Special Report #4:
Hong Kong Private Practice Survey
 President and Fellows of Harvard College
Team members of this report
School of Public Health, Harvard University
Professor Winnie Yip
Professor William Hsiao
Anupa Bir
Hong Kong Medical Association
Dr. Kin-Hung Lee
Dr. Kai Ming So
And Council Members
The private practice survey was conducted jointly by the Hong Kong Medical
Association and Harvard University in 1998. The primary objective of the survey is
to provide up-to-date, fair and accurate descriptions of private practices in Hong
Kong. This information is important background information to the overall study of
the strengths and weaknesses of the Hong Kong health care system, as well as to the
development of viable alternative financing and delivery options.
The survey collected information on practice capacity, payment arrangements,
practice expense, charges, referral patterns and views about participation in
managed care. The specific questions that the private provider survey attempts to
answer include:
1. What is the capacity of the private sector to treat more patients?
2. Given practice expense patterns, what volume and fee level need to be assured in
order for private practice to survive?
3. How, and to what extent, does communication take place between public and
private providers?
4. To what extent has managed care and contract medicine penetrated into private
practice?
Other than findings for the entire sample, results were also presented separately for
generalists and specialists, and for Estate Doctors Association (EDA) members and
non-members. In instances where differences between the mean and median are
large, both are reported.1
Of approximately (3800) members of the Hong Kong Medical Association in private
practice who received the survey, 603 responses were received. The response rate is
16%2. Given the relatively low response rate, the generalizability of the results
should be interpreted with caution. Nonetheless, this survey provides information
on the major areas of private practice that does not exist at present in Hong Kong.
1. Background
The physicians who responded to this survey had an average of 13 years of
experience in private medical practice. Almost half, 44% reported practicing as
general practitioners only, 24 % practiced in a specialty only, and 32% practiced in
both general medicine and specialty care. Of those who only practiced as specialists,
the most frequently reported specialties were Pediatrics, Obstetrics and
Gynaecology, Opthamology, Orthopedics, and Psychiatry. The physicians who
reported both general and specialty practices had different specialties. The most
common ones being Family Medicine, Pediatrics, General Surgery and Internal
Medicine.
1
2
This means that the distribution of the variable in interest is skewed.
The 1996 HKMA Survey on Physicians’ Fees had a response rate of 20%.
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Report #4: Private Practice Survey
Other than being members of HKMA, 40% of the respondents were also members of
the Estate Doctors Association, and 18% were members of other associations,
including Practicing Estate Doctors Association, Chinese Doctors Association, and
the Public Doctors Association.
Eighty two percent of respondents practiced in one private clinic, while 15%
practiced in 2 clinics. Most physicians report that they are in solo practice (80%),
while 11% are in multispecialty practice and 7% in a single specialty practice.
Almost all (93%) of EDA doctors are in solo practice as compared to 77% of non
EDA doctors (Tables 1a and 1b).
2. Practice Capacity
The sample of private physicians responded that they worked an average of 40 hours
per week, seeing an average of 36 patients daily. More than 80% of physicians
expressed that they would like to see more patients. On average, they would like to
see 60 more patients a week.
Consistent with expectation, generalists had higher patient volume than specialists.
Generalists worked 46 hours per week, and saw 44 patients per day. In comparison,
specialists practiced 35 hours per week and saw 30 patients per day. Generalists
responded that they would like to see 77 more patients per week, while specialists
would like to see 51 more patients per week (Table 1a).
EDA doctors tend to have higher patient volume than non-EDA doctors, partly
because more of the responding EDA doctors were generalists. EDA doctors
worked an average of 46 hours a week and saw 46 patients per day. Non-EDA
doctors worked on average 36 hours per week and saw 30 patients per day. While
80% of non-EDA doctors said that they would like to see more patients, 88% of
EDA doctors would like to see more patients. The number of patients that EDA
respondents would like to see more are significantly higher than those for non-EDA
doctors, 87 compared to 45 per week (Table 1b).
