guangdong, there were 25,000 recorded incidents last year alone. Many reasons have been put forward by academics and politicians to explain the epidemic of violence - but there has been little actual study of the contributing factors. Now researchers have interviewed patients and medical staff in seven Guangdong hospitals to get some feedback from the grassroots.

The results of the survey are published in the BMJ this month and one theme emerges: mistrust.

The survey found that there was widespread mistrust of doctors and healthcare staff by the public, based on well-grounded beliefs that there was widespread injustice and commercial bias in the Chinese healthcare system. Patients believed that decisions on their treatment were based more on hospital revenue than need, while at the same feeling resentment that they had to wait for hours to see a doctor for just a few minutes. Costs and financial injustice were a major source of anger: people cited examples of patients being refused treatment - or having treatment terminated due to inability to pay fees.

Doctors also believed there were major injustices in the healthcare system - saying their workloads were far too high and the salaries did not reflect their years of training, long hours and high pressure. They also said that they did not trust patients to behave in a civilised manner, with many being demanding or suspicious.

Patients had little trust in the official dispute resolution systems. They believed that hospitals and law courts were unlikely to give time or serious attention to patient complaints and felt there was little chance of redress for any deficiencies or mistakes. For this reason, patients said they would be more likely to get a result - an apology and compensation - if they used physical and verbal threats, disruption of the hospital and violence to gain attention.

The survey also heard from doctors that their training had not prepared the for communicating with patients or having a good bedside manner.

Both patients and physicians were critical of the government's response to rising violence - namely increasing levels of security guards at hospitals. They said this just inflamed the situation, creating a siege them-and-us mentality and did little to address sudden violent assaults on staff.

The researchers - including several China-based doctors - are openly scathing about the policy response from Xi Jnping and his administration.

"The moral crisis that our study revealed in Chinese healthcare demands a legal and regulatory response as well as a moral one. The Chinese phrase “zhibiao bu zhiben” means treating the symptoms and not the disease. Cracking down on violence and enhancing security measures are unlikely to fundamentally alter patient–physician mistrust and may inadvertently undermine trust."

They put forward three policy suggestions to tackle the climate of mistrust that is driving the violence in healthcare. Firstly they say hospital 'commissions' and incentives to staff for overservicing must be abolished and financial conflicts of interest must be addressed.

Second, doctors and hospital staff need better training in communication, ethics, professionalism and dispute resolution. Finally, there needs to be an atmosphere of trust in which the public are willing to negotiate and seek non-violent solutions, while doctors must be willing to apologise to patient families and accept reasonable consequences for medical error. st.

Similar findings were made in a separate study of junior doctors in three Nanjing hospitals recently. The study found that junior doctors felt extremely frustrated at having studied for up to a decade but having only a lowly job title and poor pay. The doctors said they worked extremely long hours and had high pressure in their work, but also faced poor prospect for promotion or increasing their income. The other main finding was that most junior doctors had experience of abuse and violence from the public, and this was a major contributor to poor quality of life.

"Although Chinese doctors feel relatively unsafe, the phenomenon does not raise sufficient concern from hospital managers . These violent events negatively affect medical workers; for instance, these workers may develop guilt and self-doubt, and such outcomes can reduce the quality of services," the study authors note.

Hospitals heed Xi Jinping's call to make use of "social capital", then rip off investors

by MICHAEL WOODHEAD
One of the cornerstones of Xi Jinping's healthcare reforms is the urging of public hospitals to take advantage of "social capital" (ie private investors) for future expansion and development.

Unfortunately, in China's murky and non-transparent climate of investment, things are quickly going wrong in predictable ways. A hospital in Jiangsu now owes its mom and pop investor almost a billion yuan, according to reports in the People's Daily. The Workers Hospital of Suqian asked locals and employees to put their capital into the hospital's investment fund and promised regular interest and dividend payments.

In 2012, a man called Chen heeded the call to invest in the Suqian hospital to help fund the building of a new hospital and to further develop and expand medical services. The hospital guaranteed a fixed income and this was backed by the local government. Mr Chen put in his 2 million yuan retirement savings and was initially  pleased with the interest payments he received on a regular monthly basis. In fact, Mr Chen was so impressed he persuaded his family and friends to invest their money in the hospital as well. In addition, local TV advertising that was aired to promote the fund resulted in more than 2000 small time investors putting close to 900 million yuan into the Worker's Hospital Investment Fund. However, things started to go wrong in April this year when the hospital defaulted on its interest payments. Investors who asked why they hadn't received their usual payments were fobbed off with non-commital replies.

However, as public complaints and protests increased, the local police and authorities have opened a financial investigation into the missing monies. So far they have found that there is not enough money to pay the interest and also not enough to repay the principal sums that were invested and which most investors are now demanding be repaid.

Several of the hospital financial managers have been detained for further investigation and the local authorities say they are now tracking a number of unauthorised financial investments. It looks very much like the Suqian people have had their social capital blown on the roller coaster Chinese stock market that crashed so spectacularly this year.

Putian cartel?

