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.

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.]

Freelance "Doctor Groups" - the first sign of workforce reforms in China

by MICHAEL WOODHEAD

The creation of some 30 independent "physician groups" (Yisheng Shoutuan, 医生集团) is the first sign of the Chinese government's 2015 relaxation of working regulations for the hospital system. The rules have been relaxed to allow "workforce fluidity" - in other words to allow doctors to work where they wish rather than being bound to a single hospital ( a legacy of the old danwei work unit system).
 he Chinese Nationa Health and Family Planning Commission (NHFPC) wishes to create a more flexible workforce and to allow doctors to work in a more more market-oriented system, supposedly to free up medical talent and overcome the current mismatch in supply and demand for medical services.

It is still early days for these doctor groups, which face problems such as how to engage with hospitals, how ensure high quality medical standards and how to take on medicolegal risk (and insurance). These are things that are usually the responsibility of hospitals and something that doctors have not had to worry about in the past.

To try tackle these issue the Beijing Henghe Hospital has set up a "doctor group collaboration model platform" to try work with doctors towards new ways of working. The group has already started to look towards the US for business and working models for doctors. Initial discussions have revealed that 55% of hospitals have doctors doing some form of 'moonlighting' - and therefore the doctor groups may formalise this working model.

Another survey found that many talented young doctors were leaving the hospital system because of the long hours, high pressure and low pay. A new freelance model may help retain the skills of these doctors, the collaboration discussion group said.

However, other doctors have pointed to the fact that the vast majority of doctors continue to work  in the public hospital system, and they say this system (and its workforce) is already stretched to breaking point. They ask how the public system will cope if many of its 'backbone' doctors reduce their commitment to practising in the hospitals - and also the reduced input in areas such as teaching and mentoring.

The group heard from some leading doctors saying there now had to be a pragmatic approach to developing Doctor-Hospital Partnerships to ensure optimum allocation of medical resources and also recognise the true value of doctors.

In one Doctor Group forum, vascular surgeon Dr Zhang Qiang said there were 10 issues facing doctor groups:
1. Doctor groups are a very vaguely defined concept.
2. Policies have to be open, pragmatic and work with the health ministry and hospitals.
3. What size should doctor groups be? How much will they be worth? And what disciplines will the consist of?
4. How will doctor groups be organised? As private companies? Co-operatives/ Joint ventures?
5. Where will doctor groups be located? In private hospitals? In large institutions or be in stand-alone clinics? Or as flexible visiting doctors?
6. If doctors join freelance groups [how] will they maintain their participation in academia, teaching and research?
7. How will doctor hierarchy and work assignments/responsibilities be arranged in private groups? In the public system there is a clear structure and system of rosters, promotion and responsibility - how will this translate in private groups?
8. How will private doctors interact and communicate online and digitally, if they do not have the support of the government and hospital system? Will there be referrals and shared care?
9. How will freelance doctor groups be financed and where will they find their start up capital from? If there is a share ownership, who will own the shares and control the doctors?
10. Will private doctor groups have clout? For example, in medical insurance will doctor groups have enough buying power and negotiating strength to be able to arrange medicolegal cover, settle medical disputes and influence policy?

China's pharma companies take a stake in public hospitals. What could possibly go wrong?

by MICHAEL WOODHEAD
China's not-very communist health minister Li Bin wants to see hospitals turn to "social capital"(ie private investors). And it is slowly starting to happen. China's 'public' hospitals are currently in a strange place - they are essentially state-owned for-profit enterprises, but bound by an odd mix of rules and regulations that keep some prices in check and yet which allow rampant price gouging and overservicing in areas such as pharmaceuticals. Not for nothing are pharmacies know as the 'gold mine' of hospitals.

To try get rid of the obvious incentives for hospital doctors to overprescribe the government is currently phasing in a ban on drug commissions. They are trying to de-link income from drug sales and hospital revenue.

However it's not clear to me how this squares with the trend for China's pharmaceutical companies to go into partnership with hospitals, and essentially to become their operators. Take the recent deal by the Guangzhou Baiyunshan Pharmaceutical Group to invest in six hospitals in the obscure Shandong city of Jining. The joint venture covers six main hospitals with around 6000 beds and a total annual revenue of 2 billion yuan.

