The Doctor-patient Relationship and Overprescription in Chinese Public

Hospitals: Defensive Medicine and its Implications for Health Policy Reform

Dr He Jingwei, Alex 和經緯 博士Assistant Professor

Department of Asian and Policy StudiesThe Hong Kong Institute of Education

Health care in China

• Heavy deterioration since 1980s• 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!

• Overprescribing drugs, high-tech diagnostic tests and profitable procedures

Average drug and clinical test expenditures in comprehensive

hospitals, 2002-2011

20022003200420052006200720082009201020110

500

1000

1500

2000

2500

3000

3500

0

10

20

30

40

50

60

70

80

90

100

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

Unit: RMB yuan

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• Test kickbacks• Fee-for-service in paying providers

However, an alternative explanation

• My interviews of 22 medical doctors in Guangdong, Shanxi, Fujian and Zhejiang, from 2010 to 2012.

• “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。”

This may not be just an excuse….

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

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 light of the rising tensions between doctors and patients, do Chinese physicians overprescribe because of concerns on medical disputes and liability?

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.

Profile of respondents

Characteristics N=504Gender Male 252 (50.0%)

Female 252 (50.0%)Hospital level Class III 122 (24.2%)

Class II and Class I 382 (75.8%)

Technical titleJunior 158 (31.3%)Middle 230 (45.6%)Senior 116 (23.1%)

Specialty

Internal medicine 146 (29.0%)Surgery 225 (44.6%)

Obstetrics & gynecology

68 (13.4%)

Pediatrics 38 (7.5%)Others 27 (5.5%)

EducationMaster and above 110 (21.8%)

Bachelor 344 (68.3%)Diploma and below 50 (9.9%)

Frequency of medical disputes encountered in the past 12 months,

assorted by specialty

Frequen

cy

Internal

medicine

Surgery Obstetrics

&

gynecolog

y

Pediatric

s

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

146 225 68 38 27 504

(100%)

Form of disputes1. Complaints to the hospital or health administration

(N=232)2. Verbal conflicts (N=204)3. Physical assaults (N=64, 12.7%)

Reasons for medical disputes reported by respondents

Medical error

Patients' unreasonable complaint

Medical harasser

Patients' mistrust

Communication problems

Financial issues

Hospital environment

26

164

48

110

118

82

48

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 over-report their deviant behaviors. Therefore, this study can still provide a minimum estimate of prevalence. – 19.4% (N=98) never; 61.9% (N=312) sometimes; 18.7%

(N=94) often

Regression results using ordered probit model

Variable Model 1 Model 2 Model 3Male -.132 (.111) -0.085 (0.113) -.031 (.114)Age .029 (.010)** .033 (.010)*** .033 (.010)***EducationMaster or above -.151 (.491) -.131 (.500) -.002 (.499) Bachelor -.429 (.490) -.366 (.504) -.277 (.503) Diploma or below -.094 (.523) .034 (.540) .038 (.539)Internal medicine .135 (.150) .318 (.158)* .329 (.159)*Surgery .143 (.137) .213 (.143) .182 (.144)Class III Hospital -.480 (.148)*** -.584 (.153)*** -.529 (.156)***Technical Title Middle -.385 (.143)** -.407 (.144)** -.364 (.146)** Senior -.462 (.215)* -.495 (.219)* -.535 (.221)**Monthly payroll income (yuan) 8,001-10,000 -1.496 (.505)** -1.632

(.501)**-1.552 (.499)**

6,001-8,000 -1.579 (.499)** -1.796 (.497)***

-1.665 (.495)***

4,001-6,000 -1.580 (.508)** -1.848 (.507)***

-1.760 (.505)***

< = 4,000 -1.103 (.564)* -1.322 (.563)* -1.146 (.564)*Workload 31-50/day - .567 (.153)*** .550 (.154)*** 10-30/day - .709 (.161)*** .616 (.165)*** < 10/day - .303 (.281) .182 (.285)Frequency of disputes 1-3 times - - .526 (.195)**0 - - .770 (.195)***/Cut1 -2.104 (.794) -1.615 (.800) -.815 (.882)/Cut2 -.243 (.792) .309 (.800) 1.151 (.824)Log likelihood -443.529 -432.696 -424.421N 504 504 504

Standard errors in parentheses; *p < 0.05, **p < 0.01, ***p < 0.001

Conclusion and implication

• While low income still drives Chinese physicians to overprescribe, previous experiences of medical disputes also motivate 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.