Sunday, 15 May 2016

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.

Sunday, 8 May 2016

After the vaccine scandal, now a cancer treatment scandal

Wei Zexi's parents
by MICHAEL WOODHEAD

For someone ostensibly responsible for healthcare, China's health minister Li Bin is keeping a very low profile throughout a string of healthcare scandals. She was invisible during the recent scandal over 2 million doses of out-of-date vaccines that were widely distributed by dodgy wholesalers. Now she is also missing in action during the national uproar over the death of a 21-year old cancer patient Wei Zexi, who was duped into having an expensive and unproven cancer treatment at Beijing's Armed Police Corps Second Hospital.

As has already been widely reported, the hapless Wei found the hospital through its paid search results coming top in the search engine Baidu. Much of the commentary so far has been around the responsibility (or lack thereof) of Baidu and its dependence on shonky medical clinics for much of its paid search advertising revenue. There has also been a lot of adverse commentary about the role of the Putian network of private hospitals. As has been mentioned several times before on this blog, the Putian 'network' is a loose association of entrepreneurial clinics and hospitals offering healthcare services on the fringe of mainstream medicine - they specialise in 'monetiseable' services such as cosmetic surgery and fertility clinics. It therefore comes as little surprise to find they are implicated in the latest scandal.

With a synovial sarcoma, Wei Zexi is said to have paid 200,000 RMB (about US$30,000) for a novel "biological immunotherapy" treatment from the Putian-affiliated oncology unit at the Beijing Armed Police Corps Second Hospital. As a medical journalist who has been reporting on oncology for more than a decade I have to say I had never heard of the so called "DC-CIK immunotherapy" offered by the hospital. I did a bit of googling (not Baidu-ing) and looking through the peer-reviewed literature, and it soon became apparent that this is an experimental therapy that sounds impressively technical but has virtually no evidence or clinical trials to support its use.

The Beijing clinic claimed that the DC-CIK technique had been invented by Stanford university in California, but it didn't take Chinese reporters long to discover that the procedure is not being used at many reputable hospitals or institution in the US. A phone call to the developer of the technique at Stanford revealed that it is being used as an adjunctive (back up) treatment for some rare kinds of myeloproliferative diseases, but it is not a mainstream therapy. DC-CIK has also been reported in the Chinese/Hong Kong media as being used as a pseudoscientific and discredited cosmetic treatment.

So what is DC-CIK immunotherapy? It stands for "Dendritic Cells and Cytokine-Induced Killer" cell immunotherapy. Dendritic cells (DC) are basically part of the body's defence system against tumour cells - they present the antigen and activate the defensive T lymphocytes that kill tumor cells. Cytokine-induced killer cells (CIK),are the body's way of killing tumour cells - but they are non specific and need guidance to recognise the tumour cell as different from a healthy cells. In theory the coupling of these two systems should create the perfect tumour fighting team. But in practice... well, look at the fate of poor Wei Zexi. There have been no clinical trials of DC-CIK, so its use is essentially just guesswork.

Putian affiliate Chen Xinxian
Meanwhile back in the murky world of Putian clinics the journalists at Caixin have been doing some detective work and found that the dodgy hospital that milked Wei Zexi out of $30,000 for a useless pseudoscientific treatment is linked to a well known Putian duo called Chen Xinxian and Chen Xinxi and their company Shanghai Kangxin Hospital Investment Inc. Matching up business and internet records, Caixin found that the Chen brothers were involved in the running of 134 military hospitals around China. The PLA has basically subcontracted out its clinics to the Chen company

Caixin went further and tracked down about 20 other hospitals that are offering the DC-CIK procedure. When contacted by Caixin, many of the hospitals denied it or refused to comment, but Caixin found evidence that they were offering DC-CIK in the form of adverts and recruitment ads that sought staff to offer the treatment.

We thus have a situation in which many Chinese hospitals are exploiting cancer patients by charging them hundreds of thousands of RMB for unproven and dangerous treatments. Many of these hospitals are linked to the military and are thus out of the usual health department jurisdiction. It's notable, then, that this week has seen the Chinese central government declaring that the PLA will have to completely divest itself of commercial ventures such as its hospitals.

In the meantime, it's worth asking how - within a month of the vaccine scandal - China again find itself with having to address a major and widespread breakdown in the quality of its healthcare services. In a developed society such as Australia or Hong Kong, shonky medical practices are kept at bay by a series of checks and balances. Why would the DC-CIK scandal not have panned out in these societies?

1. If a clinic in Sydney or Hong Kong started advertising and offering DC-CIK to cancer patients, it would quickly come to the attention of the media, possibly by whistleblowers. Lack of press freedom in China - and fear of retribution against whistleblowers - means that this check is weak or missing.

2. Medical practitioners in developed countries also face scrutiny from their peers in the form of medical boards and general 'collegiate' links that make it clear what is accepted practice and what is not. An oncologist in Hong Kong or Sydney would be guided by professional guidelines on 'best practice' - and the use of DC-CIK would certainly not be construed as acceptable practice by a reasonable practitioner. The doctor would first warned by his peers and then brought before the medical board and struck off if he/she offered shonky treatments such as DC-CIK. This is obviously not happening in China, despite reports that the clinicians offering DC-CIK are retired or part time senior doctors.

3. There is obviously a problem with clinical governance in China - it is not identifying and addressing bad practice. In developed countries, bad doctors are also kept at bay by a mix of accreditation - having to meet defined professional standards - and also the threat of medicolegal action. This basically means that a doctor or clinic in Sydney or Hong Kong that offered a dodgy treatment like DC-CIK would have its ass sued off - and face a big compensation payout. But in China the jails are now full of lawyers who made the mistake of standing up for the rule of law.

4. And of course dodgy medical therapies are also kept at bay by advertising standards. If Google or a media outlet pushed a dodgy treatment like DC-CIK they would be prosecuted and fined for  deceptive advertising - or for promoting therapeutic claims that are not backed up by evidence. In China, however, Baidu is quick to censor words such as Dalai Lama, but is is given official blessing to rake in millions from advertising dodgy Putian clinics.

One final comment on the whole Wei Zexi/Putian/Baidu saga: it's worth noting that the President Xi Jinping is a former governor of Fujian and has close links to the region that includes Putian. He has gone on record as saying he considers the area his second home. Do the dodgy operators of Putian hospitals gain some degree of patronage and protection from their former provincial boss?