3. Financial Arrangement
This information was of particular interest when the survey was designed, as there
was relatively little known about the newer payment arrangements private practice
face, and the degree to which they are being adopted. The survey specifically
collected information on the following types of financial arrangements (see
attachment):
 Fee for service in which patients pay directly out-of-pocket without any
insurance or medical benefits coverage;
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Report #4: Private Practice Survey
 Medical insurance provided by a third party which reimburses the physicians
their usual fees (e.g. HSBC Medical Insurance, National Mutual, BUPA, etc.,
excluding contract medicine);
 Contract medicine with employer negotiated fee schedule (e.g. Hong Kong
Bank, Jardines, Swire, etc.);
 Contract medicine with discounted fees;
 Contract m4edicine with prepaid medical scheme.
Fee-for-service
Fee-for-service still accounted for the biggest patient share for most private
practices. All physicians in the sample had patients who paid out-of-pocket and they
represented about 70% of the patient share (Tables 2a and 2b).
Medical Insurance
Approximately 90% of the physicians in the sample had patients who were covered
by medical insurance. Among these physicians, 10-15% of their patients was
covered by such insurance. Although non-EDA physicians were more likely to be
covered by medical insurance than EDA doctors, the differences were not
statistically significant. Contrary to expectation, physicians report that only 70-80%
of their usual charges was reimbursed by these insurance schemes (Tables 2a and
2b).
Direct contract with employers
Approximately 60% of the responding physicians had direct contract with employers
who usually reimburse them on a fee-for-service basis. These contracts covered
about 10% (median) of their patients, and they covered a larger share of patients for
non-EDA than for EDA practices. Such contracts usually reimbursed only 50-60%
of the usual charges of the physicians (Tables 2a and 2b).
Contracts: discounted fees
Discounted fees and prepaid schemes are more recent forms of payment
arrangements between physicians and payers in Hong Kong and they cover a smaller
proportion of practicing physicians. About 40% of physicians responded that they
had discounted fee contracts. EDA doctors tend to be more likely to have such
contracts than non-EDA doctors (50 vs 35%). However, such contracts only
covered about 10% of physician total practice volume and they reimbursed about
50% of physicians’ usual fees (Tables 2a and 2b).
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Report #4: Private Practice Survey
Contracts: prepaid
Under prepaid contracts, physicians are paid a pre-agreed sum of money in advance
to provide care for a number of patients. Only about less than 20% of the sample
was covered by prepaid contracts. These contracts reimbursed only about half of the
physicians’ usual fees. However, specialists in the sample reported that only 35% of
their usual fees were reimbursed (Tables 2a and 2b).
4. Practice Expense
The total monthly expenditure reported is approximately HK$100,000. Although
expenses for specialists are slightly higher than for generalists, they are not
statistically significant. About 30% is spent on rent, 30% on medical supplies, and
30% on staff salary (Tables 3a and 3b).
5. Current Charges and Trends
Table 4a presents mean and median charges by generalists and specialists. There are
noticeable and statistically significant differences in charges by class of bed.
Wherever there are significant sample sizes, charges for generalists and specialists
are compared. As expected, specialists charge significantly higher prices than
generalists.
Table 4b presents charges for EDA and non-EDA doctors. For almost all cases for
second and third class beds, EDA charges are significantly lower than non-EDA
charges.
Table 4c compares charges for years 1996 and 1998 for generalists and specialists.
Over time, charges have remained relatively stable, with some minor drops for GPs
and increase for SPs.
6. Referrals
In the analysis of care in the health care system in Hong Kong, the interface between
the public and private sectors has been carefully examined. Any patient being
referred from one physician or institute to another relies on the information being
transferred in order for informed decisions to be made. This section of the survey
collected information on referral practices. Overall, responding physicians refer
about 8 patients a month to public MDs or institutions. Among the referring
physicians, more than 50% of them receive reports from the referred physicians less
than 7-10% of times. The majority waited until the patients return next time to find
out the results of referral. On the contrary, referred physicians in the private are
6
Report #4: Private Practice Survey
much more likely to report back to the referring physicians. The most common form
of communication between referral is through written letter. This implies that the
quality (e.g. thoroughness, clarity, etc) of the letter is critical in the referral system of
Hong Kong. Referral patterns between generalists and specialists, and EDA and
non-EDA doctors are relatively similar (Tables 5a and 5b).