Meanwhile, China's private hospital market has started to take off in a big way with more than 8000 hospitals and clinics in the loose "Putian Network" forming an procurement alliance. The Putian hospitals network is a loose association of healthcare establishments set up from the 1980s onwards by entrepreneurial families from the Fujian town of the same name. Although suffering from a poor reputation for marketing of dodgy services such as fertility clinics and cosmetic centres, many of the Putian hospitals are trying to transition into more respectable establishments. Several of the hospitals have formed groupings and sought investors through IPOs. Now the Putian group hospitals say they are seeking to consolidate and form buyer's groups to give themselves greater purchasing clout. However, Putian hospital are still suffering from a credibility after being banned from Baidu for their dodgy advertising claims.

High Noon for dodgy drug trials: China cracks down (again) on pharmaceutical data fraud

by MICHAEL WOODHEAD
Eight years ago, the Chinese government took a rather drastic step to clean up fraud and corruption in its drug regulator - it shot the director of the State Food and Drug Administration. However, this has  now been shown to be just another example of the uselessness of capital punishment as a deterrent, because the Chinese government has now announced ANOTHER crackdown on pharmaceutical drug registration fraud.

Although not spelling it out as such, the Chinese ministry of health has basically admitted that there has been ongoing and widespread clinical trial fraud since 2008. Not exactly a ringing endorsement for the succesors to the hapless Zheng Xiaoyu (above).

Despite efforts to correct the situation, the new director of the China FDA, Bi Jingquan (in office since 2015) has announced that the problems of clinical trial fraud have not been fixed. On 22 July he issued proclamation 117, which states that the China FDA is to review the registration applications for more than 1600 drugs, to verify the data as genuine. In a sign of how bad things are, the China FDA has described this as a "last chance amnesty" for all the naughty companies who have submitted false data to come clean. Leniency for those who confess ... and for those who don't - three years exiled in the wilderness. Yes, the China FDA is going to blacklist the drugs and companies that are found to have acted fraudulently - if they don't put their hands up and admit to it. They will be banned from re-submitting any drug registration applications for at least three years.

Not surprisingly, the pharmaceutical industry is not happy with this situation. In fact, they are shitting bricks and calling it "7-22" - the industry's play on 9-11. They know the government means business this time because of what happened to GSK - the Anglo-US company was fined a whopping 3 billion yuan ($489 million) for dodgy goings on within its sales force.

But to be fair on Big Pharma, it's not all their fault. The real villains are the so-called Clinical Research Organisations (CROs), which are agencies that actually do most of the local clinical trial work on behalf of the pharma companies. According to Caixin magazine, industry insiders acknowledge that the CRO sector in China is riven by fraud and corruption. Pharma companies pay the CROs to obtain the clinical trial data for China and submit it to the regulators. However, it's an open secret that the trials allegedly run in China's hospitals have been fixed or faked,  and the regulators bribed or blindsided.

To use the words of a regulatory agency insider, "the chaos has not been effectively curbed" since 2008 and therefore the CROs are being invited to undergo a period of "self examination" and verification of their results. The China FDA is tearing up its 2001 guidelines for drug registration and is starting afresh with more rigorous rules. The CROs have a chance to correct their irregularities or will be banished for three years. It is hope the shake-up will clean out what it currently a rotten and severely compromised sector - but this remains to be seen.

The last word goes to an insider at a reputable company - he says the short term effect may well be a kick up the arse for the CROs and the pharma industry, but old habits die hard. He says the only way to achieve positive long term change is to overhaul the management of CROs and pharma companies - and build expertise based on technical and scientific ability, not an ability to bend the rules

The medical appointment "add-on" phenomenon - why China's doctors see far more patients than are booked to see them

by MICHAEL WOODHEAD

A fascinating article run by Xinhua this week describes the so-called "add-on" (加号) system in which doctors squeeze in far more patients than are registered to see them. The official reason for this practice is that doctors often feel sympathy for ailing out-of-towner patient who cannot get a booking to see them that day. However, as the article reveals, the add-on patients are often more to do with doctors making informal arrangements seeing patients with guangxi (connections) or to see patients who have bought their booking slips from ticket scalpers.

To understand the add-on phenomenon you first have to understand how China's medical appointment system works. To see a doctor in China you have to 'register' (gua hao, 挂号) at the front desk of the hospital before you can get to wait at the clinic And with demand for doctor appointments far outstripping supply, this means patients have to queue very early (often overnight) and for a long time to get one of the limited slots available to see a doctor in their chosen department. There are two kinds of bookings: general and specialists.

Typically, a doctor in a  hospital outpatient clinic will work a morning shift from 8am to 1pm. Assuming that he or she works five hours without a break and sees patients for an average of five minutes (far too brief for an adequate consultation), the doctor could be expected to see 12 patients an hour - or 60 patients per shift. However, some doctors are seeing 50% or even 100% more patients per day than their official limit. Why so?

The Xinhua reporter describes the situation in the Chaoyang Hospital dermatology department, where he sees an impoverished family of 'waidiren' (out of towners) sitting with their ailing grandfather in the waiting room late in the afternoon. They are surrounded by their travel luggage and are telling the clerk that they have come from a remote town in a nearby province especially to see the doctor. At 6pm it is time for the doctors to finish their shift, but the doctor agrees to see the old man without a booking as a jia hao (add on).  The patient is given a ticket with the doctor's signature and the clinic chop, and his family are able to take this to the registration desk to get an official registration slip to see the doctor.