UPDATE: 14/5/2016

A search of PubMed shows there are virtually no clinical trials of DC-CIK published in major peer reviewed journals outside of China. Virtually all the studies are from Chinese centres and they are published in obscure Chinese-language publications. That's not to say there aren't any studies worth looking at. However, even one of the most reputable studies I was able to find showed only  a minimal effect of DC-CIK on cancer outcomes: in a two year study in lung cancer patients, the mortality difference at two years was 5%. In other words only one in 20 patients would still be alive as a result of treatment after two years. Put another way, for every 100 patients treated with DC-CIK, after two years 75 would be alive, whereas 70 would be alive if they received standard chemotherapy. Did the doctors treating Wei Zexi tell him that 19/20 patients would get no benefit for their 300,000 RMB?

Monday, 2 May 2016

A tale of medical murder and extortion


by MICHAEL WOODHEAD
It sounds like the plot of a TV detective thriller but this is real life. A 41-year old man is brought by a friend into a Chengdu hospital suffering from diarrhoea. They both appear to be respectable middle class citizens. The illness is not serious, and the man is treated in the usual way for acute gastroenteritis. He is given intravenous antibiotics including clindamycin, and usually his symptoms would be expected to resolve within 24 hours. 

However, an hour after the antibiotics have been given, the man loses consciousness, turns blue and dies. All attempts to resuscitate him by hospital staff fail. He appears to have died from cardiac arrest. The victim's companion becomes indignant, agitated and blames the hospital staff for negligence. He says the clindamycin may have triggered the cardiac arrest and should not have been used. He demands compensation otherwise he will commence an expensive lawsuit against the hospital for damages.

At this point some of the medical staff find something suspicious about the behaviour of the 'respectable' man, his certain knowledge knowledge of clindamycin's rare side effects, and advise that the body undergo an autopsy. The victim's friend becomes more agitated at this suggestion, but the body is taken away for examination.

A detailed physical examination reveals a small puncture in the back of the victim's left hand. This was the intravenous line where a catheter had been inserted to give the antibiotics. To rule out the possibility that a nurse had given the wrong drug, the pathologist orders tests run on the victim's blood sample, and these come back with surprising results. The victim appears to have been sedated and anaesthetised, because the blood contains high levels of propofol - the anesthetic that killed Michael Jackson. It also contains the sedative midazolam and the muscle relaxant vercuronium. Combined, these three drugs would be sufficient to cause rapid respiratory failure and cardiac arrest. That's why they are used to execute prisoners in the US.

The victim's friend was apprehended and questioned by police and the true story emerged.
He confessed to secretly added mannitol - a liquid laxative - to the victim's drink, which caused diarrhea. Next, the man brought his apparently sick friend to the hospital for treatment. When the victim fell asleep and no other people were present, the man injected 10 mg of midazolam into the victim's vein through the path established for fluid infusion. Next, the companion twice injected 200 mg of propofol and 4 mg of vecuronium into the victim's vein. A few minutes later, the victim's breath and heartbeat stopped.

The perpetrator was revealed a surgeon with four years' experience who had gained access to the drugs from a former colleague at the hospital. He would have got away with the crime - and perhaps received a large sum in compensation if his behaviour had not raised suspicions of the vigilant medical staff.

This case is reported in the Journal of Forensic Sciences by Dr Ye Yi and colleagues of the Department of Forensic Analytical Toxicology, West China School of Basic Science and Forensic Medicine, Sichuan University, Chengdu. The fate of the perpetrator is not given, but it can be presumed he was tried for homicide - and if found guilty, received the death penalty.

Monday, 25 April 2016

"Three Lows and One Missing" - Is China on target to deploy 700,000 general practitioners? (short answer: no)

by MICHAEL WOODHEAD

Being a medical journalist in Australia, I've come across a few academics and leaders of medical groups who have marvelled at China's stated aim to deploy an additional half a million general practitioners by 2020. In a country where there are 25,000 general practitioners, the numbers are mind boggling and the ambitious target seems laudable. When I say that this may be an unrealistic goal given the current paltry state of primary/community care in China, I am viewed as a something of an overly-negative cynic or even vaguely racist.

It's therefore reassuring to see that my expectations are in line with those of the president of the China Medical Doctor Association, Dr Zhang Yanling. This month the CMDA chief was one of several big potatoes who showed up at the "2016 GP Training Forum and 13th Community Health and General Practice Annual Conference" held in Beijing on 23 April

The main speaker at the meeting was National Health and Family Planning Commission (NHFPC) Deputy Director Liu Qian, who said that creating a primary care system was one of the key aims of China's healthcare reforms. He said the creation of a primary care workforce was seen as an important step by top leaders such as Xi Jinping and Li Keqiang, who sent a message to the conference to make serious efforts to implement the policy.

Director Liu made the usual top bureaucrat exhortations to strengthen/promote/deepen reform of the medical education system to make this so. However, even he was realistic enough to admit that of the current 120,000 medical trainees only 13,000 (about 10%) were training as general practitioners and some of them may be hospital based rather than in community clinics).

He also acknowledged that China's entrenched doctor system was geared towards hospital-based specialists and that there was only weak support for general practitioners. There is no culture of primary care in China and this is reflected in the lack of training opportunities, low social status of community doctors "and the trust of the masses of trust is not high". Unsurprisingly, therefore, being a general practitioner is not a very attractive career option for any would-be doctor.

Director Liu then went on to make more of the usual remarks about strengthening the education system to train more general practitioners and making more efforts in this direction  etc etc

He was followed by Dr Zhang Yanling of the CMDA , who expanded on what the director said by coining the phrase the "Three Lows and One Missing". General practitioners suffer from "Low Pay, Low Motivation, Low Social Status and Missing Education" said Dr Zhang.

He said that in words, China's authorities had expressed strong support for the WHO-expounded principle of primary care and having general practitioners as gatekeepers to the hospital healthcare system. However in practice, general practice was weak, underdeveloped and had only patchy distribution across the country, he noted. While there are some general practitioners in bigger cities and in some regional hospitals, the biggest gap for primary care was in township and smaller county hospitals which were often both understaffed and underused. Dr Zhang used the Chinese saying "Swallows sitting in the doorway" to express the deserted state of China's township hospitals - because patients do not trust the doctors and take their illnesses straight to the bigger hospital "centres of expertise".