The local health department has 49% stake in the new Jining health provider company, while the pharma company has a 33% stake in return for 5 billion yuan investment. Other stakeholders include investment companies, with between 15% and 2% interests.

Analysts say the new joint venture will allow industrial groups to make profits from controlling supplies of pharmaceuticals as well as medical devices, supplies and equipment. I'm no health economist but I can't see how allowing a pharma company to own and operate all of a city's hospitals is good for the patient. Who decides which drugs are made available at the hospital - and what happens to the competitor products? Also what is to stop overservicing, as we have seen so evidently a problem in the current system?

As a commentator in Caixin magazine concludes:

"With deals like this we need to first be clear what is the purpose of the restructuring of public hospitals, and through the restructuring of what kind of results you want to achieve? These issues need further study and discussion. "

Top 10 hospitals in China

by MICHAEL WOODHEAD

I'm not a big fan of top 10 lists, and I would approach this one for hospitals in China with caution. The China 2014 Good Hospital Ranking is produced by the Fudan University Institute of Hospital Management.

I'm not quite sure what criteria they use to decide what makes a good hospital but they claim it is based on factors such as clinical competence, scientific research and academic rigour. How they measure that objectively is anyone's guess. The Fudan team also say they consulted many 'national experts' to rank the country's top hospitals. They say the rankings are a good guide to clinical excellence and should be a benchmark that other hospitals strive for.

I don't think anyone is going to see any surprises in the list - all the top hospitals are the 'usual suspects' in the major cities such as Shanghai and Beijing and Guangzhou. I'm also not sure what the point of league tables for hospitals is - if you asked me to name the top 10 hospitals in Australia I could tell you quite easily without having to do a ton of homework - just based on location and whether they are teaching hospitals with a good research culture.

The rankings actually extend to 100 top hospitals, but I've only listed the top 10 here for brevity. I'm also not sure what the point of doing these survey on an annual basis is - it's not as if hospitals will move up and down the list very much and whether that is significant anyway. Any doctor will tell you that some good hospitals can have very bad departments and vice versa - some hospitals have a good reputation in certain specialities and can be terrible for others. Much of it is down to personalities and medical politics. I can also think of some 'good' hospitals that are over-rated and charge exhorbitant fees based on their reputation and "closed shop" monopoly status.

But what do I know. Here's the list:

1. Beijing Union Medical College Hospital
2. Sichuan University, West China Hospital
3. People's Liberation Army General Hospital (aka 301 Hospital, Beijing)
4. Shanghai Jiaotong University Affiliated Ruijin Hospital
5. Xijing Hospital (No 4 Military Hospital) Xian
6. Zhongshan Hospital, Fudan University, Shanghai
7. Huashan Hospital, Fudan University, Shanghai
8. Zhongshan Hospital, Guangzhou (First Affiliated Hospital of Sun Yat-sen Univeristy)
9. Tongji Medical College Hospital, Shanghai (Huazhong University of Science and Technology)
10. Peking University First Hospital

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..

Doctors tempted by offers from private hospitals

by MICHAEL WOODHEAD
As China tries to develop its private healthcare sector, some doctors are contemplating a move from their high workload, low paid public hospital positions to the private sector. One Shanghai obstetrician with 10 years' experience was interviewed by Caijing and said he was tempted to make the move to the widening private sector, but not for financial reasons. He said he could already earn 300,000Y (US$47,000) a year in the public hospital, counting bonuses, which was comparable to the private hospital salary. What attracted him to private work was the lower workload and the opportunity to have more patient continuity.

"In public hospitals every day you need to see hundreds of patients, and you have no energy left to do academic work, research and innovative practice. In the private hospitals there is reduced patient throughput and often the patient will follow you from start to finish - and this is a more valuable medical experience," said Dr Liu. "None of my friends who have switched to a private hospital have shown any regrets," he added.

Another reason for moving into the private sector is independence, say doctors. One said that private hospitals offered more clinical and financial autonomy than a public hospital where you worked under the authority of a 'big medical leader' and were also subject to the rigid career path and control of hospital management. In a private hospital there was more opportunity to select your patients, treatments and also have an equity stake in the business, he said.