The doctor later explains to the reporter that because of his conscience he feels unable to turn away the desperate family who have been waiting there all day. However, he says he nevertheless feels guilty because his 'extended shift' also means that others have to stay behind - the nurses, clerks, pharmacists and security staff.

The doctor says that all departments have 'add-on' patients, some more than others, and each clinic and each doctor has a different policy about how to deal with them. Some doctors and clinics refuse to have 'add-on' patients, even putting up signs saying they are banned, while others reluctantly agree to see some of the more pitiful cases - the elderly and the seriously ill. Some clinics even leave spare room for add-ons and the doctors try to 'triage' their add-on patients to sort out the most deserving and to weed out the tricksters, malingerers and the ones who have paid for their registration.

The situation is complicated because not all 'add-on' patients are genuine. Some are simply putting on an act because they could not or would not wait in line to get a registration ticket. The doctor describes one woman who came to the waiting room with a wheeled suitcase, lamenting that she had  got off the train from a distant town and needed to see the big city specialist. However, an eagle-eyed nurse noted that the woman's suitcase was very light and obviously empty.

The other big problem with add-on patients is that they are exploited by the thriving trade in add-on appointments by scalpers known as 'hao fanzi' (号贩子).  These are the 'black hand' middle men who hang around the hospital lobby pretending to be patients and getting registration tickets which they then sell on illicitly to  patients who have missed out or don't want to line up early in the morning. To combat this, hospitals have introduced a system of ID checks, with registration tickets only valid for the person who has booked them. If the scalpers are unable to get registration tickets directly from the lobby office, they instead try to get bookings by posing as add-on patients. According to Xinhua, the going rate for a scalper-obtained place to see a doctor is 200 yuan for a general appointment and 300 yuan for a specialist booking.

One doctor told the reporter that the fake scalper 'patients' were often convincing or persuasive and he felt too tired at the end of a long day to try work out if an add on patient was genuine or not. The scalpers also cause annoyance to Beijing residents. One local 70 year old man waiting in the rheumatology department told the Xinhua reporter that he had tried to get to see the doctor for three days but had not been able to get a ticket despite queuing for hours each day. He said he resented outsiders and scalpers taking up the appointments that should be prioritised for local patients.

However another doctor hinted that about half the 'add-on' patients were not outsiders or scalpers but connections - guangxi. They would be patients with some connection to an important person, whom the doctor would 'fit in' to repay a favour, build up guangxi 'credit' or perhaps they were just friends or relations. There are also hints that many of the add-on patients use 'hongbao' bribes to be fitted in to see the doctor at the end of his or her clinic. But another doctor said that add-on patients were not a source of extra revenue - quite the opposite. He said doctors were paid a base salary and therefore if they saw more patients they did not increase their income.  He added that it was not uncommon for a doctor to work a five hour shift from 8am to 1pm without a break. He joked that he dare not drink tea while at work as he never even had an opportunity to go to the bathroom because of the number of patients waiting to see him.

For whatever the reason, the problem of add-on patients is obviously a major one - and yet another example of the problems that come from a health system centred on overloaded city hospitals.

China healthcare's "Sunshine Act" and the journalist who exposed corruption: common cause?

[Banner outside Beijing court says: Support Journalist Chai Huiqun!]

by MICHAEL WOODHEAD 

With China's media often containing significant items of "managed opinion" it's hard to tell whether common themes that emerge in coverage are coincidence or not. Take this week's high profile case of a health journalist involved in legal action over an article in which he exposed corruption in purchasing at a Sichuan hospital. Is this a case of censorship by litigation - or is the government trying to use this case to back its own policy of reforming hospital purchasing?

The legal action in question is between the China Medical Doctor's Association and Southern Weekend journalist Chai Huiqun. The CDMA has lodged an official complaint against Chai to authorities over his reports about corruption in purchasing of medical equipment at the Mianyang Hospital following the major earthquake there in 2008. Chai wrote articles exposing inflated prices claimed for old equipment. The scam was based around the hospital claiming generous funding was spent on expensive ultrasound scanners but actually buying cheap second hand ones.

As reported by RFA, the CMDA put in a complaint to the All-China Journalists Association (ACJA), claiming that the stories were fabricated, and offered as evidence receipts proving that the hospital equipment was genuine. The ACJA accepted the complaint, which was a major blow to Chai's reputation and which effectively blacklisted him.

Now Chai has counterattacked with a legal action in a Beijing court, claiming 20,000 yuan damages and demanding that the statements and articles issued by the CMDA are retracted. In his claim, Chai points out that the receipts are for the wrong kind of scanners, new models which weren't even available in 2008. The court has yet to announce its verdict.

Chai is one of China's leading investigative journalists, working for the relatively liberal Southern Weekend (while it is relatively 'open' its contents cannot be syndicated). He specialises in exposing the dark side of the healthcare industry in China - and has made many enemies. If he is stymied, this will be a major blow for open-ness in the healthcare system in China.

However, Chai may be working in the right direction. Local governments and health departments are being ordered by the central government to clean up their acts and be more transparent and accountable in their purchasing of healthcare supplies.