7. Attitudes and reactions to managed care
The majority of respondents (76%) feel threatened by managed care. The most
commonly cited reason for participating in managed care is to increase patient load
(~70%). On the other hand, the most commonly cited reasons for NOT participating
in managed care plans are low financial reimbursement and the fear of loss of
autonomy (Tables 6a and 6b).
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Report #4: Private Practice Survey
Table 1a. PRACTICE INFORMATION
Q. no.
7
8
9
9b
10a
10b
10c
Survey question
How many hours/wk do you practice in all clinics?
How many patients/day do you see in all clinics?
Would you like to see more patients/week? Yes(%)
How many more patients would you like to see
weekly?
Type of practice:
 Solo
 Single specialty partnership
 Multispecialty partnership
GPs
mean
46
44
86%
77
SD
15
26
87
87%
4%
10%
Specialists
mean
35
30
80%
51
SD
14
29
63
80%
10%
11%
Table 1b. PRACTICE INFORMATION
Q. no.
7
8
9
9b
10a
10b
10c
Survey question
How many hours/wk do you practice in all clinics?
How many patients/day do you see in all clinics?
Would you like to see more patients/week? Yes(%)
How many more patients weekly?
Type of practice:
 Solo
 Single specialty partnership
 Multispecialty partnership
8
EDA
mean
46
46
88%
87
93%
0.2%
13%
SD
16
29
96
non EDA
mean
36
30
79%
45
SD
14
26
56
77%
10%
15%
Report #4: Private Practice Survey
Table 2a. PAYMENT ARRANGEMENTS
11
Are you a paid-salary staff of any private
clinic?
12
Do you share profit in any private clinic?
13
What % of all patients pay fee-for-service
(out-of-pocket)?
14
What % of all patients are covered by medical
insurance?
15
What % of your charges are reimbursed by
medical insurance?
16
What % of patients are covered by direct
employer contracts?
17
What % of your charges are reimbursed by
direct employer contracts?
18
What % of patients are covered by discounted
FFS contract?
19
What % of your charges are covered by
discounted FFS contract?
20
What % of patients are covered by prepaid
contract?
21
What % of your charges are reimbursed by
prepaid contract?
NA: the question does not apply to the respondent
GPs (%)
Mean SD
13
Median
NA
Specialists (%)
Mean SD
Median
10
NA
19
68
28
80
16
69
24
75
15
18
10
17
18
10
64
40
80
12
59
40
70
9
19
24
10
41
13
17
8
40
51
33
60
38
48
32
50
44
14
14
10
62
12
15
5
53
47
28
55
55
43
30
50
63
16
18
10
78
17
17
10
79
54
34
60
80
40
32
35
8
Median
NA
Non-EDA (%)
Mean SD
Median
13
Table 2b. PAYMENT ARRANGEMENTS
11
Are you a paid-salary staff of any private
clinic?
12
Do you share profit in any private clinic?
13
What % of all patients pay fee-for-service
(out-of-pocket)?
14
What % of all patients are covered by medical
insurance?
15
What % of your charges are reimbursed by
medical insurance?
16
What % of patients are covered by direct
employer contracts?
17
What % of your charges are reimbursed by
direct employer contracts?
18
What % of patients are covered by discounted
FFS contract?
19
What % of your charges are covered by
discounted FFS contract?
20
What % of patients are covered by prepaid
contract?
21
What % of your charges are reimbursed by
prepaid contract?