However the doctor noted that there was less job security and often questionable quality of care and backup in private hospitals compared to the public system. He noted a clear divide between domestic and foreign-funded private hospitals. Foreign joint ventures tended to have little interaction with public hospitals as the quality of care was generally good. However he saw many 'referrals' of patients from private hospitals where patients had not been properly assessed or had spent tens of thousands of yuan for minor ailments. Most of the doctors in the tertiary public hospitals would opt for foreign-invested hospitals, he suggested.

Inequality in China healthcare - fixing it isn't easy

by MICHAEL WOODHEAD
The Chinese government acknowledges that serious inequalities exist in the country's healthcare provision - rural areas are seriously under-serviced compared to the cities. 

More than a decade ago the government announced a grand plan to try address some of these inequalities - by sharing the expertise of big city hospitals with rural areas. The plan was for medical personnel from tertiary hospitals in prosperous eastern China to spend time in placements and long-term exchanges in disadvantaged rural hospitals and clinics in poorer parts of western China.

However, the so-called "Myriad Doctors Supporting Rural Health Care Project" has not been a complete success (to put it mildly), according to a letter in the Lancet this month from Dr Wang Tao of the Shanghai Jiaotong University Sixth Affiliated Hospital.

After touring western districts to see the progress of the project in its 10th year, Dr Wang found that it had helped bring medical personnel and technology to some poorer areas. However, the project was also under-resourced for such a major undertaking. Lack of funding meant that hospitals struggled to pay their seconded medical workers an adequate wage. The transfer of five senior doctors from each supporting [eastern China] hospital to a disadvantaged hospital on six-month shifts also proved impractical.

"These long-term arrangements create a huge burden for hospitals in eastern provinces and can cause personal difficulties for medical staff," he writes.

Another problem was that medical resources were allocated by government bureaucrats rather than determined by need.

"Coordinating this huge project that involves thousands of hospitals and medical workers according to strict policy guidelines is extremely tough, and inefficiencies and repetitive allocation of resources inevitably arise," says Dr Wang.

The project has not done much to address inequalities in healthcare, he reports. Latest figures show that eastern China areas have average annual healthcare funding levels of 1067 yuan per person, whereas in western China hospitals have only half that level of resources (about 500 yuan per person). Inequalities also exist in the numbers of hospitals, doctors, nurses and beds between eastern and western China.

"Healthcare inequalities remain a serious problem and necessitate support projects for the foreseeable future," Dr Wang suggests.

He asks whether market forces could succeed by encouraging hospitals in eastern provinces to open public or private amenities in the western provinces.

"New sources of income might provide sufficient motivation to create efficient, high-quality services. The fear is that new sources of income might cause new problems, counteracting the government's attempts to reduce inequality. Nevertheless, the consistent provision of an excellent level of health care in China, particularly in less developed areas, still has a long way to go."

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.

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year

For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

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.

What are hospitals like in China? (Answer: congested)

by MICHAEL WOODHEAD
Another week and another series of brutal attacks on hospital staff in China. This week it was the turn of an unfortunate female neurologist in Huizhou, Guangdong, who had her hand almost severed when she hacked with a machete by a disgruntled male patient. The man said he was unhappy with his treatment and attacked without warning when the doctor was on her ward rounds.

The authorities have made the usual responses - they have arrested the offender and tightened up security at the hospital. Tributes and donations have poured in from citizens sympathetic to the plight of the injured doctor. A petition against violence in healthcare has garnered half a million signatures from doctors - and the Guangdong health department has ordered that all medical institutions have a police office installed and manned around the clock.

The attack was one of 12 high profile violent incidents against health staff that occurred last week in China - including the smashing up of the 301 PLA Hospital in Beijing. What is the underlying reason for these attacks? One of the main factors often mentioned is that China's hospitals are simply overloaded and cannot offer adequate care to all patients - who then become angry and violent.

Is this because China's health system is underfunded or inefficient? Some interesting answers on the real situation about China's congested hospitals emerged this week in a lengthy paper in the academic journal Health Policy and Planning. It's worth reading if you want to know the background to China hospital system and how it got into the mess it's now in.

The authors paint a much more nuanced picture of China's hospital system than the usual overcrowded/underfunded/profit-seeking complaints. First of all they bust some myths. For a start, China's healthcare system is not massively underfunded by international standards - but it is  unevenly funded, with most resources devoted to city hospitals.