In Beijing this week the Municipal Health and Family Planning Commission has launched a "Sunshine Program" to reveal the true value and scope of healthcare purchasing. Hospital and health institutions must publish comprehensive 'shopping lists' of all their purchasing and tenders, including all items and prices. This is to encourage and genuine free and open market for hospital supplies and to avoid dodgy backroom deals, the health department says.

If this kind of system had been operating in Mianyang in 2008, perhaps Chai would not have had anything to report.

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.


And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

CPPCC - what they're saying about health

It's that time of the year again - the Chinese People’s Political Consultative Conference (CPPCC). The toothless talking shop cum fancy dress parade as deputies from around China meet to chinwag and talk up the government's policies. It's an occasionally interesting forum - some grievances are allowed to be aired, but usually only to justify measures that are already being taken.
There has been quite a bit of talk about healthcare this year. Most of the problems discussed are ones that have been given a regular airing on this blog: doctors' income linked to overservicing, excessive workload of doctors and the issue of publish for promotion. On the last point, Prime minister Li Keqiang attended one meeting that heard about the problem of junior doctors having to publish academic papers in order to qualify for promotion. He was told that more than a quarter of doctors had their articles written for them by ghostwriters and agencies. The PM said this was a bad situation and doctor's should be rated on their practical skills, not writing skills.

Our old friend Professor Zhong Nanshan made an appearance at one People's Conference, at which he re-stated his concerns about doctors' pay being linked to sales of drugs and number of procedures and devices provided. He cited the case of one cardiologist who implanted several expensive cardiac stents for a patients who was not even seriously ill. Zhong Nanshan said the problem of doctors' ethic arose because up to 80% of their income was tied to hospital profits. This meant doctors were given quotas to meet and the 'profit-driven' mentality meant that hospitals were more like department stores than public health facilities, he said. Zhong Nanshan said that to end the problem of overservicing there was a need to de-link doctors' incomes from prescribing and servicing levels. Doctors should be paid a higher basic salary that reflected their worth, he said - and he stressed this did not mean a return to the 'iron rice bowl' mentality.

The problems caused by pharmaceutical commission were highlighted this week by the news that GSK is to sack 110 of its employees in China in the wake of last year's massive bribery scandal that resulted in the company being fined  $450 million. The widespread use of bribes, commissions and backhanders caused a lot of pain for the multinational pharma company when exposed. The staff who have lost their jobs may well be scapegoats. The man at the top, CEO Andrew Whitty, kept his job but had his salary package halved to a measly $6 million. Whitty said  “substantial changes” had been made at GSK China, including training for managers in anti-bribery and corruption practices.

Other 'unhealthy tendencies' raised at the CPPCC include the hospital VIP suites reserved for officials and local bigwigs. Professor Huang Zemin of East China Normal University said hospitals had two different worlds, with the VIP outpatient wards reserved for officials being quiet and luxurious whereas the outpatient room for the general public was crowded and noisy. A fair point, but the VIP suites have already been slated for abolition, so he's hardly breaking new ground there.

And also from the CPPCC, a cry for help from the paediatricians.  One of the country's top paediatricians, Professor Shu Xiaomei, told the CPPCC that there was a crisis in paediatrics as very few doctors go into this branch of medicine in China. The reasons are that paediatricians earn very little compared to other doctors, again because they don't prescribe so many drugs or do many procedures). Another reason for the unpopularity of paediatrics is the high workload and the huge pressure from pushy parents - often leading to violence when things go wrong. Professor Shu said there was also no formal training program for paediatrics, unlike other specialties and therefore the speciality was a 'tree without roots'.

The workforce theme was raised by another delegate at the CPPCC, who said that China simply does not have enough qualified doctors to do everything that the public expected of them. His succinct appraisal was that "without more doctors, all discussion about health reforms is empty talk. "
Other CPPCC delegates said that the push to create a primary care system based around community clinics was commendable but facing the major problem of neither doctors nor patients wanting to go anywhere near primary health clinics. Dr Zhao Ping, of the Chinese Academy of Medical Sciences, said patients did not go to local clinics because they had poor equipment and poorly trained staff and could not refer to the best specialists.
"People don't trust these clinics and hospitals. The thing is, people want to go to better and larger hospitals, and so do healthcare workers. We don't have a mechanism in-place to keep our best healthcare workers at community clinics," he said.

But it's not just the CPPCC, here are some other major medical news stories from China this week:

• Two doctors in their 20s have died suddenly of 'overwork' in the last few weeks, prompting some doctors to say that the pressure of work is too high.

• Baidu's CEO Robin Li says Baidu is looking at online appointment systems.

• China's first new advertising law in 20 years is expected to tighten up regulations around advertising of medical products and healthcare services .

• A Fuzhou doctor became a social media viral sensation when he was photographed working while hooked up to an IV infusion. Weibo users praised him for his dedication for working while sick. 

• International medical experts have expressed concern at China's crackdown on ketamine. While the drug is sometimes abused, it is also a very important and safe anaesthetic, and any restriction would be a major blow for safe surgery in poor countries, they say.