Dr Zhang said three things are needed to build a primary care system in China:

1. A commitment to build a large and sustainable primary care workforce based on teams of well trained general practitioners who are well remunerated and have a graded career pathway, similar to hospital doctors, rather than being in a dead end job.

2. A robust training system that ensures the primary care workforce is motivated and highly skilled - including the retraining and upskilling of allied health practitioners and physician assistants to make a primary acre team. Dr Zhang said the current projections were that China should have 1 GP for every 2000 citizens, which would require 700,000 primary care practitioners by 2020. However, based on current training capacity of 172,000 doctors and doctor assistants, there would still be a shortfall of 400-500,000 general practitioners by 2020.

3. Training pathways including residencies will need a partnership between government departments of health and education along with medical professional groups such as the CMDA. Working together they will need to establish a GP training group with well qualified educators that can set standards, plan training place numbers and oversee assessment and accreditation.

Dr Zhang concludes that a general practitioner primary care system is possible so long as there is good policy, clear commitment from government and cooperation from government departments, industry, the profession and good guidance from academics.

The two day conference also heard from a host of academics and experts in primary care from China, Hong Kong and and foreign countries such as Canada and Australia.

We wait in hope to see if the fine words of the conference delegates are actually matched with government funding and backed by policy that is actually implemented.


Sunday, 17 April 2016

Heathcare privatisation: China adopts the US model

by MICHAEL WOODHEAD

Prepare for the Mayo Clinic with Chinese Characteristics. This year China is taking the first steps towards creating the equivalent of US group medical practices such as Permanente and the Cleveland Clinic.

The so-called "Doctor Groups" (Yisheng Jituan, 医生集团) are springing up around the country -  mostly in major cities of the affluent Eastern provinces. They are being set up in response to the loosening of the government's rules on how and where doctors can operate - clinicians are no longer tied to the tertiary hospitals and are now being encouraged to be 'fluid' and 'open'. In response, at least fifteen doctor groups have been set up in 2015 and 2016, usually based around one location and with one specialty.

These are not socialist collectives nor are they not-for-profit groups. Instead they are privately financed businesses that are being set up with large investments from major industrial players such as pharmaceutical companies. These are groups that are seeking profits and market share as a return for their investment. Not sure how PRC's Marxist theorists will explain this away.

A typical example is the Yibai Pharmaceutical Anhui Oncology Group. This covers ten leading cancer specialists and their staff, as well as specialist treatment facilities in the Anhui and Shanghai area - services that include diagnostic imaging, radiotherapy, microsurgery and chemotherapy. The pharmaceutical backer has invested hundreds of millions of dollars already and is hoping to use its industry experience and connections to package other services such as pharmacy, supply chain and IT services. According to an investment analyst, the Yibai group is hoping to make 500 million RMB profits within two years.

Yibai is just one example: others include the Medical Imaging Group - an alliance of imaging facilities covering 27 hospitals including the Beijing Union Medical College Hospital, and Beijing PLA General Hospital.

Another doctor group is United Lige, which has a looser structure covering many cities and provinces including Beijing, Tianjin, Shanghai, Chongqing, Jiangsu and Zhejiang. It aims to bring smaller groups of doctors together in private clinics under the Lige banner.

Others Doctor Groups include
  • Sanjia (Mobile phone referral, liaison etc services)
  • Mingyi Hui (a multi-speciaity consortium that aims to offer family care from children to the elderly, with an online/telehealth emphasis)
  • Song Dong Lei Neurosurgery Group (Shanghai)
  • Pumai Doctors Group (collaboration with Chow Tai Fook to set up polyclinics in Shanghai)
  • Yongchun Male PLastic Surgery Group ( Shanghai Woxin Hospital)
  • Fenlan/Huaxia Pathology Group (Set up with more than 120 pathologists in conjunction with the China Medical Association Pathology Society, this group has received 30 million investment and will provide specialist pathology services via a network of 60 hospitals).
  • Famous Doctor Fertility Group (Shenzhen based, set up by veteran Obstetrics and Gynaecology specialist Gong Xiaoming)
Most of the private doctor groups are financed by domestic companies, many with little healthcare experience. But rather than doing joint ventures with western healthcare companies to get foreign know-how, Chinese newcomers to private healthcare are simply buying up foreign healthcare providers. The Luye Medical Group recently bought the Australian private hospital consortium Healthe Care for $938 million. Luye's Charles Wang says the new doctor groups aiming to do business outside the big hospital environment lack operational expertise, and they are hoping to transfer such skills from the Australian outfit to the Chinese market.

This is what he told the Australian Financial Review:

"When things change in China, they tend to happen very fast. Doctors and practitioners forming their own doctor groups is something that never would have happened until last year. They are now leaving the public sector and forming their own groups, and once that gains momentum, you will see it rapidly become more westernised."

According to the AFR, the idea is not to parachute Australian executives into China, but to export the way Australians manage their hospitals, including finances, procurement, risk and clinical control.

"I expect you'll see, in time, structured medical programs, and we'll go up to China and do training and bring middle managers down here in Australia. In clinical areas there will be doctor mentoring and nursing programs,"  says Healthe Care's CEO Steve Atkins.

My own view is that it will take a lot to break up the power of the big hospitals. There are a lot of vested interests involved. The move to private doctor groups also raises the question of what impact this will have on the capacity of the existing public hospital system. If the most talented doctors can work outside the system, who will replace them? If top surgeons take two-three days a week doing private work, who will fill their positions in the public hospitals for clinical work and training?

There are many unknowns, but with official backing from the health minister and the Premier, expect to hear a lot more about Doctor Groups from 2016 onwards.

Tuesday, 12 April 2016

Health ministry gets serious about promoting TCM


by MICHAEL WOODHEAD
If you have depression take a herbal infusion of daylily. If you have avian flu, use a few capsules of anti-cold Chinese herbs. These are just as effective and much cheaper than using western pharmaceuticals. That's the official advice from the National Health and Family Planning Commission this week.

At a press briefing organised in Beijing, the ministry's propaganda chief Mao Qun'an said that it was important to look at the public health advantages of using Traditional Chinese Medicine for fighting and reducing the burden of disease, as demonstrated by officials from Gansu province. He said the TCM promotion efforts of Gansu's health department were the "correct direction" and should be a model that other provinces can learn from.

He introduced TCM advocate Liu Weizhong from Gansu, who described how daylily was being sold by the ton in Gansu for the treatment of depression.

