Doctor-Patient Relationship and Overprescription in Chinese Public Hospitals: Defensive Medicine and Its Implications for Health Policy Reforms

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1 Doctor-Patient Relationship and Overprescription in Chinese Public Hospitals: Defensive Medicine and Its Implications for Health Policy Reforms Dr He Jingwei, Alex 和經緯博士 Assistant Professor Department of Asian and Policy Studies The Hong Kong Institute of Education

2 Health care in China Heavy deterioration since 1980s Medical impoverishment ( 看病貴 ) and expensive access to care ( 看病難 ) Double-digit escalation of health care expenditures 6% of GDP Vast supplier-induced demands Enormous provision of unnecessary care ( 過度醫療 ) 20-30% of China s total health expenditures are spent on unnecessary care. 1% of GDP! Symptoms Overprescribing drugs, high-tech diagnostic tests and profitable procedures

3 100 million yuan Total health expenditure, % 5% 4% government health expenditure total health expenditure health expenditure/gdp 3% 2% 1% 0%

4 Average drug and clinical test expenditures in comprehensive hospitals, Unit: RMB yuan Average drug expenses per inpatient stay Average clinical tests expenses per inpatient stay Average drug expenses per outpatient visit Average clinical tests expenses per outpatient visit

5 Why do they overprescribe??? The target income hypothesis A physician is motivated to maintain a certain level of income and if his/her actual income falls below this target, the physician will then behave as an income maximizer until the target income is met (Newhouse, 1970; Rice, 1983). Chinese situation Poorly paid doctors 80.5% of physicians in the sample were paid between 4,001 yuan and 8,000 yuan per month. Strong incentives to overprescribe Various bonuses account for 50-60% of income. Physicians have to meet revenue targets. Drug commission ( 藥品回扣 ) Test kickbacks ( 開單提成 ) Fee-for-service in paying providers

6 However, an alternative explanation My interviews of 22 medical doctors in Guangdong, Shanxi, Fujian and Zhejiang, from 2010 to The reputation of doctors has declined rapidly over the years. Patients and their family members are often very suspicious of our diagnoses and treatments. The number of medical malpractice lawsuits has risen. The consequences of getting swamped into medical disputes or even being sued could be rather severe. Our reputation would be ruined, we may be penalized by the hospital, and there is even a possibility of imprisonment! To reduce the risks of misdiagnosis and to retain essential evidence for use in a lawsuit, sometimes we do have to prescribe more [tests, procedures and/or drugs]. Not to mention that many patients may charge us for negligence if we don t do so. 這些年醫療行業的聲譽下滑很快病人和家屬越來越不信任醫生醫療侵權官司越來越多對於我們醫生來說, 萬一捲入醫療糾紛甚至被起訴, 後果是非常嚴重的首先, 自己的名譽會受到打擊, 還會被醫院處分, 甚至有可能坐牢! 為了避免誤診, 為了在被起訴的時候手裡能保存一些證據 ( 如 CT 檢驗單化驗單等 ), 有時候我們不得不多開一些 ( 檢查藥品等 ) 而且有時候你不給開檢查或者開藥, 病人和家屬還會罵你不負責任

7 This may not be just an excuse.

8 Defensive medicine Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid certain high-risk patients or procedures, primarily (but not necessarily solely) because of concern about malpractice liability (US Office of Technology Assessment,1994 ). Empirical evidence in US, Japan, Italy, Canada, etc. Defensive practice has made no positive contribution to quality of care but has brought about tremendous pressure on health care costs (Coyte et al., 1991; Hiyama et al., 2006; Kessler et al., 2006; Catino, 2011). The costs of defensive medicine in the US alone are estimated at between 26% and 34% of the country s total annual health expenditure (Jackson Healthcare, 2011). Another reason explaining overprescription

9 Research question The total number of medical disputes has been increasing by 22.9% per year since 2002 in China. On average, each Chinese hospital deals with 27 cases of violence targeted at doctors per year (Xinhua Daily Telegraph, 2013). A profession called the medical harassers ( 醫鬧 ) has sprung up to facilitate patients blackmailing their doctors for compensation. In a recent survey of doctors in Liaoning Province, 47.2% respondents reported serious dissatisfaction with their relationships with patients (Wu et al., 2013). In light of the rising tensions between doctors and patients, do Chinese physicians overprescribe because of concerns on medical disputes and liability?