Gong Xi Fa Cai! Medical news in the Year of the Sheep

Chinese New Year is upon us, with businesses closing up for a long holiday and most Chinese families looking forward to a reunion. But of course people still get sick at Spring Festival and the Chinese media has been full of stories praising the heroic and dedicated doctors and nurses who forego the holiday and put duty ahead of family to stay at work.  There are stories of doctors working solo for 24 hours to keep up with all the demand during the Spring Festival. From Hubei there is the story of the man bitten by his rabid pet dog who went to the hospital and was hugely relieved to find that the infectious diseases doctor was on duty to give him a rabies injection. At Fuzhou Hospital on New Years Eve the medical and nursing staff gather together to have the "big family banquet" that they would normally have with their families at home.  And there is even a story of the doctor at a Zhejiang leper colony who was urged by his ailing patients to go home and see his family rather than spend New Year on duty at the sanatorium.

Not all doctors have been heaped with praise at Chinese New Year, however. In Guangzhou there has been an uproar among the medical community after the city authorities sent anti-corruption teams in to raid hospitals just before Spring Festival. The city disciplinary affairs committee said the inspection teams were looking for evidence of bribes and 'hongbao' (red envelopes) given by patients to doctors. The raids have so far turned up little evidence of bribery, and doctors have been indignant at being suspected of corruption. They objected to having their everyday items such as snacks being documented - and also being questioned in detail about the origin of their possessions - and even for receipts for goods. Doctors said the actions of the inspectors went beyond their powers and the actions should have been a matter for the police. One doctor said a public hospital was not a place where bribes could be openly given or solicited among colleagues - and he was also indignant that many doctors had prepared hongbao or gifts for their families which were assumed by inspectors to be bribes from patients.

Chinese New Year is also a peak risk time for influenza in China. In Guangdong it has been reported there have been 53 cases and 13 deaths from  H7N9 avian influenza. In neighbouring Hong Kong there has also been a very severe flu season caused by the regular influenza H3N2 strain which has been causing as many as 18 deaths per day in the city. There have been reports of shortages of antivirals such as Tamiflu in Hong Kong, and the flu vaccine this year has been ineffective because the H3N2 strain of flu is a new mutation that is not covered by the vaccine. Of course influenza does not stop at the border, so we can only assume that the flu toll has been equally high in mainland China.

Another major infectious disease under the microscope this week is the recent outbreak of measles  affecting more than 1200 people in Beijing. Infectious disease specialists in the capital found that most of the cases originated in wholesale clothing markets popular with  locals and international visitors - so an MMR vaccination might be a pre-requisite if you are going to the Silk Market. The analysis found that many of the cases occurred in migrant workers who (unlike Beijing residents and tourists) had low levels of measles vaccination. The researchers recommended that outreach services be set up to vaccinate migrant workers in Beijing and "the offer of measles vaccine to workers as they register to live and work in the commodity markets might be a reasonable strategy to prevent future measles outbreaks."

In other news this week - the high demand for blood products in China is driving  a thriving black market in organised gangs of donors, organised by the so-called "blood heads" who are paid thousands of RMB for supplying blood. In the field of diabetes, some Chinese endocrinologists have been blasted in the pages of the Lancet for writing a review article that recommended the use of expensive new drugs as first line treatment for diabetes. Their critics say the endocrinologists failed to mention the more effective and cheaper drugs such as metformin - and the Chinese doctors also failed to mention their financial conflicts of interest with the Big Pharma makers of the expensive new drugs.

And finally, the quality of medical education in China has been questioned in several articles published this week. The Year of the Sheep is a milestone for China's medical educators in that they are now requiring a standard 5+3 medical degree + internship program be implemented nationally. However, some commentators have said that the new system will be no better than the current haphazard postgraduate 'Masters' programs if medical graduates receive insufficient clinical experience and supervision. They also say that the internship scheme should include 'exit examinations' to ensure that trainees have actually acquired the specialist skills they have trained in. Coincidentally this week Shanghai media report that trainee doctors get little experience in anatomy because there is a national shortage of donated cadavers. Chinese culture prohibits citizens from 'donating their bodies to science' as is done in the west. This means that Chinese medical graduates get all their anatomy learning from textbooks and have very little "hands on" experience. This is worrying for students going into specialties such as surgery - as they may never have practiced techniques such as cervical spine surgery before being asked to do the real thing. Not surprising then that a special anatomy cadaver training class at Shanghai's Fudan University was heavily oversubscribed.

新年快乐!

Beijing doctor explains on Youku about bribes and commissions

by Michael Woodhead
A video is circulating on Youku of a man purporting to be a former surgeon at a Beijing hospital, explaining how the red envelope bribe and commission system works in China. 
The erstwhile doctor, claimed to be  Li Rui of the Beijing Aerospace Institute Hospital Urology department. He said that during his time working in surgery, doctors would make huge commissions by charging patients exhorbitant sums for ancillary items such as a 1500 yuan gauze pad to stop bleeding, on which they earned a 30% fee. He said surgeons performed many simple operations such as removing appendix in 10 minutes and then adding lots of expenses to the bills. Dr Li said it was best to work in procedural specialties such as orthopaedics, surgery and obstetrics where there were more opportunities to perform operations and use expensive medical supplies and devices. The man was purportedly giving a presentation at the well-known New Orient academy  in Beijing, although the institute denied any knowledge of his working there. In a statement the Beijing Aerospace Institute Hospital denied the man's claims, describing them as baseless and slanderous. The hospital said there had been a Dr Li working at the hospital but he had been absent for six months and thus his contract was terminated. The hospital said the man's statements on video lacked credibility, citing as an example that there was no way a surgeon could do an appendix removal in 10 minutes, even with the most modern equipment.
However, the video has been widely circulated on Chinese social media sites, drawing comments on the greed and corruption of doctors and the profit-seeking nature of public hospitals.