"Gansu is a poor province but we have harnessed the power of herbs such as daylily as a low cost way to manage disease in the population," he said.

"When Gannan Tibetan country has landslides many of the local people suffered from insomnia, anxiety and depression. We put two tons of day lily in 12 cauldrons, gave every person a paper cup and treated 7000 people at a cost of 1.4 yuan each. The depression was all gone," he said.

[A quick google search shows that daylily aka Hemerocallis is a traditional herbal remedy that contains active ingredients including clonidine - a drug for hypertension that can cause neurospychiatric effects].

Likewise Liu Weizhong claimed that avian flu, which caused many deaths and serious complications in China, could be easily and successfully treated with just three or four capsules of a Gansu TCM remedy that cost less than 200 yuan. This was much better than the regular medical treatment for avian flu that cost ten times as much, he said.

Another TCM panacea was the health prevention kit issued to households which consisted of a bag of salt, scrapers, plates, cupping utensils and a thermometer.

Liu Wenzhong said farmers were told to boil some fennel and pepper leaf and use this with the equipment as a cure for 13 kinds of disease, including cervical spondylosis, thyroid nodules, cough, pharyngitis, lumbar disc prolapse, frozen shoulder, arthritis, stomach pains, and especially senile prostatic hypertrophy.

These folk remedies might sound like old wives' tales. but they have the official backing of the State Council as well as the National Health and Family Planning Commission.

In February the State Council issued a "strategic plan for development of Chinese medicine," which said that with the ageing population "there is an urgent need to develop and make good use of Chinese medicine".

The NHFPC agreed, saying that Gansu was leading the way in developing TCM and putting it at the centre of healthcare.

Sunday, 3 April 2016

Three vastly different articles on medical disputes - which one gets closest to the truth?


by MICHAEL WOODHEAD
Violent and disruptive medical disputes have become so common in China that they barely rate a mention in the media any more. There has to be something quite different about an attack on doctors for it to make the headlines these days. The recent incident in which a mob of disgruntled relatives of a former patient took over a Shenzhen hospital and forced doctors to kowtow to a 'shrine' was one such incident.

In response, the Chinese authorities have said they will now adopt a new zero-tolerance approach to such protests and attacks on healthcare staff.

"Vice Public Security Minister Huang Ming said police will crack down on hospital-related crimes and show zero tolerance to perpetrators who assault and injure medical personnel. He made the remarks at a meeting on safeguarding order at hospitals and promoting harmonious doctor-patient relations on Thursday."

Ho hum - we've heard it all before. Every time there is a violent attack on hospital staff there are pledges to crack down, strike hard etc etc. A few weeks later it is business as usual. As I've written on this blog before, nothing will change until the government addresses underlying reasons for these disputes: under-resourcing of hospitals leading to ridiculously high throughput of patients - 3 minute consultations in which patients are barely listened to and prescribed the most expensive treatments (so that the hospital can get a bigger profit).

According to the latest empty promise to 'take action' the minister Huang "ordered better settlement of medical disputes by taking precautions, conducting risk assessment and spotting and containing disputes at an early stage." Gee thanks.

The article also makes the implausible claim that the number of hospital-related cases of violence continued has fallen four years in a row, and is down 12.7 percent year on year. The reality is quite the opposite.

And while on the subject of propaganda, the Hong Kong based SCMP, always keen to peddle a  more palatable version of Beijing's policies to foreigners, this week has an interview with a doctor who believes the answer to medical disputes is in looking to China's history. In a Q&A article, journalist Zhuang Ping throws a few easy questions to Dr Yang Zhen, a surgeon and deputy chief of the hospital administration office in Shanghai’s Zhongshan Hospital.

Dr Yang says China should take a look at how doctors in China traditionally established good relations with patients. Other than a few glib statements about being nice to patients and showing a more human face, he doesn't explain how doctors will make this happen when they have to rush through 80-120 patients in one short shift ( and prescribe enough drugs to them to hit their salary bonus target). All pretty worthy sounding but meaningless, really.

The article with the greatest insight into China's medical disputes in published in an academic journal (Health Economics, Policy and Law) and is based on interviews with 12 doctors from a multitude of specialties working in Shenzhen.

Interestingly, the article starts off by directly contradicting the claims of the public security minister,  quoting figures from the China Hospital Association showing that the number of medical disputes has increased by about 20% a year.

"Once worshiped as ‘angels in white,’ members of the medical profession in China are facing unprecedented challenges. Due to the deteriorated public trust during the marketisation reforms of the last three decades, Chinese physicians are working in an antagonistic environment. Heavy workload, low remuneration, and tainted social prestige have left millions of physicians feeling undervalued and
made medicine a career to be avoided, a situation rarely seen in other Confucian societies," it notes.

The article makes several points about medical disputes that have been raised before - but also includes one new one that is unique and potentially game changing.

The authors say that whatever the causes, medical disputes are rarely settled through legal channels, despite there being an officially recommended dispute resolution pathway and laws that in theory should cover medicolegal areas of dispute. The reality is that patients and their families have found that they are much more likely to get results - and get them much faster - if they take matters into their own hands. In other words, mob rule. According to the article, aggrieved patients and relatives of those affected by medical misadventure have found that they can get financial compensation and see their grievances gain attention if they take violent and disruptive action against hospitals and their staff. In practice this means staging demonstrations, blockading departments - and even whole hospitals - and threatening staff. They do it because it works.

This is the testimony of one of the doctors interviewed:

"Because the macro political environment attaches paramount importance to the so-called
‘maintenance of social stability,’ hospital managers are very afraid of high-profile incidents because local government may blame them for failing to mitigate the tension. If payment can quench patients’ anger, hospital managers would certainly love to do that, even when the patients are obviously blackmailing them. Patients also know the hospitals’ mentality very well, and actually take advantage of it. Some have chosen to stage farcical protests because doing so best maximized their interests. In fact, they deliberately avoided legal resolution because they knew hospitals would satisfy their monetary demands anyway."

The article goes on to say that hospitals fear high-profile protests because of the detrimental impact on their reputation, (which would inevitably affect their income) and also the political mandate imposed by local government to avoid mass incidents.

"They are also generally reluctant to resort to legal channels as litigation will not only ruin their reputation, but also consume a great deal of energy and time. Many studies have identified private settlement as the most popular means of resolution, even when patients’ complaints are clearly
unreasonable," it says.

