Sunday, 26 July 2015

Universal health insurance comes one step closer - but who's paying?

The big healthcare news from China this week is that a health insurance safety net for serious illness is being extended nationally. This means that if all goes to plan, poor people who develop catastrophic diseases such as cancer should not be left destitute by medical bills for care. Pilot programs that have been running at provincial level will now be extended to all provinces, according to an announcement by the State Council on July 22.
This will be good news for the many sad and desperate Chinese families who face financial ruin because of medical bills - or who are simply unable to pay and have to watch their loved ones die of treatable diseases. Some of them resort to all kinds of bizarre publicity stunts and begging methods to try raise the money to pay the medical bills. I have recently before about a girl who offered herself as a bride to any man who would pay her brother's medical bills.

According to the China Daily (hardly the most reliable of outlets), the meeting chaired by Premier Li Keqiang, cover for major illnesses will "cover all the subscribers to the urban and rural resident basic medical insurance as of the end of 2015", with full implementation in all 6800 public hospital in China by 2017.

A spokesman for the council said that there were 700 million impoverished people in China, of whom about 10 million are suffering from a chronic disease or major illness.The scheme will cover 50% of expenses initially, but this will be increased over time.

According to state media, the funding for the scheme will come from existing insurance accounts and therefore "will not be a financial burden to the beneficiaries". However, it also slipped in the detail that the safety net scheme will be run by commercial insurance agencies chosen by the government through bidding, with limits of 2-5% on profit margins.

"Introducing the third-party commercial insurance as operators will bring a better inspection performance to control medical fees and prevent waste or ill-designed fees" a government spokesman said.

China's commercial insurance companies are keen to get into the lucrative business of providing private health insurance. However, reading between the lines, it looks like the government has told them that covering the safety net for the impoverished will be a condition of their getting access to this market.

As China Daily, puts it:

Wu Ming, a professor of public health at Peking University, said many insurance companies may compete for the business despite lower profit margins, since it can bring many potential benefits.
"Participation in the program can pave the way for the insurers to enter further into the medical care sector in the future," she said.

However, as the more reliable Caixin magazine reports, commercial insurance companies are worried about the financial implications of taking on serious health insurance policies. The various pilot projects run in places such as Jiangsu and Zhejiang have shown the potential for major cost blowouts for uncapped schemes, and also problems with defining which illnesses are covered and who should pay for what. In some cases local governments, which administer (and fund) health insurance schemes tried to unload all their difficult patients onto the safety net. Or as they told Caixin magazine: "all the risk, none of the power, no voice".

The commercial companies also fear that they will be required to take on patients only after they have gone through the regular health insurance system over which they have not control. They believe that if they have a full package of insurance they would be able to control costs (and potentially prevent patients from developing serious illness) rather than just picking up the pieces.

At the State Council meeting chaired by Premier Li Keqiang, the government said it would be keeping a close watch on the safety net scheme and conducting many checks and inspections to ensure there was no abuse of the scheme.

Sunday, 19 July 2015

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

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.

Sunday, 12 July 2015

The medical side-effects of China's stockmarket crash


Headaches, irritability, depression and most of all insomnia are the most common medical side effects of China's stockmarket crash, doctors say.

Mental health specialists at Guangzhou's prestigious Sun Yat Sen Hospital say they have seen a stream of unwell patients this week suffering from the mental effects of severe stress from the stockmarket collapse.

"Some people can not sleep at night, have difficulty falling asleep or wake up in the early hours three or four times a night.
Many people have overt physical symptoms such as palpitations, chest tightness, aches and pains, stupor and confusion," says psychiatrist Dr Wei Qinling.

Dr Wei says the worst affected people are those with a casino mentality towards the stockmarket and those with little mental resilience, who are most at risk of severe depression, mental confusion and possible suicide risk. Other common reactions are despair, alcohol abuse and loss of motivation. Some workers in the finance industry say there is nothing to work for anymore, and they have lost a reason to work. Others have lost their livelihoods altogether. Dr Wei says some have gone on extreme drunken binges to try wipe out the stress.