Cancer treatment unaffordable | Drug pricing corruption | Premier tackles HIV stigma | Rare diseases not reimbursed | US medical exams popular in China

Public punchbag to pay son's cancer fees
In Beijing a man who cannot afford the Y700,000 ($114,000) medical bills for his son with leukaemia has offered himself as a public punchbag to raise money. The man called Xia Jun stands outside Guomao station and asks for 10 Yuan to be thumped. He says he has collected 10,000 yuan in one day without anyone taking up the opportunity to hit him.

Corruption on drug price setting cited as reason for abolition
The recent move to abolish price caps for prescription medicines was triggered by corruption in the agency charged with setting drug prices. Critics said officials in the National Development and Reform Commission (NDRC) were under investigation by the anti-corruption and bribery bureau under the Supreme People's Procurate for taking bribes. Pharma company executives said the current pricing system forced them to pay bribes to regulators to set higher procurement prices.

Premier lends support to ending HIV stigma
Premier Li Keqiang has shown public support for people with HIV and aimed to dispel prejudice and ignorance about the infection by visiting  a HIV clinic at the inspected Beijing You'an Hospital.
 For World AIDS Day, the Premier met HIV patients and healthcare workers and said the old attitudes of fear surrounding the topic of HIV must be abandoned and HIV patients need more care.

Rare diseases slip through the health insurance cracks
China's health system is not working for children with rare diseases, as their families face high treatment costs and no access to medical fee reimbursement, according to an article in the SCMP. One mother of a 3-year old boy with Langerhans cell histiocytosis (LCH) said his bills for diagnosis and treatment had reached nearly 200,000 yuan ($33,000), of which just 4,800 yuan ($780) had been reimbursed by the rural medical insurance scheme.

US medical exams popular in China
Thousands of China's medical students and young doctors are studying for the US Medical Licensing Examination (USMLE) that will allow them to practice medicine in the US. However, despite studying for up to 1500 hours for the exam, many of them say they are taking it to improve their medical skill rather than just to get a better paying job. Many Chinese students said the US medical exams taught them a more patient-centred approach and put more emphasis on communication and empathy rather than just rote-learning of medical facts. The test is also taken by many of the 60,000 foreign students studying medicine in China.

Doctors refuse red envelope pledge | Online pharmacies to be allowed | Chinese diabetes patients don't adjust diet

Famous doctor won't sign bribe pledge
One of China's leading doctors has refused to sign the government's anti-bribery pledge against accepting red envelopes, saying it is an ineffective and damaging document. SARS hero Professor Zhong Nanshan said the no red envelopes pledge was not a legally-binding document and its ethical pledges were already contained in the Hippocratic Oath that doctors already swore when they graduated from medical school. He said that if doctors signed the pledge it would be a tacit admission of guilt that all doctors were accepting bribes for preferential treatment, which was not the case. He added that signing the pledge also sent the wrong signal that doctors were to blame for the high costs of medical bills, which he said were actually driven by systemic problems such as the linking of hospital doctors incomes to overservicing and the lack of government funding for government hospitals.

Online pharmacies permitted from 2015
Online sales of prescription medicines in China may begin within months, according to the China Food and Drug Administration. The regulatory agency is expected to announce new policies that will allow  online prescription medicine sales as early as January 2015. Pharmaceutical retailers have said the opening up of online medicine sales will open up a potential 10 billion yuan market for drugs. However, the expected increase in  online pharmacies will have a major impact on bricks and mortar pharmacies, they have warned.

Diabetes patients don't adjust diet
Chinese people with diabetes have little idea how to manage their diet so as to better control their condition, a new study shows. A survey of 100 people with type 1 diabetes by researchers at Peking University People's Hospital found that less than half had ever seen a dietician and few monitored or adjusted their diet to help control their blood glucose levels. The study found that while 64% were aware of carbohydrate counting', only 12% ever used the technique

How GSK bribed doctors in China: the gory details

GSK's Mark Reilly, given a suspended prison sentence by Chinese court for bribery.

by Michael Woodhead
The main points of GSK's record 3 billion yuan ($500 million) fine for bribery in China have been reported elsewhere - I won't go over the same ground.

Suffice to say that several senior executives (including one from the UK) have been implicated in the giving of massive levels of bribes/kickbacks to institutions and hospitals in China to promote the  use of GSK's drugs. The company was also found guilty of transfer pricing - dodgy accounting to transfer profits out of China via pricing mechanisms that favoured the revenues of the parent company over the China subsidiary.