Also, China's hospital system is not uniformly overloaded - only the tertiary (highest level) hospitals are. The lower-level hospitals at county and township level are often underused and deserted because patients flock to what they perceive as the top quality care available at tertiary hospitals in cities.

The authors explain that this has come about for two reasons. Firstly, when China's hospitals were reformed by Deng Xiaoping, the high level city hospitals got a lot more investment and incentives than the township and country hospitals. This created a vicious circle because the large hospitals were able to invest in better equipment, and attract more patients. better staff and thus earned more 'business' (and income) while the county hospitals lost out.

However, the high level hospitals had two problems - they invested in infrastructure rather than staff, creating a shortage and misallocation of skills at the tertiary hospitals, where many staff are wasted dealing with minor illness.

Secondly, the tertiary hospital were bound by tight regulations on prices for essential drugs and medical services.  To overcome this, they invested in many unofficial services (eg cosmetic surgery, fertility clinics etc), which diverted resources away from frontline care. The restrictions on prices meant that hospitals had to overservice to gain more revenue - but it also meant that patients had no 'price signal' to seek care from local hospitals. They could get good care  at the tertiary hospital for the same price - even if it meant facing overcrowding and rushed consultations.

This, then, is the current situation in China's hospitals - an imbalanced system in which all patients flock to the short-staffed higher level hospitals, creating congestion and strife. The article by Dr Sun Zesheng and colleagues at the Zhejiang University of Science and Technology, Hangzhou, offers a simple solution: deregulate prices. They say that tertiary hospitals should charge a premium for their services, and patients should be encouraged to seek less expensive alternatives for non-urgent care at local hospitals and clinics. However, they also warn that the government must invest in better equipment and medical staff resources at lower level hospitals.

Until that happens, the big city hospitals will remain congested - and the pressure (and attacks) on staff will persist.

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.

Healthcare reform in China - The Five Reforms and why they will fail

by MICHAEL WOODHEAD

As part of its latest round of healthcare reforms the Chinese government has released  a handy guide to the five top things it is doing to overhaul the creaky hospital system. The snappily titled "Guiding Opinions on Pilot Comprehensive Reform of Urban Public Hospitals" is really just a wish list for what the government would like to  see happening in the public hospital system.

Bear in mind that in China a "Public Hospital" is not  a public hospital as we would understand it in Britain or Europe. It's not a government-funded hospital that provides universal care. No, it's a state owned enterprise that runs a user-pays health institution. No money, no treatment. It's true that most people have some kind of government-subsidised health insurance that may cover some of their medical bills, but here again the public hospitals have a monopoly on that income - until this year private hospitals were not eligible for medical insurance rebates.

Anyway, all that is changing with the new Five Reforms:

1. Management Reform

The government says hospitals must adopt a more independent and accountable management system - recruiting outside experts and taking on board evaluation and performance review systems. They must start to subject themselves to outside scrutiny from consumer and industry groups and  - here's the killer - be transparent with their data. In other words, reveal their costings (insurance companies will love this) and their activities. A big ask. Expect massive resistance.

2. Revenue Reform

Hospital must stop relying on profits from sales of drugs and medical devices for their revenue. At the moment hospitals get 40-60% of their revenue from markups on drugs, medical equipment etc, and only a small proportion from medical fees and government subsidies. The central government wants to reverse that, and is going to ban drug commissions. To make up the lost revenue the hospitals must increase medical fees. Patients won't like that. There have already been riots in pilot trial sites in Sichuan by kidney dialysis patients who saw their cost of treatment go up 200%. The local government backed down.

3. Performance Reform

Hospitals must ditch the current system that forces doctors to overservice in order to achieve their bonuses. They must ditch the contracts that link doctor's remuneration to prescribing and procedure numbers, and replace it with a performance system based on clinical outcomes, service and efficiency.

4. Gatekeeper Reform

The government wants a primary care gatekeeper system and says tertiary hospital must stop being the One Stop Shop/First Port of Call for all and sundry.  Medical insurance policies are to be changed to force patients to attend local community clinics for minor illness and then be referred to local hospitals before going to a major tertiary hospital. The  major city hospitals will be reserved for more advanced and complex care patients. They must stop offering outpatient care for minor illnesses. This will take some getting used to because at the moment all Chinese make a beeline for 'the best hospital' as soon as they have a cough or cold.