And in what some are calling "stocks syndrome", people suffers from sever stress from the sudden reversal from riches to destitution. This is a mix of severe anxiety, guilt, frustration and mental paralysis. Dr Wei says some people have symptoms that are so severe they may require hospital admission and antidepressant treatment.

However, at the Beijing Union Medical College Hospital Department of Psychological Medicine, Dr Li Jianzhong says some people are looking for a quick fix for symptoms such as insomnia. Some of the most difficult to treat are those who were most greedy when the market was good and became obsessed with the stockmarket. After making large gains they are now in denial and are unable to accept that they have made losses and cannot adjust to reality. Counselling may be needed, but it requires people to learn about "spiritual wealth" as well as financial wealth, he says.

Dr Li says there are two steps to treating "stock syndrome". Firstly, people must identify the cause of their symptoms and learn to manage the stressors through activities such as deep breathing and findings distractive activities such as walking or sport. Secondly, people must find an alternative to obsession with the stockmarket and focus on that.

In Shanghai, psychologist Dr Chen Gong says there has been an increase in patients with 'financial stress' but it would be an exaggeration to say his department has been overwhelmed. For him, two of the most serious consequences of mental stress from the stockmarket are cardiovascular and cerebrovascular disease. These may be triggered by severe stress, and people must learn to change their habits and behaviour to have a more balanced life, he suggests. Another problem with financial stress is its effect on the family,and relationships, he adds. He recommends that people talk openly with their family and focus more on family activities rather than being preoccupied with speculating on shares.

Dr Wei, however, warns that for some people the stockmarket has become a form of addiction, just like gambling. He warns family members to look out for signs of addiction and to recommend counselling and treatment for those who have become addicted to the stocks - and are at risk of withdrawal symptoms.

Monday, 6 July 2015

China's universal health insurance? Well, that depends what province you live in

China's government now claims that something like 90% of the population are covered by health insurance. It's a statistic that's repeated by people who should know better - including the editor of the Lancet.
In reality, the level and breadth of health insurance varies significantly between different provinces. Some have high rates of coverage, some have high rates of investment in their health funds. Some have both, some neither. An interesting analysis in Caixin by Yang Mingyu shows why the patterns of health insurance have emerged.
[Health insurance coverage (left) and investment per person (right) by province]

He divides the provinces into four groups, characterised by their health insurance profile.
Some he describes as ideal, with high rates of cover (80-90%) and investment (100-1800 yuan per person). These tend to be the affluent eastern coast provinces of Guangdong, Zhejiang, Jiangsu. A second group, typified by Beijing, Shanghai, Tianjin, (and weirdly, Tibet) have high rates of investment in their health insurance systems, but coverage isn't so great - sometimes as low as 60%. The third kind of insurance pattern is the 'cover' province: Sichuan, Guangxi, Chongqing, which have high rates of insurance cover but only modest investment in them. And finally we have the poor relations - the low cover and low investment provinces such as Heilongjiang, Jilin, Liaoning.

Yang Mingyu says the  patterns are explained by a combination of economic strength, internal migration and the government's policy to maintain social stability. Investment in healthcare is seen as a major way of preserving social stability. Therefore, the government has invested heavily in health insurance in some of the  provinces where there have been large inflows of migrant labour. Conversely, some of the poorer provinces  have a left behind population of mostly elderly and children with high healthcare requirements but little capacity to contribute to healthcare costs. The government has promoted wider membership of health funds in these areas to reap premiums needed to support the health infrastructure.

However, there have been some 'backward' conservative provinces with few financial resources and also little investment in the health funds.

The article concludes by saying that some provinces need to be encouraged to reform their health insurance systems and provide more cover or investment to suit local needs, even if the local circumstances do not favour it.

Sunday, 5 July 2015

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

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


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.