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.

Gaokao madness: hospital works overnight to do myopia surgery to help kids meet college entrance criteria

by Michael Woodhead
As if the phenomenal pressure of the gaokao ((高考) college exams was not enough, students in Liaoning are also putting themselves through last minute laser eye surgery to meet college eyesight entrance criteria.
A report from Dalien describes the plight of students wanting to get into the city's law schools, which are run by the PSB and lay down strict criteria on having good eyesight. After several days of exams, students than had 48 hours in which to undergo surgery before having an eye exam to assess their vision. Explaining the last minute rush, families said they were unaware of the college entrance criteria or were not willing to have their children undergo eye surgery while preparing for the all important gaokao exams. However, on learning that perfect eyesight was a requirement for entrance, many students went straight from their final exam to the eye clinic to have corrective eye surgery. One clinic in Dalian reported staying open all night and having eye surgeons on overtime into the early hours to perform a string of last minute operations on desperate students. A surgeon reassured parents that it usually took only 8-12 hours to recuperate from laser eye surgery, and their children should have perfect eyesight in time for taking their eye exam in nearby Jinzhou 48 hours later.

News in brief: clinical studies from China

Measles is now rare in Guangzhou thanks to vaccination, but complete eradication will require vaccination of transient populations who now account for more than half of cases.

People who have a heart attack in China delay going to hospital for more than two hours, often because they don’t recognise the symptoms or their importance.

Chinese people consume dangerously high amounts of salt, with a Yantai study showing that 97% of men and 87% of women had intakes of over 6 g salt per day (mostly from added salt and soy sauce). Salt intake was related to high systolic blood pressure.

More than one in four new mothers in Guangzhou experience post-partum depression.

Compulsory routine infant vaccination with pneumococcal conjugate heptavalent vaccine would reduce pneumococcal disease in China by at least 32%, would prevent 2,682 deaths in the first five years of life and would save $1,190 million.

In rural China epilepsy goes untreated or undertreated in two out of three people with the condition, a Sichuan study has found. One third of people with epilepsy did not know about the disease and had not sought medical help.

The cultural pressure for gay men in China to marry means that their wives face a high risk of HIV and syphilis, researchers from Ningbo say. They found that only one in four gay men always used condoms with their wives, which explained HIV rates of more than 8% in women married to gay men.

Low vitamin A levels are linked to eye cysts (chalazia) in south west China

Weather has an important influence on measles transmission in China, with infection more likely after cold spells and during dry weather.

Telescreening reveals high rate of eye disease in Chinese people with type 2 diabetes

A telescreening programme in Shenyanhg has shown there is a high prevalence of fundus pathology among patients with type 2 diabetes, and in most of the cases, this was newly detected.
In a study involving 528 patients with type 2 diabetes mellitus from Fengyutaun in Shenyang, researchers from the Department of Ophthalmology, The First Hospital of China Medical University, Shenyang used telescreening to look for signs of any diabetic retinopathy, signs of glaucoma and signs of age-related macular degeneration (AMD).
The main ocular fundus pathologies were diabetic retinopathy,  (14%), of which 87% cases were newly detected, AMD was detected in 11% of patients and glaucoma in 12%. The risk factors for fundus pathology were long duration of diabetes,  higher fasting plasma glucose and glycated haemoglobin (HbA1c) levels.
"Community screening for fundus pathology among patients with a long duration of type 2 diabetes and high fasting plasma glucose and HbA1c levels using a telescreening model will provide an effective strategy for the prevention and treatment of fundus pathology," the study authors concluded.
Read the full study at: BMJ Open

Room for improvement on cataract surgery

Rural Chinese hospitals could increase their cataract surgical output and quality but health managers are a major barrier to change, new research shows.
A survey of attitudes to improving cataract surgery posed questions to hospital administrators, doctors, and nurses at 28 county hospitals in Guangdong Province. It found that all groups identified a critical need for enhanced management training for hospital directors.
Doctors and nurses suggested reducing surgical fees to enhance uptake of cataract surgery , though administrators were resistant to this. While doctors saw the need to improve equipment, administrators felt current material conditions were adequate. The hospital staff surveyed believed that patient satisfaction was generally high, but this finding was in contrast with other studies in the area, highlighting a potential area for intervention, the researchers say.
Source: Investigative Ophthalmology

Half a million Chinese are blind due to diabetic retinopathy

The prevalence of visual impairment due to diabetic retinopathy in Beijing residents was 0.25%

by Michael Woodhead
More than half a million older Chinese people have lost their sight due to diabetic retinopathy, a major study carried out by Beijing researchers has found.
Dr Qi You and colleagues from the Beijing Institute of Ophthalmology, Beijing Tongren Hospital screened a population of more than half a million rural residents near Beijing who were aged over 55. The study involved over 2500 ophthalmology technicians who carried out visual screening checks for retinopathy.
Of the  562,788 people screened, 54,155 (9.6%) had a visual acuity of <0.30 in at least one eye.
The most common cause of vision impairment was cataract, which was seen in 19,163 (3.4%) of people. Diabetic retinopathy was detected in 2.7% of the population screened. Visual impairment due to diabetic retinopathy was bilateral in 66% of these patients.
The prevalence of visual impairment associated with diabetic retinopathy was 0.25%, which is similar to the results of the previous Beijing Eye Study, in which 0.54% of people screened showed
severe non-proliferative or proliferative diabetic retinopathy.
"Transferred to the total population of China of 206 million subjects aged 55-85 years, it
indicates that 514,000 Chinese in that age group are blind due to diabetic retinopathy," they conclude.
Source: Clinical and Experimental Ophthalmology