5. Private Interest Reform

State-owned hospitals must be opened up to outside private business interests - the so-called 'social capital'. Private companies must be allowed to take on major roles within hospitals, along with insurance companies, and other medical foundations. Most importantly, they must have access to health information data.

The long and short of this guidance is that the closed and tightly-controlled monopoly situation for state owned hospitals must be bust open. At the moment, state-owned hospitals are the empires for local government bureaucrat-business chiefs. They jealously guard their business and their revenue stream - which is patients and the drugs and treatment they receive.

In an interesting opinion article in Caixin this week, Tsinghua University health economist Li Jiangge says that previous efforts to reform the hospital have failed because they simply have too much power and have too much to lose. He cites the example of government programs to provide  affordable treatment for cataracts. Although the central government provided generous funding to set up cataract treatment programs, most local governments blocked these projects in their areas because they would lose the lucrative income from doing the operations in their own hospitals. In other words - hospitals will block anything they see as competition or which undermines their own services. Likewise with kidney dialysis: China has 3 million people with renal failure needing dialysis, but only 400,000 get dialysis. The remainder go untreated and have early death because public hospitals will not allow private operators to enter this area and compete with them.

As Li Jiangge says, private investors and public hospital managers are "strange bedfellows" with conflicting and competing interests, who cannot be expected to co-operate. The few attempts at encouraging private industry to go into partnership wit public hospitals have not been a great success, he says.

Li Jiangge says private hospitals will only flourish when they are independent of the public system and have access to the same advantages such as medical insurance rebates and access to health data. Furthermore, he says private hospital development has been held back by lots of regulations that make them subject to local government control - including many "not-for-profit" rules. He says private companies should be allowed to do what they do best - make profits and take them away. The role of government should be to focus on "public health" matters such as disease control, vaccination and basic health services, he argues.

China healthcare headlines - June 2015

Beijing to ban smoking in public place 

Smoking will be banned in public areas of Beijing such as restaurants, offices and on public transport from 1 June, but enforcement is in doubt. According to the new anti-smoking rules, smokers will face
fines of 200 yuan ($32.25) for smoking near hospitals and schools, while business can be fined up to 10,000 yuan ($1,600) for failing to enforce no-smoking areas.

Doctor killer executed

The man who stabbed a doctor to death at a Wenling hospital in a dispute over  surgery outcomes has been executed in Zhejiang. The man called Lian Enqing murdered an ENT specialist in October 2014 because he was upset about the poor results of surgery on his nose.

Air pollution triggers hospital admissions

Hospital admissions for respiratory problems increase dramatically when air pollution PM2.5 particle levels exceed a threshold of 200 µg/m³ according to researchers from Shandong.

Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf

Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf

Private hospitals blocked by public hospital chief

Despite being encouraged by central, the development of private hospitals is being blocked by the all powerful managers of major public hospitals, according to an article in Caixin. Analysts say that public hospitals are effectively operating as for-profit monopoly providers and they are loathe to give up their staff or patients to private newcomers.

Health minister's book published by Elsevier

Former health minister Chen Zhu is having a book publichsed by international medical publisher Elsevier. The book entitled Healthy China 2020: Strategic Research Report, is an in-depth review of China's past present and futre healthcare developments, with contributions frm many leading healthcare figures.

China's hospital league tables published

A league table of China's best hospitals, ranked by department, has been published by the China National Medical Information Center. The ranking tables put hospitals in the three major cities of Beijing, Shanghai and Guangzhou at the top of most lists, according to criteria for 19 different specialities.

Are Chinese hospitals safe? Fear of blame and shame is common, but the overall safety climate is good

by MICHAEL WOODHEAD

China may not have as many ambulance-chasing lawyers as the US, but healthcare staff live in fear of making mistakes because of a culture of blame and shame. Not so much "Better Call Saul" as "Better Keep Quiet".