In a second part of the study, two thirds of 300 doctors surveyed described relations with patients as 'very tense' and a similar proportion (65%) had been physically assaulted at least in the previous year.

The authors of the study say there are several key lessons for preventing and managing medical disputes in China. First and foremost is the need to reduced doctors' workload to a level where they have time to interact with patients and spend a meaningful amount of time with patients to allow good communication, adequate assessment and diagnosis and explanation of medical matters so that patients can make 'informed choices'.

Secondly, there is an urgent need to remove the profit/bonus incentives for doctors so that they paid according to their performance on good clinical practice rather than on how many drugs they have prescribed.

The study authors have a rather bleak outlook about the possibility of curbing attacks on healthcare staff - at least in the short-to-medium turn:

"For decades, health policy reform proposals have always put financing reforms, realignment of provider incentives, or organizational restructuring first. However, the [medical dispute] crisis in China shows policymakers and advisors the detrimental consequences of hostile interactions between doctors and patients. While it is not unreasonable to expect systemic reforms to restore trust between the two parties, one must bear in mind that it may take much longer than anticipated to see the effects; in the meantime, the dysfunctional doctor–patient relationship continues to deteriorate," they conclude.

Tuesday, 29 March 2016

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.

Monday, 28 March 2016

Week 2 of the vaccine scandal: latest developments


by MICHAEL WOODHEAD
It is quite remarkable that in the middle of the second week of the scandal around distribution of dud vaccines there has been no comment whatsoever from China's health minister Li Bin. In fact the response from the Chinese government could be summed up as an attitude of "Crisis? What crisis?"

The official line has been to focus on the perpetrators - the illegal wholesalers and distributors in Shandong -  and to avoid any analysis of how things could go so badly wrong - and what the Chinese public should do about it all.

It seems clear that the government has been 'harmonising' (deleting and censoring) media and online articles and social media discussions relating to the vaccine scandal. The media articles that originally drew attention to the crisis have been removed, and instead replaced with bland assurances from officials that the matter is being investigated and all should be well.

Most of the permitted coverage has been along the lines of the WHO China response, namely:

  • The dud vaccines are unlikely to cause any adverse effects even if not handled according to the cold chain.
  • Most of the vaccines have already been used, and there have been no reports of spikes in adverse events.
  • The illegal distribution is being investigated and the perpetrators brought to justice.
That's it.

There has been no response to important questions such as:
  • How many people received dud vaccines and have any of them acquired diseases because of poor immune protection?
  • What are the most frequent and potentially most severe diseases covered by the dud vaccines?
  • What needs to be done to trace/follow up/test and re-vaccinate those who have received dud vaccines?
  • How can the public be reassured that vaccines currently in the system are not duds? Batch numbers? Locations?
These are just a few of the fundamental questions that any professional and competent medical regulator such as the FDA would be asking. And yet in China there has been no such response. There have been some vague reassuring statements from the China FDA, but no detailed information about the scale of the problem and how it will be addressed.

Once again the "SARS hero" Dr Zhong Nanshan has been given airtime to comment. Speaking at a national influenza conference in Hainan (unfortunate timing) Dr Zhong said there was no need to doubt the quality of Chinese made vaccines and no reasons for panicked parents to seek foreign vaccines or to go to places such as Hong Kong for vaccinations. He also said (quite rightly) that he hoped the vaccine scare would not undermine China's immunisation program, which has markedly reduced or eradicated diseases such as measles, whooping cough, polio and hepatitis B in China.



Fine words, and not to be disputed, but there is a need for more leadership on this issue if public faith in the public vaccination system is to be restored. As I've said before, trust is not easily won and it is a two-way street. If the government does not trust the public with information - if it closes down the communication channels and deletes articles about the vaccine problems then it will just encourage the public to turn to the rumour network.

On a wider level there is little hope for a robust medical and healthcare safety system when there is a culture of punishing those who speak out. In other countries there has been grudging acceptance by authorities that transparency and accountability are needed in clinical matters to ensure safety. Staff have to feel confident that they can speak out - and also feel that it is their duty to do so, rather than feel intimidated or a false sense of loyalty to persons or organisations. In China under Xi Jinping there is currently a major crackdown on those who are outspoken or who dare to question "the core".

And so at the end of March we find that China is facing its biggest health safety crisis since the melamine in milk saga of 2011. And yet if you turn to the medical forums such as DXY.cn there is no discussion and no advice there. They have presumably also been 'harmonised'. A week ago when the scandal first became public, the Deputy director of the Department of Immunology at Peking University Professor Wang Yue expressed shock at the safety implications of the dud vaccine trading.

"This is murder" he said, referring tho the likelihood of people dying from vaccine preventable diseases.

The article has now been taken down.

It's important for Li Bin to show some leadership and act swiftly to restore the public's faith in China's vaccination system. If not, vaccines may become like China's milk formula industry - untrusted, shunned and encouraging consumers to turn to expensive alternative 'grey market' suppliers.

Meanwhile, here are some links to articles of interest:

SARS hero Zhong Nanshan reassures on the vaccine problem, urges public to maintain faith in China's vaccine program

Propaganda Ministry directive: "Don't hype the news on illegal vaccines"

VOA article on the vaccine articles that have been removed and the vaccine keywords that have been blocked on social media

Netizens claim that China's propaganda ministry is highlighting news about Japan's war crimes as a distraction from discussion about vaccine scandal

Hong Kong media raise fears that vaccines may be the new milk powder - will mainland 'raiders' flood Hong Kong to buy up good quality vaccines?

Thursday, 24 March 2016

11 things we know about the expired vaccine scandal




by MICHAEL WOODHEAD
The expired vaccine 'shame' originating in Shandong has caused a huge outcry of concern in China and has prompted angry reactions from the very top leaders, including Li Keqiang. 

Here's what we know so far:

1. More than 2 million doses of expired or spoiled vaccine worth $88 million have been sold by a rogue Shandong wholesaler since 2011.

2. Between 12 and 25 different vaccine products were involved. They were Class 2 (non-essential/optional) vaccines such as rabies and Japanese encephalitis, which are distributed via private wholesalers rather than though the centralised buying system used for Class 1 (essential/state-funded vaccines). The vaccine products affected are said to include: 
  • Rabies, Rabies immune globulin
  • Varicella, 
  • Haemophilus influenza B (Hib), 
  • Pneumococcal polysaccharide vaccine (23-valent) 
  • Meningococcal A/C vaccine 
  • Influenza vaccine, 
  • Hepatitis B vaccine
3. The mother and daughter team of rogue sellers have been arrested, along with 37 other suspects in Shandong. They are believed to have bought cheap vaccines that had expired or had not been stored or transported according to cold chain methods to ensure they remained viable. Three pharmaceutical companies have been investigated and one has had its manufacturing and distribution suspended. A further nine wholesalers are under investigation.