10 Methodology Survey of licensed medical doctors in Shenzhen December 2013 Random sampling When the health bureau was hosting physician training programs The opportunity of getting selected was the same to all. We randomly picked a few sessions and distributed the questionnaires. 600 distributed and 504 collected Response rate: 84% The sample represented 2.1% of all licensed doctors in Shenzhen.

11 Profile of respondents Characteristics N=504 Gender Male 252 (50.0%) Female 252 (50.0%) Hospital level Class III 122 (24.2%) Class II and Class I 382 (75.8%) Junior 158 (31.3%) Technical title Middle 230 (45.6%) Senior 116 (23.1%) Internal medicine 146 (29.0%) Specialty Surgery 225 (44.6%) Obstetrics & gynecology 68 (13.4%) Pediatrics 38 (7.5%) Others 27 (5.5%) Master and above 110 (21.8%) Education Bachelor 344 (68.3%) Diploma and below 50 (9.9%)

12 Frequency of medical disputes encountered in the past 12 months, assorted by specialty Frequency Internal medicine Surgery Obstetrics & gynecology Pediatrics Others Total None 64 (43.8%) 131 (58.2%) 44 (64.7%) 21 (55.3%) 18 (66.6%) 278 (55.2%) 1-3 times 62 (42.5%) 72 (32.0%) 19 (27.9%) 11 (28.9%) 8 (29.6%) 172 (34.1%) 4-6 times 12 (8.2%) 14 (6.2%) 3 (4.4%) 2 (5.3%) 1 (3.8%) 32 (6.3%) 7-9 times 6 (4.1%) 4 (1.8%) 1 (1.5%) 1 (2.6%) 0 12 (2.4%) 10 times 2 (1.4%) 4 (1.8%) 1 (1.5%) 3 (7.9%) 0 10 (2.0%) Sub total (100%) Form of disputes 1. Complaints to the hospital or health administration (N=232) 2. Verbal conflicts (N=204) 3. Physical assaults (N=64, 12.7%)

13 Reasons for medical disputes reported by respondents Hospital environment 48 Financial issues 82 Communication problems Patients' mistrust Medical harasser 48 Patients' unreasonable complaint 164 Medical error 26

14 Probing defensive medicine In view of the tensions between doctors and patients, do you prescribe diagnostic tests or procedures that are clinically unnecessary, to avoid possible troubles (such as disputes and lawsuits)? often, sometimes, and never. Although there might be bias introduced by respondents reluctance to reveal their deviant behaviors, it is easy to understand that if there are motives for misreporting, physicians will naturally tend to under- rather than overreport their deviant behaviors. Therefore, this study can still provide a minimum estimate of prevalence.

Regression results using ordered probit model Variable Model 1 Model 2 Model 3 Male -.132 (.111) -0.085 (0.113) -.031 (.114) Age.029 (.010)**.033 (.010)***.033 (.010)*** Education Master or above -.

15 Regression results using ordered probit model Variable Model 1 Model 2 Model 3 Male (.111) (0.113) (.114) Age.029 (.010)**.033 (.010)***.033 (.010)*** Education Master or above (.491) (.500) (.499) Bachelor (.490) (.504) (.503) Diploma or below (.523).034 (.540).038 (.539) Internal medicine.135 (.150).318 (.158)*.329 (.159)* Surgery.143 (.137).213 (.143).182 (.144) Class III Hospital (.148)*** (.153)*** (.156)*** Technical Title Middle (.143)** (.144)** (.146)** Senior (.215)* (.219)* (.221)** Monthly payroll income (yuan) 8,001-10, (.505)** (.501)** (.499)** 6,001-8, (.499)** (.497)*** (.495)*** 4,001-6, (.508)** (.507)*** (.505)*** < = 4, (.564)* (.563)* (.564)* Workload 31-50/day (.153)***.550 (.154)*** 10-30/day (.161)***.616 (.165)*** < 10/day (.281).182 (.285) Frequency of disputes 1-3 times (.195)** (.195)*** /Cut (.794) (.800) (.882) /Cut (.792).309 (.800) (.824) Log likelihood N Standard errors in parentheses; *p < 0.05, **p < 0.01, ***p < 0.001

16 Conclusion and implication While low income still drives Chinese physicians to overprescribe, previous experiences of medical disputes also motivates them for the purpose of self-protection. Proving the practice of defensive medicine in the Chinese context The ongoing national health care reform must pay closer attention to the escalating doctor-patient relationships.

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