Sunday, 21 February 2016

Why Beijing's war on hospital ticket scalpers is doomed to fail: top cardiologist says jail sentences won't fix supply & demand problem



by MICHAEL WOODHEAD
This week a Beijing court sentenced 15 hospital ticket scalpers to prison sentences varying from 19 months to two years in jail. It's all part of a very public crackdown on the practice of 'entrepreneurs' buying up the hospital clinic reservation numbers (guahao, ) that are needed to gain access to see a doctor. Typically, these hospital tickets cost 20 yuan at the front desk but are bought up and sold for ten or more times their face value by scalpers (piao fanzi, 票贩子) who operate in gangs around the foyers of public hospitals.

In theory, China's hospital clinics operate on a first come, first served basis. Whoever is prepared to queue up early at the hospital ticket window in the morning gets the tickets. In practice, the scalper gangs either send their agents to stand in line and book an appointment - or they have inside connections with hospital staff to procure the tickets through the back door. The corrupt practice has been going on for years, but made headlines in January when a video emerged showing a young rural migrant woman ranting about the scalpers at a Beijing obstetrics hospital. The video went viral on China's social media channels and there was soon public pressure for 'something to be done'.



As in the past, the hospitals and the Beijing health department announced yet another "get tough" campaign on scalpers. They sent in the PSB to round up the usual suspects. They also issued a series of "Five Musts" measures that included real name registration procedures and an end to collusion between hospital staff and scalpers. And as usual, an example has been made of a few offenders in the media. The Party has listened to the masses and taken action. Never mind that the 15 offenders sent to jail weren't actually scalpers, but fraudsters. They had hired hospital rooms in which they used bogus doctors to swindle unsuspecting out-of-towners into jumping the queue and paying for dodgy TCM treatments.

But even if the authorities had enacted a serious and enduring action against hospital ticket scalpers, it still would not make any difference, according to one leading cardiologist.

Professor Yang Qing, has worked at the cardiology department at the Sichuan University Huaxi Hospital for 20 years. He says the problem is not due to the scalpers, who are only the symptoms of a monopolistic system. Professor Yang says it is important also not to blame doctors, who are also constrained by the system.

According to Professor Yang, every day his hospital cardiology clinic in Chengdu is besieged by patients from far and wide, seeking a consultation. Patients come not only from Chengdu, but also from across the province and even from overseas. A typical clinic has 20 allocated slots to see patients with an average consult duration of 6 minutes - but most will actually fit in 30 patients by running over time. Every day at the front desk he is mobbed by people saying: "Professor Yang can you add an extra place for me?" Some are very deserving patients who have traveled a long distance to see him - even renting rooms near the hospital. Others are former patients who want continuity of care and to be followed up by the same treating doctor. And there are also 'insiders' - acquaintances, connections and people who work in the hospital who seek an appointment with him.

Professor Yang says the demand for 'tickets' is inexhaustible and he only has a finite amount of time in a working day. On a typical day he works right through an after noon clinic without a break even to go to the bathroom. He is supposed to finish at 5pm, but usually does not actually finish until at least 6pm. If there is a chance he will add a few extra places, but he says he feels bad for not being able to accept all the requests. And his colleagues all feel the same way. They are not heartless, but they have other responsibilities and things to do - not to mention family life. Professor Yang says that in addition to attending to patients in the outpatient clinic he must also do surgery, supervise junior staff, take part in research and write reports. He must attend medical conferences and teach students.

Professor Yang says that the demand for hospital tickets is high, but the price is low and does not reflect the 'economic value' of the doctors' skill and experience. The scalpers are simply selling the doctor's appointment at a price the market is prepared to pay, he says. And the 'profit' is going to criminal gangs instead of to the hospitals.

Professor Yang says that what the scalpers do is an unsatisfactory and unfair situation, but he believes it is inevitable under a monopoly system. It would be unrealistic to expect them to be stamped out - and even if all the ticket scalpers were removed there would still be an imbalance between supply and demand of medical appointments, he says.

"When a resource is scarce, and when everyone wants to have this resource, the authorities' fight against ticket brokers is meaningless," he says.


Professor Yang says that in theory a system that guarantees low prices is good because it makes treatment affordable for everyone. However, in practice he says low prices enforced within a monopoly lead to low quality care and also to the 'detestable' practice of scalping.
 
Professor Yang's solution is a free market one - free up the doctors to set their own prices and let them manage their own patients. In this way, there will be competition between doctors that will keep prices low and affordable while raising levels of service and quality, he believes.

[Editor's note: Given that they have been given prominent place in the state media, Professor Yang's pro-market comments are presumably endorsed by the government and China's minister for health. It's notable that the learned professor suggests a new model based on the US free market healthcare system, and makes no mention of other more successful models such as the gatekeeper' system of Britain's NHS. 

The kind of problems that Professor Yang describes do not occur in the UK  because that country (like many others) has an efficient primary care gatekeeper system that ensure that patients do not go straight to hospital. To see a hospital specialist, patients in countries such as the UK and Australia must first go to see a community-based general practitioner, who decides if and where they should be referred. This means that patients with minor illness and chronic disease can be managed in the community' rather than clogging up the overloaded hospital system. It also means that patients are sent to the most appropriate specialist. 

Of course the system isn't perfect because financial restraints mean that public hospital patients often have to wait months for an appointment to see the doctor. In countries such as Australia, patients can jump this queue if they have private health insurance (but they still need a GP referral) But if any patient needs urgent care, they can receive it. 

Interestingly, China is pursuing both these options. It is loosening the monopoly of public (actually state-owned for-profit monopoly) hospitals. China is also moving towards a community/family doctor system. However the progress is glacial because of the entrenched financial interests of local governments [and managers] in their local hospital monopoly. So is the solution to hospital scalpers a crackdown, free-market healthcare or a gatekeeper system? You decide ...]

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