4. The National Health and Family Planning Commission and the China FDA say they are now "resolutely investigating the relevant departments" and actively tracking down where the vaccines have been sold to 24 provinces. Officials say each vaccine and recipient should be traceable by barcode and batch number. Authorities are now investigating the case at the behest of Premier Li Keqiang, who has called in law enforcement authorities and said there were obvious loopholes in the regulatory system for the supply and distribution of Class 2 vaccines.

5. The WHO say that there should be no major adverse effects in recipients of vaccines that have expired or not been handled according to the cold chain procedures - however the recipients may not have received an adequate immune response and would not be protected against the infections for which the vaccine was given. The WHO has urged the Chinese public to maintain faith in the immunisation system and it emphasises that vaccination programs have helped reduce China's high burden of infectious diseases.

6. The NHFPC says there have not been any notable spikes in vaccine related adverse effects but it is now checking figures - particularly for the Shandong area.

7. Chinese netizens are asking why the information was only brought to light in February 2016 when the authorities became aware of the problem in April 2015. This raises obvious questions of whether vaccines could have been traced and recalled before being given to unsuspecting patients.

8. There has been public outrage and 'vaccine panic', with many Chinese expressing scepticism about the quality of Chinese made and distributed vaccines and anger about the integrity of the medical safety surveillance and regulatory system. There are fears for vaccination rates may fall as the public lose faith in public vaccine programs.

9. Some of the more open media outlets have blamed China's lax approach to food and medicine safety on the authorities' lack of accountability and transparency and also the routine censorship of and control of 'bad' news. Caixin magazine ran a feature that harked back to a previous hepatitis B vaccine adverse events scandal from 2013, but the article was later deleted.

10. Some analysts have said that the Class 2 non-essential vaccine distribution system is ripe for corruption. It has minimal regulation and there are strong financial incentives for unscrupulous wholesalers and local disease control departments to collude to make commissions and backhanders off sales of unreliable vaccines.

11. China CDC director Wang Huaqing says that after a full investigation some children and adults may need to undergo repeat vaccinations to ensure they are covered against certain diseases. However he says the more widespread impact is likely to be on herd immunity levels in the population rather than individual risk of infection.

Wednesday, 23 March 2016

Will hospitals go bankrupt as drug commissions are banned?

A letter in Lancet Global Health this week from urologist Dr Guan Xiao and colleagues at the Xiangya Hospital, Changsha, Hunan:

On Jan 15, 2016, the National Health and Family Planning Commission of China reported its work plan for 2016 at a press conference in Beijing, mentioning that it will expand the public hospital reform to 200 cities in China. The core part of the reform is to ban the price increase of drugs and materials, reduce the cost of medical examinations, and appropriately raise the price of medical services provided by physicians, such as surgery.
However, under this circumstance, public hospitals in China are now in the dilemma of whether to choose reasonable hospital operational costs or public welfare. With the increasing demand for health-care services, the operational cost of hospitals will inevitably increase. For public hospitals, drug sales account for about 40% of their revenue, and medical income (eg, from examinations, laboratory tests, and operations) brings in about 49%.2 With the ban on charging extra for drugs and materials, as well as the reduced cost of examinations, hospitals' revenue is likely to reduce. Although the income from medical services will increase, this factor is far from enough to offset the operational cost, which will result in a great reduction in many public hospitals' gross revenue, even leaving some hospitals at a financial loss. According to some health insurance policies, there are limits on how much a patient can spend on their treatment. If the total cost exceeds the limit, then the hospital might not get the balance from the health insurance department. Because of these health insurance issues, hospitals have no choice but to reduce the use of expensive but effective drugs and materials. However, this move could compromise the quality of medical services.
The government's subsidy accounts for only about 8% of public hospitals' revenue, putting these institutions under great pressure. Public hospitals have to seek new ways to make a profit instead of only sticking to their public welfare goals. The government has lowered medical costs in response to public demand; however, the subsidy remains the same. To solve the dilemma hospitals are now facing, the government should increase the subsidy to a level that is enough to cover operational costs without damaging the medical staff's initiative. Investment in health-care services takes up only about 6% of finance expenditure in China, compared with about 15% in developed countries. Additionally, the adjustment of the prices of medical services is lagging far behind the market prices. The mechanism of adjustment for these prices should be revisited.
People could benefit a lot from the launch of the public hospitals reform. For public hospitals, it is not a simple choice of choosing survival of the organisation or public welfare. We should find balance between them.

Monday, 21 March 2016

Five healthcare stories making the headlines in China this week

At least two million doses of spoiled vaccine have been traded by rogue wholesalers based in Jinan Shandong. Health authorities in the province say they are trying to track down the vaccines, which were sold by a mother and daughter criminal gang despite being past their expiry date or having failed cold chain storage and handling procedures. The vaccines, worth at least half a million yuan, were for conditions such as influenza, hepatitis B, and were sold to many provinces including Hubei, Anhui, Guangdong, Henan, and Sichuan. The scandal is seen as a major failure of provincial and national drug regulatory authorities.

The first vaccine against hand-foot-and-mouth disease (HFMD) caused by enterovirus 71 (EV71), has been launched by a Chinese company. The Institute of Medical Biology, Chinese Academy of Medical Sciences, says the China FDA approved the production of the vaccine in December, 2015.

A new national survey has found poor morale among China's doctors, with 87% saying they would not want their children to enter the medical profession. The survey of doctors in 31 areas found that 80%of doctors believed the fees and remuneration were far too low, and wanted them raised to reflect their true value. About two thirds of doctors believed they were overloaded at work, and only 34% felt they got sufficient sleep.  

At the NPC Premier Li Keqiang says one of his priorities is to achieve national portability of medical insurance schemes at a faster pace. He also plans to cut red tape to make it easier for retired people to claim medical insurance benefits away from their hometown and for aged care homes to offer medical services. Meanwhile. health minister Li Bin said her priorities were to cut out hospital ticket scalpers and to have a phased and orderly introduction of the Two Child Policy.