NA: the question does not apply to the respondent
9
EDA(%)
Mean SD
9
NA
13
72
24
80
20
68
27
75
12
14
8
19
20
10
66
42
84
12
58
39
70
10
14
20
5
43
17
21
10
40
52
34
60
45
51
32
50
43
11
11
8
48
15
17
10
65
45
27
50
49
45
30
50
66
21
20
15
78
14
16
7
79
48
32
60
81
47
34
50
80
Report #4: Private Practice Survey
Table 3a. PRACTICE EXPENSE
22
23
24
25
Total monthly expense for your practice (HK$)
% of total expenses spent on rent
% of total expenses spent on medical supplies
% of total expenses spent on staff salary
GPs (%)
Mean SD
96527 92904
31
15
30
23
28
14
Median
80000
30
30
25
Specialists (%)
Mean
SD
119017 129177
29
23
32
17
27
12
Median
100000
30
30
25
Table 3b. PRACTICE EXPENSE
22
23
24
25
Total monthly expense for your practice
(HK$)
% of total expenses spent on rent
% of total expenses spent on medical supplies
% of total expenses spent on staff salary..
EDA (%)
Mean
SD
113480 99155
Median
80000
non EDA (%)
Mean
SD
115600 132698
Median
90000
28
30
27
25
25
25
32
31
28
30
30
25
14
24
13
10
24
17
13
Report #4: Private Practice Survey
Table 4a. CHARGES
26a1
26a2
26a3
hospital daily charge 1 class
hospital daily charge 2 class
hospital daily charge 3 class
GPs (HK$)
Mean SD
1092
598
745
289
514
227
26b1
26b2
26b3
bedside procedure charge 1 class
bedside procedure charge 2 class
bedside procedure charge 3 class
1853
1318
922
26ci1
26ci2
26ci3
ultra major operative procedure 1 class
ultra major operative procedure 2 class
ultra major operative procedure 3 class
NA
NA
NA
70347
48077
38170
42094
25749
78589
60000
45000
30000
26cii1
26cii2
26cii3
major operative procedure 1 class
major operative procedure 2 class
major operative procedure 3 class
NA
NA
NA
42338
28502
18104
25403
15181
9157
38000
25000
15000
26ciii1
26ciii2
26ciii3
intermediate operative procedure 1 class
intermediate operative procedure 2 class
intermediate operative procedure 3 class
NA
NA
NA
26160
17669
11974
17762
12170
9320
21000
15000
10000
26civ1
26civ2
26civ3
minor operative procedure 1 class
minor operative procedure 2 class
minor operative procedure 3 class
3249
2471
1754
2476
1680
1145
2500
2000
1500
8229
6376
3619
6076
8313
2178
7500
5000
3200
27ai
27aii
27aiii1
27aiii3
GP average charge- regular consultation
GP average charge- extended consultation
GP average charge- simple procedure
GP average charge- complex procedure
186
247
327
1125
75
118
234
821
170
200
270
1000
250
336
486
1657
112
182
451
1276
200
300
300
1000
27bi
27bii
27biii1
27biii3
Specialist average charge -regular consultation
Specialist average charge -extended consultation
Specialist average charge -simple procedure
Specialist average charge -complex procedure
NA
NA
NA
NA
430
616
777
2988
190
326
671
3853
400
500
600
2000
18
13%
2%
20
28
number of patients you ordered labs/xrays for/wk
17
29
do you own lab facilities
16%
30
is your clinic located in a public housing estate
26%
Note: refer to survey for description of procedure types.
NA: sample size too small to calculate valid summary statistics.
