My new favorite quote

“I have two sick patients: the person in the bed and the system I work in. My job is to fix both.”

“While the landscape in the UK is very different than that of the US (with far more bureaucratic inertia to overcome),” Watcher notes, “I still believe that acute physicians would do well to be—and be seen as—the MD leaders in systems improvement.”

The passivity of physicians toward their ability to influence the system is something I saw repeatedly during my time in China. And if you thought UK bureaucracy was a stumbling block, Chinese Communist rule might as well be a red brick wall.

Nevertheless, there’s reason to believe that doctors may have the insights to address systemic problems such as distorted price schedules and pervasive informal payments. Doctors I’ve interacted with–especially younger ones–have sheepishly told me about the practice of accepting red packets with a little extra something for services offered. Not because they’re trying to squeeze every penny they can out of patients (although some no doubt see it that way). Because (1) this kind of informal, under-the-table payment sometimes constitutes the majority of their salary, and because (2) there’s not way for them to realistically refuse when it’s passed down to them from senior members of management, unless they would like to get fired for the martyrdom of upholding principles.

The pricing system in China is another interesting case. All providers in China must charge fees according to regulations set by the Price Commission. In an applaudable act of goodwill, the Price Commission has set prices of basic and preventive services low to ensure that they remain affordable for every citizen. So low, in fact, that hospitals soon found themselves going bankrupt because the cost of providing the services exceeded the revenue they were receiving. So then the Price Commission came up with an ingenious solution: set prices for technology-intensive services higher than costs, so that the hospital can cross-subsidize.

The result? Massive overprovision of medically unnecessary, expensive procedures and underprovision of basic and preventive services. In some rural areas, this has resulted in less than 2% of drug prescriptions being “rational”.

In the “demand-inducement” model of healthcare provision, the utility that physicians gain from overprescribing to increase profits is balanced by the discomfort they feel from knowingly harming a patient with medically unnecessary procedures. Assuming that personal medical ethics are still alive in China (and I very much believe they are), perhaps some of the best ways to solve these systemic perverse incentives might come from the doctors themselves.

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