Hong Kong's largest chain of private health clinics, Human Health Holdings Ltd says it plans to open clinics on the mainland. The company is offering shares and says it plans to use the revenue to open clinics in China's major cities over the next three years. It partnered with China Ping An Insurance Holdings to open its first clinic in Shanghai last year.

Sunday, 20 March 2016

Giving birth in Shanghai


by MICHAEL WOODHEAD

China has one of the highest rates of caesarean section in the world, and China's health ministry has for years been paying lip service to the idea that this is not such a good thing and that vaginal births should be encouraged.

However a recent in-depth investigation of birth practices in Shanghai by a joint team of US and Chinese obstetrics researchers found that the practice of caesarean section has become entrenched in the system as the norm and little effort is being made to tackle the situation.

The investigation, led by Dr Susan Hellerstein of Harvard Medical School and Brigham and Women's Hospital, found that caesarean section was being encouraged by the hospitals as a way of coping with the huge workload of birthing mothers (16 million babies are born in China every year, 200,000 in Shanghai alone). The high rates of caesarean section were also being driven by mothers wanting a quick and 'safe' birth on a lucky day, and also driven by hospitals wanting to avoid medical disputes with patients.

The end result is that China's hospitals are simply not set up to allow women to have vaginal births - the obstetric hospitals do not have labour rooms and do not have the staff to allow women to give birth by labour rather than by caesarean.

As part of their investigation the team, which included Professor Tao Duan, Director of Shanghai Woman's Healthcare Institute, visited five public hospitals and one private (VIP) hospital in Shanghai. They asked many questions both of women and of the medical staff.

They found that Shanghai has a three tier obstetrics system. The highest tier is the so-called VIP private system, which functions at the one top end private hospital with exhorbitant fees by Chinese and international standards (about US$19,000 for a caesarean section birth).

The second - and largest - tier is the Shanghai public hospital system for city residents. This offered a basic obstetrics package, which usually involved a scheduled caesarean and two days of recovery, for a cost of about $1000. Most of this was in theory claimable on the health insurance that is provided by employers. (Some public hospitals offered 'VIP packages' and add-ons at a cost of $5000).

The third tier is the migrant workers' obstetric hospital network. These basic clinics offer a minimal obstetrics service for about $300.


The investigators found that women have to pay upfront for all services and then claim back what they can from any insurance that they have. In practice, this often means women have to queue for long periods to register and pay for each of their antenatal visits.

One of the most striking things the US researchers noticed about the Chinese maternity hospital system was the high number of patients and low numbers of staff. It was quite normal for a single obstetrics outpatient clinic to have 80-120 women scheduled in one eight hour day. Even the "VIP" services saw 40-60 patients a day. Although women got to have very little time to spend talking with the doctor, the researchers noticed that they tended to have more tests and investigations, which they found to be part of a 'defensive medicine' trend.

The high number of patients also put pressure on women to have caesarean sections - a typical birthing unit could expect to deliver eight babies in an eight hour shift, with each caesarean section taking about 30 minutes ( in contrast to vaginal birth taking from 4-24 hours). The average caesarean section rate observed in the Shanghai hospitals was 66%. The women who did have a vaginal birth did so alone (family are not permitted to be present at the birth) and without the aid of analgesics - no epidurals! Women usually had to share a maternity ward with up to four other women and did not have any personal or emotional support from either nurses or doctors.

New mothers are allowed to stay in the hospital for two days of postnatal care after a caesarean section and four days after a vaginal birth. This time was deemed important to Chinese families so that the new mothers could avoid 'hot and cold', rest and consume traditional soups, the researchers found.

When the researchers interviewed mothers and doctors at the hospital they found several factors that encouraged caesarean sections. Firstly there was maternal preference - Chinese women did not want to go though the pain of vaginal birth and feared this would spoil their health and sexual function. They also preferred the convenience and speed of caesarean section, especially as it could allow them to have a baby on a lucky day. Most believed that caesarean section was safer.

The doctors interviewed also said that pressure from women and their families was a major factor in encouraging caesarean sections to be the norm. Most doctors expressed strong feelings about the risk of disputes with patients and their families over medical events, with more than 60% having had experience of serious medical disputes with patients - often physical. Doctors also conceded that there were 'system' pressures on them to provide caesarean sections - it was more efficient and financially lucrative for the hospital, and doctors' salaries were based on the number of women who were managed though birth every day.

It was also noticeable that obstetrics medical staff were very concerned about maintaining their high reputation and did not want to discuss errors and problems with their peers and certainly not with patients.

"The concept of protected open medical discussion of errors or poor outcomes, transparency with patients, and patient apology were neither well developed nor deemed culturally acceptable by most chiefs of services," they noted.

The researchers found that hospitals were geared up to provide caesarean sections as the main method of delivery - the ratio of operating suites to labour suites was 2:1, in contrast to maternity hospitals western countries where the ration is heavily in favour of labour units over operating theatres.

While the main part of the investigation was carried out in 2012, the US researchers returned in 2015 and found there had been no change to the maternity hospital setup.

"We observed that ... most public obstetric care did not meet rising patient expectations with ward style labor and delivery suites, lacking family involvement, pain control, and emotional support in labor. In the cosmopolitan environment in Shanghai, with advanced public transportation and ubiquitous high tech consumerism, the public health care system lagged significantly in development and appeared out of synch with other aspects of society."

They concluded that the high rate of caesarean sections is likely to continue in China's hospitals due to the high throughput' of women in the maternity system and the institutional factors that promote an 'efficient' rate of births. The high caesarean rate is also reinforced by societal and institutional pressures that put the emphasis on convenience and control in contrast to the untidyness and unpredictable nature of a spontaneous vaginal birth.

The full article is published in the journal Birth.