While in the west there is now an attempt to make healthcare staff be more open and transparent in reporting medical mistakes, it seems like China has a long way to go in overcoming cultural barriers to admitting to errors. In a survey of 1272 healthcare staff at Shanghai hospitals, researchers found that there was a high level of fear of being blamed and fear of being subject to shame. Almost three quarters of staff said they would be disciplined if found making a mistake and 42% thought that asking for help was a sign of incompetence. A similar proportion of staff - 42% - thought that telling others about mistakes was embarrassing, and 40% of thought that it was better to not report errors in the hope that nobody would notice the mistake.

Worryingly, work pressure was also a major factor in mistakes - and covering them up - with about 60% of staff saying that with higher workloads, management forced them to work faster and taking shortcuts that might negatively affect patient safety. About 40% of hospital staff said they had witnessed a coworker do something that appeared to be unsafe in patient care in the last year and one in three staff admitted they had done something that was unsafe for patient car.

The fear of blame and shame phenomenon appears to be an Asian and Chinese concept. The 40-70% levels of 'blame and shame' fears seen in the study were much higher than the 5% rates seen in U.S. hospitals. As the authors note:

"Chinese society tends to be more collective than the Western society, which is called “familial collectivism” People admitting mistakes do not only embarrass themselves but also embarrass the team. Thus, [healthcare] workers may be reluctant to admit to making mistakes in China."

Interestingly, doctors had the highest levels of  “fear of shame” and the researchers said this chimed with the finding that Chinese doctors do not believe that “human error is inevitable”,  - in other words, Chinese doctors feel they must act like gods and be seen to be infallible - whereas admitting a mistake would be a sign of incompetence. This is consistent with “fear of shame” being particularly high among physicians. The Confucian ethic was also seen in the high levels of fear about reporting mistakes made by more senior staff that endanger patient safety.

Nevertheless, the overall safety climate in hospitals was no worse than that seen in the US, with 15% of staff giving 'problematic' responses to safety questions. As the authors said, Chinese healthcare workers are only likely to report mistakes and safety issue when they feel psychologically safe and do not have to fear being blamed and shamed.

The findings are published in BioMed Central.

Alibaba Health, iKang, Online consultations, Tobacco advertising ban, Antibiotics in food, HIV discrimination

by MICHAEL WOODHEAD

Hello and welcome to another week of China Healthcare. As China makes headlines around the world for its slowing economy, few have remarked that China's entrepreneurs are taking a different and more rosy view by re-focusing on healthcare. This week the Alibaba internet billionaire Jack Ma has issued a $2.5 billion vote of confidence in the prospect for online pharmacy in China by transferring his pharmacy e-commerce section to Alibaba Health ("Ali Jiankan" or alijk.com).  According to the WSJ, "Alibaba said the deal would position it to sell prescription pharmaceuticals should China’s reforms allow retailers to move in that direction".

At the same time, Forbes has profiled another internet millionaire who has made his fortune by turning to health. Zhang Ligang made his first fortune by founding the travel booking site e-Long, but he is more famous for building a chain of private clinics under the banner iKang. And if China really does shift to a more private healthcare system, companies like iKang should be at the forefront of the wave.

The NHFPC has banned online medical diagnosis. In a statement this week the health ministry said medical consultations cannot be conducted online as there have been too many cases of unqualified people offering medical advice, purporting to be experts. The ban does not seem to apply to accredited hospitals that have approved programs. What this means for online doctor apps such as Spring Rain (www.chunyuyisheng.com) remains to be seen.

Children in China are exposed to a wide variety of antibiotics in food, which may promote resistance. A study in Shanghai that tested the urine of more than a 1000 children aged between 8 and 11 years of age found that as most had traces of at least one antibiotic and many had several antibiotics in their system.  Altogether 18 different antibiotics were found in the urine of Shanghai children, reflecting the high levels of antibiotics used in food production in China. This was confirmed by another report out this week which noted that the Chinese food and livestock industries use 100,000 tons of antibiotics  a year to promote growth in animals reared for their meat.

A total ban on tobacco advertising n China has been urged by the WHO. The head of the China office of WHO said China had a treaty obligation to phase out tobacco advertising, and should start to do so at retail points of sale. However, the powerful state-owned tobacco industry might baulk at that. The relative power of the health and tobacco industry was shown this week when health minister Li Bin noted that new graduates could earn twice as much in the tobacco industry compared to medical graduates working in hospitals. She made the point that the basic salary for a university graduate working in the tobacco industry was 4571 yuan a month compared to only 2100 yuan a month for a junior doctor. Li Bin said there was a need to learn from Adam Smith and pay the market rate for medical graduates - and this would mean patients being prepared to pay higher medical fees.

