An Analysis on Obstacles An Analysis on Obstacles to Medical to Medical

Professionalism in China:Professionalism in China: A look at the A look at the

PracticalPractical

Linying Hu Ph.D.Linying Hu Ph.D.Peking University Health Science CePeking University Health Science Ce

nter nter

Problems and Problems and BackgroundBackground

First fundamental principle of First fundamental principle of Medical Professionalism: Medical Professionalism: Primacy of Patient WelfarePrimacy of Patient Welfare

“ “This principle is based on a dedication to This principle is based on a dedication to serving the interest of the patient. Altruism serving the interest of the patient. Altruism contributes to the trust that is central to the contributes to the trust that is central to the physician–patient relationship. Market forces, physician–patient relationship. Market forces, societal pressures, and administrative exigencies societal pressures, and administrative exigencies must not compromise this principle.must not compromise this principle.””

————Medical Professionalism in the New Millennium: A Medical Professionalism in the New Millennium: A Physician Charter, Physician Charter,

Annals of Internal Medicine, Feb. 2002, Volume 136, 3.Annals of Internal Medicine, Feb. 2002, Volume 136, 3.

““Primacy of Patient Welfare” Primacy of Patient Welfare” in Chinain China

Da Yi Jing ChengDa Yi Jing Cheng Medical Moral Norm and Regulation,Medical Moral Norm and Regulation, (19 (19

88, MOH); 88, MOH); Moral Norm and Regulation for Chinese Moral Norm and Regulation for Chinese

MedicineMedicine,(1992, State Council),(1992, State Council) Law on Licensed Doctors of the PeoplLaw on Licensed Doctors of the Peopl

e’s Republic of China,e’s Republic of China, (1998, (1998, the NPC Sthe NPC Standing Committee tanding Committee ))

Primacy of Patient Primacy of Patient WelfareWelfare

Primacy of patient welfare means:Primacy of patient welfare means:

Patient-centered, providing patients Patient-centered, providing patients the most appropriate high qualified the most appropriate high qualified care that patient needs most. care that patient needs most.

Investigation SubjectsInvestigation Subjects

1. Payment system1. Payment system

2. Worries about potential risks 2. Worries about potential risks

3. Non-economic promotion3. Non-economic promotion

4. Health care system4. Health care system

Investigation SubjectsInvestigation Subjects

Are above factors obstacles to Are above factors obstacles to medical professionalism in China?medical professionalism in China?

How do these factors influence How do these factors influence physician’s behavior of putting physician’s behavior of putting patient’s welfare first negatively?patient’s welfare first negatively?

MethodologyMethodology Literature StudyLiterature Study Papers published in important and influencial ChinPapers published in important and influencial Chin

ese journals and major conferences from 2000-2008ese journals and major conferences from 2000-2008 In-depth InterviewIn-depth Interview 31 doctors, including Internal, Surgery, OB. Pediatri31 doctors, including Internal, Surgery, OB. Pediatri

c, Shychatric; c, Shychatric; 70% from big comprehensive hospitals;70% from big comprehensive hospitals; 20% from mid-level hospitals;20% from mid-level hospitals; 10% from local community hospitals10% from local community hospitals Interview outlineInterview outline 2 hours/interview2 hours/interview

Models of Current Models of Current Payment SystemPayment System

Model 1Model 1 ：： Professorship and administrative pProfessorship and administrative position-centered payment system osition-centered payment system

25%

35%20%

10%10%

Professi onal ism Admi ni strative Posi ti onMore workl oad

Teachi ng andResearchi ngOther

Analysis of Model 1Analysis of Model 1

Strong political administrative style Strong political administrative style Weak impulse to behavior ethically Weak impulse to behavior ethically

Model 2Model 2

Model 2: Profit-centered Model 2: Profit-centered Payment system Payment system 　　　　

Profi t70%

Servi ce Qual i ty

10%

Compl i ance wi th rul es

10%

Care Quality10%

Profi t

Servi ceQual i tyCare Qual i ty

Compl i ancewi th rul es

Case of Model 2: Bonus System Case of Model 2: Bonus System of a Cardiovascular Divisionof a Cardiovascular Division