Most of the western reports have focused on the implications for GSK and for the prospects of western businesses in China. Surprisingly few have questioned the ethics of what GSK was doing - except to suggest that "Chinese companies were all doing it, it's the way of doing business in China."
I have been reading some of the Chinese language media reports, and they give a lot more detail of the practices GSK was found guilty of. Very few western media reports have focused on the actual bribery methods used by GSK or the specifics of the transfer pricing arrangements (which I presume are not confined to China).

Here are a few examples reported in the Chinese media:

1. According to Chinese prosecutors the bribery was systematic and on a huge scale. Drug reps bribed doctors. Area managers bribed hospitals and 'VIP clients'. Country managers bribed officials in charge of distribution and purchasing. Bribery was done via travel agencies, gifts, sponsorship and through entertainment budgets and PR agencies. There were separate promotional teams for different product groups - the cold chain (vaccine) group is said to have spent 130 million yuan bribing officials in the regional Communicable Diseases Centres with everything from cameras and electronic equipment to cars.

2. How were individual doctors bribed? One liver specialist physician in Hunan called Dr Lee told the court how it worked. For every lamivudine prescription he wrote he was paid 20 yuan by GSK rep. For every new patient he got a bonus of 100 yuan. Dr Lee said every month he wrote about 150-200 prescriptions for lamivudine and started 5-8 new patients on the drug. Do the maths - that 12,000 yuan ($2000) a month, or 144,000 yuan ($23,400) a year.  Dr Lee said the GSK rep arranged to pay him his commission every month at a special meeting when he would be paid for 'lecture fees' and travel expenses for the company. He received these fees 12 time a year but only did 3-4 lectures for GSK each year.

3. It wasn't just individual doctors who were bribed - the court heard how professional 'medical associations' also had huge sums of money transferred to their accounts from GSK to promote the endorsement and use of their products. Medical groups also received millions of yuan in material bribes such as non-medical items like fridges, cars and TVs. Hospital managers were also bribed millions to influence their purchasing policies - sales reps were given a 'Great Wall Plan' and a 'Dragon Plan' of incentives to persuade hospitals to abolish their 'Chinese-made generic drugs only' policies.

The end result was that Chinese consumers paid more for their medicines. Drugs such as Contac, Fenbid and lamivudine were overpriced up to seven-fold compared to other countries. The unit cost of lamivudine was said to be 142 yuan in China compared to 18 yuan in South Korea and 30 yuan in the EU, Japan and Hong Kong. Drug prices were padded to pay for kickbacks. About a third of the cost of GSK pharmaceuticals was said to have been to cover 'commissions', according to a financial controller. This meant Chinese consumers paid 30% extra for drugs  just to cover the cost of bribes.

GSK was driven by high pressure sales tactics for pharmaceuticals: GSK's revenue in China rose from 3.9 billion to 7 billion yuan between 2009 and 2012. The sales workforce increased from 1000 to 5500 people over that period, and each rep was given a budget of 3000-5000 yuan per month to influence prescribing - presumably though officials, doctors and health institutions. Sales reps were promised unlimited bonuses and membership of an 'Elite Club' with foreign travel if they met their targets

Cooking the books: from 2009-2013 GSK had almost 22 billion in revenue from drug sales in China and yet recorded a profits of only 100 million yuan. Investigators found this was due to a 'Five Step' transfer pricing system, by which the costs of products such as the antibiotic Zinacef were inflated at various stages of production in Italy and Cyprus until eventually 'sold' to the China subsidiary. This was a way of repatriating profits back to the US, but again meant that Chinese patients paid far more than they needed to for drugs.

The overall picture is not pretty - call it what you want - commissions, kickbacks, bribes, - GSK was guilty of them but they were by no means the only pharma company in China  doing it. Commissions and kickbacks are obviously widespread in the Chinese health system, and others have been caught out - such as in the Zhangzhou, Fujian case last year where 73 hospitals were found to be guilty of accepting bribes.

In Chinese media reports on the GSK case, most commentators have concluded that the massive fine and the jail sentences will be a lesson to the pharma industry - and the stamping out of bribes will result in lower medicine prices for Chinese consumers.

However, one leading financial commentator has said the GSK case is a prime example of China's tactic of "killing the rooster to scare the monkey"  - but it would not work. Cai Shen Kun says corrupt practices are so entrenched in China's pharmaceutical industry and are so much a part of the healthcare system that even a major case like the GSK one will not put a stop to them. He says kickbacks have become an unwritten rule in the industry that all insiders believe that nobody can ignore if they want to make sales - even a major international company like GSK.

Cai Shen Kun says the long term solution is to reform the health and pharmaceutical system to make it transparent and remove the incentives for commissions. He also says nothing will change until those who accept the bribes are brought to justice - and that means prosecuting the  government officials and senior doctors who accept the 'crazy money'.

Why Chinese patients are turning against their doctors: contrasting articles by the New Yorker and BMJ

by Michael Woodhead
Two very interesting and very different articles this week on violence against doctors in China: one in the New Yorker and another in the form of a study in the BMJ Open. 