And finally the question arises of whether anti-HIV discrimination still exists in the China's hospitals. A patient at the Sichuan University Huaxi Hospital says he was refused surgery when doctors discovered his HIV positive status. The man said he had been scheduled to have surgery for haemangioma but it was cancelled and he was told that he would instead be kept 'under observation' instead. The hospital rejected the discrimination claim, saying that it was standard practice to keep patients under observation before going ahead with surgery for this condition.

Private health insurance in China: expansion blocked by hospitals

One of the key elements of the Chinese government's health reforms is to increase the role of private health. One way in which they are doing this is to encourage Chinese citizens to take out private health insurance to supplement the meagre coverage provided by government. The government is expected to offer policy support - including tax breaks - to encourage commercial health insurance providers such as PICC. However, according to Caixin, the growth of private health insurance is being stymied by the entrenched power of state-owned hospitals. Insurers are unable to offer a viable insurance product when they have no control over hospital costs or procedures - in other words, insurer-dictated managed care is essential for health insurance to make a profit. In addition, insurers need access to data and social security system figures if they are to manage their risks adequately - and they have been denied access to this information by local governments who fear losing control over their social security arrangements. Some Chinese health insurers have tried to partner with foreign insurers to build on their experience and technical know-how, but a joint venture between China Pacific Insurance Group C. (CPIC) and Germany's Allianz SE in Shanghai collapsed after less than a year when the European partners found that the insurer had no sway over hospitals.
We have already heard how doctors are unwilling to work in the private sector  - despite official encouragement - because they fear being 'excommunicated' by their main employers, the all-powerful state hospital system. The entrenched power of the big hospitals also appears to be another major barrier to any evolution towards private provision of healthcare in China.

Military hospitals in China: unaccountable and a law to themselves

by Michael Woodhead
It comes as a surprise to many visitors to China to discover that the swish medical facility in the middle of town is called something like the People's Liberation Army 301 Hospital. 

Military hospitals are a major feature of China's healthcare system - most cities have a major hospital run by the military, whether it be the army, navy or airforce. But don't expect to see them staffed by China's answer to Hawkeye or Major Burns. They are, for all intents and purposes, little different to other hospitals in appearance. No uniforms in evidence, they seem to be just state-owned profit-driven operations, like any other Chinese hospital.

However, according to an article by Zhao Han in Caixin this week, the military hospitals are a law unto themselves. The reporter relates the case of a bogus doctor working in Beijing who stole the identity of a real Shanghai doctor. When the Shanghai doctor discovered this, she demanded that the fake doctor return her identity documents and records. However, when reporters made further inquiries, they hit a brick wall of military secrecy because the fake doctor had been working at a clinic affiliated with the military PLA 466 Hospital.

When the matter was taken up with the authorities, they also got short shrift from the army hospital:

"The health bureau that oversees medical facilities in Haidian District, where Beijing No. 466 Hospital is located, said it does not have the authority to supervise military-affiliated hospitals.
Calls to the health division of the People's Liberation Army's General Logistics Department were not answered," Caixin reports.

This case illustrates a common observation about military hospitals in China - they are effectively beyond the control of the health department. What this means for China's health reforms - and the supposed development of private hospitals in the country - remains to be seen.How will the military react to the unpopular proposals to deregulate hospitals and reduce  profit-linked overservicing practices? Will they also support the move to primary care by allowing doctors to work in the community and accepting new referral networks (and thus losing revenue?) I doubt it.

And as we have recently seen with illegal organ transplantation, the military hospitals network is also protected from action against unethical practices. How the military hospitals are treated will be a true test of whether Xi Jinping is serious about health reforms and rule of law in China.

Research fraud and inappropriate treatment: my blog about medical news from China for Sunday 15 February.