11
1104
785
532
25
Median
1000
700
500
Specialists
Mean
1598
976
602
(HK$)
SD
685
363
249
Median
1500
900
600
1500
1000
800
3570
2758
1568
2682
3235
1198
3000
2000
1000
Report #4: Private Practice Survey
Table 4b. CHARGES
26a1
26a2
26a3
hospital daily charge 1 class
hospital daily charge 2 class
hospital daily charge 3 class
EDA (HK$)
Mean
SD
1142
423
765
231
512
158
26b1
26b2
26b3
bedside procedure charge 1 class
bedside procedure charge 2 class
bedside procedure charge 3 class
2471
1744
1284
26ci1
26ci2
26ci3
ultra major operative procedure 1 class
ultra major operative procedure 2 class
ultra major operative procedure 3 class
NA
NA
NA
26cii1
26cii2
26cii3
major operative procedure 1 class
major operative procedure 2 class
major operative procedure 3 class
30669
21816
13584
18204
11254
6024
30000
20000
12000
44382
29697
18785
25698
15359
9288
40000
26500
16000
26ciii1
26ciii2
26ciii3
intermediate operative procedure 1 class
intermediate operative procedure 2 class
intermediate operative procedure 3 class
17394
11572
7408
10078
5128
3145
15000
10000
8000
26949
18284
12192
18025
12436
9572
22000
15000
10000
26civ1
26civ2
26civ3
minor operative procedure 1 class
minor operative procedure 2 class
minor operative procedure 3 class
4777
3468
2254
2982
2023
1271
4000
3500
2000
8342
6562
3659
6560
8714
2344
8000
5000
3000
27ai
27aii
27aiii1
27aiii3
GP average charge- regular consultation
GP average charge- extended consultation
GP average charge- simple procedure
GP average charge- complex procedure
174
223
327
1155
51
79
243
899
170
200
250
900
247
342
453
1471
115
181
415
1121
215
300
350
1000
27bi
27bii
Specialist average charge -regular consultation
Specialist average charge -extended
consultation
Specialist average charge -simple procedure
Specialist average charge -complex procedure
309
417
111
191
300
400
453
649
193
330
400
500
553
1881
424
1283
455
1500
828
3128
730
3689
600
2000
20
25
27biii1
27biii2
28
number of patients you ordered labs/xrays
14
for/wk
29
do you own lab facilities
14%
30
is your clinic located in a public housing estate 27%
Note: refer to survey for description of procedure types.
NA: sample size too small to calculate valid summary statistics.
12
2051
130
1004
16
Median
1000
800
500
non EDA (HK$)
Mean
SD
1602
735
977
378
603
268
Median
1500
900
600
2000
1500
1000
3463
2679
1464
2618
3274
1134
3000
2000
1000
71646
48898
31043
41001
25844
14020
60000
45000
30000
16%
3%
Report #4: Private Practice Survey
Table 4c. CHARGES OVER TIME
26a1
26a2
26a3
hospital daily charge 1 class
hospital daily charge 2 class
hospital daily charge 3 class
1996
GP
Median
1200
800
400
26b1
26b2
26b3
bedside procedure charge 1 class
bedside procedure charge 2 class
bedside procedure charge 3 class
2500
1500
1000
1500
1000
800
2750
1900
1000
3000
2000
1000
26ci1
26ci2
26ci3
ultra major operative procedure 1 class
ultra major operative procedure 2 class
ultra major operative procedure 3 class
70000
30000
20000
NA
NA
NA
60000
40000
25000
NA
NA
NA
26cii1
26cii2
26cii3
major operative procedure 1 class
major operative procedure 2 class
major operative procedure 3 class
27500
15000
10000
NA
NA
NA
35000
20000
15000
NA
NA
NA
26ciii1
26ciii2
26ciii3
intermediate operative procedure 1 class
intermediate operative procedure 2 class
intermediate operative procedure 3 class
15000
9500
5000
NA
NA
NA
20000
13000
8000
NA
NA
NA
26civ1
26civ2
26civ3
minor operative procedure 1 class
minor operative procedure 2 class
minor operative procedure 3 class
5000
3500
2200
2500
2000
1500
8000
5000
3000
7500
5000
3200
27ai
average charge- regular consultation
150
27aii
average charge- extended consultation
200
27aiii1 average charge- simple procedure
300
27aiii3 average charge- complex procedure
1000
NA: sample size too small to calculate valid summary statistics.