The New Yorker story is in the usual stylish narrative, but I prefer the BMJ Open article, because it has more facts and more insights, even if it is a dry scientific paper. In the New Yorker, writer Chris Beam uses the example of the murder of a doctor in Harbin to shine some light on the whole fraught situation of violence against doctors in China. The story focuses on the case of a young man from a small town who had debilitating and degenerative back pain (ankylosing spondylitis) and who was unable to get satisfactory treatment from a Harbin hospital. He also had TB, which made treatment with an immunosuppressive drug even more difficult. Frustrated at his patchy and expensive treatment, the young man returned to the hospital and attacked the first doctor he could find, and killed an 'innocent' medical practitioner who had nothing to do with his care.

Chris Beam tells the story well and uses it to give some background on the health system in China and why so many patients and their families turn violent when they are treated so badly. However, I found the article was a bit too focused on the legal side of things (the American obsession with law once again?) The article doesn't really explore the root causes of violence: the built-in pressure in the system to overprescribe and over service, the rising cost of treatment and the hugely overloaded hospital system. Beam does cover China's health reforms, but strangely fails to mention the recent moves to encourage private clinics and the use of primary care clinics.

Another factor not really touched on by the New Yorker article is the patient/family faults: for me some of the key factors in China's medical disputes are rising expectations combined with ignorance (poor health literacy) and readiness to use brute force. This is not just confined to health: see how Chinese travellers behave when flights are cancelled or hotel rooms are overbooked.

That's why I prefer the BMJ Open article by Dr Jiang Yishi and colleagues at the School of Public Health, Fudan University, Shanghai. Their article takes a look at the reality of the complaints systems that exist in Chinese hospitals - and finds them sadly wanting. Dr Jiang and colleagues undertook the first in-depth study of how the complaints system works for patients and for doctors and hospital staff. They conducted interviews with all 'stakeholders' and found that in many cases, the system is broken. In theory, a patient with a grievance has several channels through which they can seek redress. They can make a formal complaint to the hospital complaints office and can also petition via a system of 'letters and visits'. Patients can also go to mediation by a third party office to settle an unresolved dispute with a hospitals. And patients can also take legal action against a hospital via  a lawsuit.

In practice, these systems often do not work. Firstly, many patients are simply unaware of the complaints system and how to use it. Hospitals don't advertise their complaints offices, which are often hidden away in an obscure corner of the building. The staff in these offices are supposed to be able to investigate complaints and arrange mediation - but in practice they are often unqualified to adjudicate on complicated clinical matters, and they are also under great pressure to deflect complaints - or dismiss them quickly. Complaints departments are understaffed and have little sway in the hospital system. Another problem with the 'complaints office' system is that it lacks transparency. Patients make complaints but they get little feedback from complaints office staff who do everything 'behind closed doors'.

On the other hand, hospitals and medical staff also express great frustration about the complaints system. Doctors say any complaints arise because they work under great pressure to see 60 or more patients in a morning and don't have time to put on a 'warm face' or to explain things in detail to patients. This lack of connection and communication leads to many misunderstandings and unhappy patients.  Doctors also say that they become the scapegoat for failings of the system: for example, (just as in the US) they are restricted in what treatments they can offer to patients by the medical insurance rules - but patients don't understand this and often get angry at being denied treatments are given treatments that come with a hefty out of pocket costs.

Another big frustration for doctors and hospitals is the rise in unreasonable complaints and the use of abuse and pressure (extortion) to get a complaint resolved with financial compensation. More than 50 doctors interviewed mentioned this 'chao' (吵, argue) phenomenon. Doctors said many patients and relatives had unrealistic expectations about what could be done by medical staff. And when things didn't have a good outcome, patients and relatives often turned to threats and 'mob tactics' to put pressure on doctors and hospitals. These unruly groups are not interested in facts or a fair settlement but want to cause as much trouble as is needed to get a financial payout.

The BMJ Open article says the whole health complaints system in China is lacking in structure and rigour: there are no standard protocols for investigating complaints, for assessing harm and no data is collected on complaint numbers or how they are followed up - and no system for using complaints to identify weaknesses or errors and give feedback accordingly. Hospitals have no incentive to collect or document complaints because it just gives them more 'black marks'. 

The overall impression of the health complaints system is that it is perfunctory and ineffective: hospital directors want complaints to be managed quickly and made to 'go away', hence the readiness to make a quick financial settlement and avoid trouble and bad publicity, especially when angry mobs are involved.

The article by Jiang concludes by identifying three crucial areas where improvement is needed in the complaints system: organisational support, personal support from hospital managers and political leaders (and patients) - and learning system to ensure that failures are identified and rectified. The solutions put forward are sensible and obvious - and the full paper is well worth a read. 

However, I  would not be optimistic about the prospects for change: many of the problems that plague the health complaints system are common to those of Chinese society in general: there is a lack of trust in institutions (in this case hospitals and health departments) which are not accountable, lack transparency and which combine vested financial interest with political power. The solutions require open-ness, accountability and an independent watchdog with teeth. In the current environment in China, those are not likely to happen. Instead, China has top-down directives to crack down on the symptoms of these failings - the government issues stern warnings and makes some highly public arrests of wrongdoers. Ultimately it will take workable systems to fix the problems of health grievances, not campaigns and punishments.