Last week I blogged about how so many medical journal articles in China are simply "vanity publications", written by ghostwriters to satisfy the doctor's need to achieve a quota of published articles. However, this week we see that there are also major problems with 'serious' research clinical trials carried out in China. An article in JAMA this week by Charles Seife reveals that the FDA found serious problems with the Chinese clinical trials of apixaban, a novel anticoagulant.
 At one site the FDA concluded that patient records had been altered. When they investigated further the FDA inspectors declared that data from 23 other Chinese clinical trial sites was suspect and should be excluded from their evaluation of apixaban (Eliquis). We often hear that western pharma companies are shifting their R&D from the US and Europe to China. It may be cheaper but with reports like this you have to wonder if it is worth it in the long run.

China is also trying to make a name for itself in high tech areas such as stem cell transplantation. An announcement in the Shanghai media said the city was to build the world's largest hospital for 'blood diseases'. This seems to be a reference to  hematopoietic stem cell transplant procedures for patients with blood diseases such as leukaemia. This is a highly specialised and expensive form of treatment for a small niche of patients (and often of limited benefit), so it is odd that a city that can't even meet demand in its emergency departments  is pushing ahead with a hospital for rare diseases. perhaps the explanation is that the project is being run by the China Stem Cell Group Co Ltd. This may be more about making profits than providing needed health facilities.

China's love of high tech for its own sake is  also manifest in the move by a Guangdong hospital to set up 1000 telehealth stations in pharmacies to provide online consults. The move by the Second People's Hospital of Guangdong to set up the Guangdong Online Hospital will reportedly include 200 doctors providing services via videolink. All sounds very modern, but how exactly does a doctor do a physical exam, order tests and imaging and provide 'hands on' care over a video link? It might be of limited value in follow up counselling consultations and for repeat prescriptions, but it sounds like a gimmick to me.

Online hospitals are supposed to help address the problem of overcrowded hospitals. I'm not sure how they will help the cancer patients who need a bed but can't get one. In places such as Changsha in Hunan the hospital bed shortages are so acute that patients have to make do with 'cancer hotels' instead. Patients with cancer who require treatment but who are on the waiting list pay 1100 yuan a month to stay in hotels adjacent to the cancer hospitals so they can go into outpatients for treatment. Locals say that about half the hotels near the hospital are occupied by patients, who face 1-2 month waits for a bed.

Breast cancer is an increasing concern in China, but rates are still not as high as in the west, perhaps due to dietary and lifestyle factors. Screening for breast cancer is also not part of the Chinese health system, although there has been some use of mammography. However ultrasound has been favoured by some Chinese clinicians, reportedly because it is more suitable to the smaller and more dense breast tissue of Chinese women. Now a study has confirmed that ultrasound is a more effective screening method for breast cancer in Chinese women. A study of more than 12,500 women who underwent either or both found that of the 30 cancers detected, five were in the mammography group and 11 in the ultrasound group, and 14  in the combined group. Ultrasound was more sensitive had the same specificity and positive predictive value as mammography. It was also considerably cheaper, costing $7876 to detect one cancer compared to $45 253 for mammography.

In other clinical news, metabolic syndrome (a highly dangerous combination of abnormal cholesterol, high blood pressure and pre-diabetes) was found to occur in 27% of Chinese people. A study of 15,477people in NE China found that 28% of men and 26% of women had metabolic syndrome. The condition was more common in Chinese on high incomes, those who ate more rice and those who did less physical activity - in other words, 'to get rich is glorious' but it also comes at a price of this disease of affluence. 

However, Chinese people might be forgiven for thinking twice about going for a jog, given the terrible air pollution in many cities. This has now been confirmed by Dr Liu Yu of the Key Laboratory of Exercise and Health Sciences at Shanghai University of Sport. This week he published an article in the BMJ which warned that the harms of ambient air pollution on the cardiovascular and respiratory systems might outweigh the benefits of exercise. He estimated that air pollution probably caused more than a thousand deaths a year in the city.

It's not all bad news from China, though. A paper published by the WHO this week shows that Chinese healthcare workers have had great success in reducing deaths from HIV using a simple 50c antibiotic, co-trimoxazole. Their study showed that giving the antibiotic at the same time as antiretroviral reduced HIV deaths by 37% - a staggering achievement. If routinely use in China for HIV patients  this could save thousands of lives among HIV positive people, the researchers sai.d Unfortunately, however, antibiotic use if often missed in this patient group.