1 head of doctor in out-patient, 3 attending doctor, 1 1 head of doctor in out-patient, 3 attending doctor, 1 senior resident senior resident 。。 Among them, Among them,

A earns 78,000 RMBA earns 78,000 RMB ，， operating 8 surgeries; B earns operating 8 surgeries; B earns 58,000 RMB, 6 surgeries 6; C earns 49,000RMB, 2 sur58,000 RMB, 6 surgeries 6; C earns 49,000RMB, 2 surgeries, D earns 12,000. geries, D earns 12,000. 　　

①①Head of clinician’s bonus: 3688 RMBHead of clinician’s bonus: 3688 RMB②Bonus sum for doctores:15000②Bonus sum for doctores:15000 －－ 36883688 ＝＝ 11312RM11312RMBB ；；③③ Bonus distributionBonus distribution ：： A with highest earning gets A with highest earning gets 70 score, other doctors’ scores are certain rates of 770 score, other doctors’ scores are certain rates of 70; One score on average0; One score on average ：： 11312/304.7911312/304.79 ＝＝ 37.11RMB37.11RMB ；；

ResultResult ：： AA ：： (70+10+10+8+8)×37.11(70+10+10+8+8)×37.11 ＝＝ 3934RMB3934RMB ；； B:B:3194RMB3194RMB ；； C:2754RMBC:2754RMB ；； D:1439RMBD:1439RMB 。 。

Model 2: Bonus System of a Model 2: Bonus System of a Cardiovascular DivisionCardiovascular Division

0

10

20

30

40

50

60

70

80

90

A B C D

Profi t

Servi eQual i tyMedi cal CareQual i tyCompl i ancewi th Rul esBonus Sum

（ Thous. RMB ）

（ Hund. RMB ）

（ Hund. RMB ）

AnalysisAnalysis

Negative effects of profit-centered bonNegative effects of profit-centered bonus system on physician’s behavior:us system on physician’s behavior:

• • Deselecting patientDeselecting patient • • Overtreatment, increasing unneceOvertreatment, increasing unnece

ssary medical costssary medical cost • • Preferring high-cost medical interPreferring high-cost medical inter

vene, despite of low health benefit, nevene, despite of low health benefit, neglecting health educationglecting health education

ConclusionConclusion

1.1. Current bonus system is mainly hospital pCurrent bonus system is mainly hospital profit-centered, rather than patient-centererofit-centered, rather than patient-centered. d.

2.2. Profit-centered bonus system becomes an Profit-centered bonus system becomes an obstacle to medical professionalism, undeobstacle to medical professionalism, undermining trust between physician and patiermining trust between physician and patient. nt.

3. Bonus system design needs more scentific 3. Bonus system design needs more scentific prudence, for the result may be unwanted. prudence, for the result may be unwanted.

SuggestionsSuggestions ：： How can patient-centerHow can patient-centered bonus system be possible?ed bonus system be possible?

1.1. Clearly setting final aim of bonus systemClearly setting final aim of bonus system

Patient-centered, increasing high Patient-centered, increasing high quality of medical care. quality of medical care.

2. Developing objective measures for 2. Developing objective measures for patient-centered bonus system, measure patient-centered bonus system, measure what is important to patient. Continuity, what is important to patient. Continuity, communication, respect for patient communication, respect for patient preferences and confidentiality, and preferences and confidentiality, and access, and high-quality medical care access, and high-quality medical care should be included at least. should be included at least.

SuggestionsSuggestions ：： How can patient-centerHow can patient-centered bonus system be possible? ed bonus system be possible? （（ contcont

i.i.））3. Set up a consistent bonus system 3. Set up a consistent bonus system

guideline at higher level, ensure guideline at higher level, ensure transparency and implementation. transparency and implementation.

4. Develop overall supportive system 4. Develop overall supportive system environment for patient-centered environment for patient-centered bonus system, including just bonus system, including just macro macro health care systemhealth care system and efficient and efficient medical risk management systemmedical risk management system..

Thank you !Thank you !