180
230
300
1000
350
500
600
2000
400
500
500
2000
13
1998
GP
Median
1000
700
500
1996
SP
Median
1450
800
500
1998
SP
Median
1500
900
600
Report #4: Private Practice Survey
Table5a Referral
31
32
33a
33b
33c
referrals/ month to public institution/MD
for what % did you receive reports from ref MD
did you try to find out from family (%)
did you wait until patients next visit (%)
did you try to contact the referred MD (%)
GPs
(Mean|Median)
10.7
20
7
41
88
7
34
35
36a
36b
36c
referrals/ month to private institution/MD
for what % did you receive reports from ref MD
did you try to find out from family (%)
did you wait until patients next visit (%)
did you try to contact the referred MD (%)
7.7
74
29
74
33
37
37a
37b
37c
37d
37e
how do you transfer patient records when referred
sent copy to referred MD (%)
gave copy to pt to take to ref MD (%)
sent a letter with a summary of pt conditions (%)
contact referred MD by phone (%)
other (%)
3
9
90
25
1
7
14
93
42
2
5
12
92
35
1
38
38a
38b
38c
what form of patient records do you keep
paper? (%)
computer? (%)
both? (%)
78
4
22
79
2
21
79
3
21
90
Specialists
(Mean|Median)
5.7
27
10
38
83
22
Overall
(Mean|Median)
8
24
10
39
85
15
6.8
80
28
64
52
7.2
77
28
68
43
90
90
Table5b
31
32
33a
33b
33c
referrals/ month to public institution/MD
for what % did you receive reports from ref MD
did you try to find out from family (%)
did you wait until patients next visit (%)
did you try to contact the refered MD (%)
EDA
(mean|med)
10.7
19
5
36
89
6
34
35
36a
36b
36c
referrals/ month to private institution/MD
for what % did you receive reports from ref MD
did you try to find out from family (%)
did you wait until patients next visit (%)
did you try to contact the refered MD (%)
6.8
73
25
76
30
37
37a
37b
37c
37d
37e
how do you transfer patient records when referred
sent copy to referred MD (%)
gave copy to pt to take to ref MD (%)
sent a letter with a summary of pt conditions (%)
contact referred MD by phone (%)
other (%)
2
11
90
25
1
7
13
93
41
1
5
12
92
35
1
38
38a
38b
38c
what form of patient records do you keeppaper? (%)
computer? (%)
both? (%)
79
3
19
78
3
23
79
3
21
14
90
non EDA
(mean|med)
6.2
27
10
41
82
21
Overall
(mean|med)
8
24
10
39
85
15
7.5
79
30
63
52
7.2
77
28
68
43
90
Report #4: Private Practice Survey
70
Table 6a. MANAGED CARE REACTIONS
Do you feel threatened by managed care- yes(%)
GPs
77
Specialists
76
Overall
76
Reasons to participate in contract medicine
 Increase patient load (%)
 More regular income and caseload (%)
 Lower admin burden (%)
 Reduce overhead (%)
 Other (%)
74
75
12
13
7
70
80
8
10
12
72
77
9
12
10
Main reasons for refusing to participate
 Busy enough (%)
 Concerned about quality of care (%)
 Feel autonomy will be compromised (%)
 Financial reimbursement too low (%)
 Concerned about financial risk (%)
 Administrative burden (%)
 Philosophically opposed (%)
 Other (%)
38
53
63
73
11
22
32
6
42
59
68
78
10
31
41
7
39
57
66
76
10
27
36
7
Do you feel threatened by managed care- yes (%)
EDA
85
non EDA
71
Overall
76
Reasons to participate in managed care (%)
 Increase patient load
 More regular income and caseload
 Lower admin burden
 Reduce overhead
 Other
77
79
6
11
8
68
76
11
12
11
72
77
9
12
10
Reasons for refusing to participate in managed
care (%)
 Busy enough
 Concerned about quality of care
 Feel autonomy will be compromised
 Financial reimbursement too low
 Concerned about financial risk
 Administrative burden
 Philosophically opposed
 Other
41
53
62
80
10
21
29
4
38
59
69
73
11
31
41
8
39
57
66
76
10
27
36
7
Table 6b. MANAGED CARE REACTIONS
15
Report #4: Private Practice Survey