Monday, 29 February 2016

How pharma companies get their drugs prescribed in Chinese hospitals

by MICHAEL WOODHEAD

I wouldn't be exactly "leaking state secrets" by revealing that China's hospitals expect bribes from pharma companies in order to stock and prescribe their drugs. The practice is so well embedded and accepted that it has its own name: "pharmaceuticals feed the hospitals". And this month there is an excellent article from UK-based Chinese researcher Dr Yang Wei, from the University of Kent, which explains how the whole process works from pharma company via hospital pharmacy to the prescribing doctor. To explore the details, Dr Yang interviewed four doctors, five hospital managers and four pharmaceutical industry managers from Shanghai. Broadly speaking, the problem of overprescribing and corruption in prescribing arises because China's hospitals get very little or no financial support from local government. They are essentially self supporting. Despite its increasing prosperity, China spends only a tiny proportion of its GDP on health (about 5%, less than Afghanistan) , and hospitals see very little of that money. As one manager told Yang:
"I think the biggest problem is that there is not enough money for healthcare sector. It is
also related to whether health care is a policy focus of the local government. I remember
that in the past the government would allocate certain percentages (of their budget) to
subsidise healthcare sector, but now it seems there is no such policy… At least in my
district, hospitals are almost financially independent."
Hospitals face rising costs, rising demand for services and yet the fees they can charge for services are capped by order of the central government. This means many hospitals are in serious financial difficulty, running into debt and unable to pay their bills for supplies. The problem is especially bad for regional and rural hospitals faced with the double whammy of wealthier patients preferring to go to city hospitals, while the local government is starved of funds due to migration of the working population to the cities.

The hospitals must therefore obtain revenue from the sales of pharmaceuticals and medical services. To ensure they receive a fixed and predictable income, the senior managers set financial and servicing targets for each hospital department. These department managers in turn set targets for individual doctors.

As one hospital department manager said:
"We have targets for each quarter, and we have to fulfil it to generate enough profits. There are regular meetings in the hospital. We discuss which medical department is not doing well in terms of meeting targets. We, doctors, all want to generate profits, and the hospital wants to generate more profits as well."
The financial revenue performance targets are thus written into the doctors' contracts, with a financial bonus dependent on meeting those quotas. According to the doctors interviewed by Yang, a typical bonus for a junior doctor is around Y2500 quarter, for a doctor whose basic salary is 5000 a month.

However, the bonuses depend on the level of seniority and also on the speciality. Doctors working in surgery and orthopaedics can earn much higher bonuses because they see more patients and can offer more interventions and services, Yang notes. Conversely, doctors in specialities such as paediatrics have a lower income from bonuses as they tend to prescribe less.

Doctors see nothing wrong with earning bonuses for overprescribing or overservicing, because their basic salaries are so pitiful for their high workload and high level of expertise:

"(Being a doctor) is a job that requires years of training and deals with lots of risks. But
their salaries, compared with their foreign counterparts are quite low…People laughed at
them and said, ‘scalpels do not even value as much as a barber’s scissors’. Do you think
this is fair?"

As well as receiving their hospital bonus for prescribing, doctors also receive kickbacks from pharmaceutical companies, based on their level of prescribing. Drugs have high profits margins for pharma companies - and some of this is passed on to the prescribers.
"The profit for the pharmaceutical company is around 5-15% of the wholesale price, and 10-30% for the hospital." - pharma industry manager.
This is where it gets interesting. According to Yang, the pharma companies have promotional budgets that they disburse to hospital in the form of bribes (incentive payments/commissions) to the doctors - but more importantly to the hospital pharmacy committee. This committee, which includes the director of the pharmacy department, the vice hospital president, directors from various medical departments, and some other specialists, decides which drugs are purchased and used by the hospital.

The committee members are targeted by pharma industry representatives, who develop personal relationships with them and offer bribes.
"The most important thing is to know who are the key persons in the Hospital
Pharmaceutical Committee …targeting the right persons is the key. The second step is to
persuade the persons to speak for you at the meeting. We offer money…It is possible that
the first time they will reject you… in the end, they will accept your money ... Some
medicines need a lot of money to get listed in a hospital, especially for Chinese medicines."
Once a hospital has agreed to stock the drug, the pharma company must then target individual doctors with offers of commissions to prescribe their particular drug. Doctors may be offered a commission of 15-20% of the drug price. This encourages doctors to prescribe the most expensive drugs and for long periods. Sometimes doctors are paid indirectly, with the drug company paying them 'lecture fees' or 'travel fees'. "
"Sometimes, a doctor does not need to give a lecture. We issue a receipt under a title of ‘fees or academic lectures’. We will transfer the money to the doctor as a way to pay for drug remunerations. This way, everything is legal."
This was seen in the major crackdown on GlaxoSmithKline in Shanghai, which resulted in a hefty fine. But according to Yang, such payments have been standard practice for all drug companies.
" Drug remunerations are paid monthly based on how much the doctor prescribes. In Shanghai, a doctor work in outpatient clinics in a Class III hospital can earn up to 50,000RMB a month from pharmaceutical companies," said one pharmaceutical representative.
As in other countries, pharmaceutical reps develop close and friendly relations with doctors in order for them to prescribe their drugs. They take the out for dinner and may also support them in informal ways such as by giving them lifts.

Because of the commissions, doctors are encouraged to look at the price of the drug first and foremost, rather than whether it is the most appropriate drug - or the best value for the patient. Doctors are also encouraged to prescribe worthless 'tonics', which have a generous markup and which they know they can offer to patients without fear of too many side effects:
"The most widely used medicine in my company is X. It could be used on a lot of diseases, for recovery. Drug remuneration is around 20% of the retail price…You may not need it, but anyway, it will not kill you (so doctors will prescribe it)…"
In the concluding remarks, Yang Wei notes that the Chinese government is now trying to move away from the commission system for drugs in hospitals. It has encouraged 'zero markup' policies for hospital pharmacies and has also introduced lowest price tenders to ensure that inexpensive drugs get first priority. However, Yang notes that faced with the need to generate revenue, hospitals simply sidestep these reforms by creative accounting and supply deals in collusion with the pharma companies. And when barred from generating income from drug sales, hospital simply switch to profiteering from other services such as medical devices such as cardiac stents (Y2000 each) - or offering unnecessary checkups and tests.
"If pharmaceutical revenues are cut down, then we have to increase other fees or increase the use of other services, such as the use of various diagnostic procedures. This is what is
happening now, and the healthcare costs will continue increase and remain high ... In order to follow the policy and to keep the profit of the hospital, hospitals may promote use of high-tech diagnostic procedures, special wards and other methods to increase non-pharmaceutical expense…"
Yang concludes that the problem of overprescribing and/or overservicing will remain until the Chinese central government and the Ministry of Health solves the problem of adequate resourcing for hospitals. Local governments have no incentive to enforce curbs on their local hospital revenue - and the central government has little enforcement clout at the local government level.

Link to full article: Health Economics, Policy and Law