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 Studies
The 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
3500
100
Unit: RMB yuan
90
3000
80
2500
70
60
2000
50
1500
40
30
1000
20
500
10
0
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
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
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
Gender
Hospital level
Technical title
Specialty
Education
Male
Female
Class III
Class II and Class I
Junior
Middle
Senior
Internal medicine
Surgery
Obstetrics & gynecology
Pediatrics
Others
Master and above
Bachelor
Diploma and below
N=504
252 (50.0%)
252 (50.0%)
122 (24.2%)
382 (75.8%)
158 (31.3%)
230 (45.6%)
116 (23.1%)
146 (29.0%)
225 (44.6%)
68 (13.4%)
38 (7.5%)
27 (5.5%)
110 (21.8%)
344 (68.3%)
50 (9.9%)
Frequency of medical disputes encountered
in the past 12 months, assorted by specialty
Frequency
Internal
Surgery
medicine
Obstetrics & Pediatrics
Others
Total
gynecology
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 disputes
1.
2.
3.
Complaints to the hospital or health administration (N=232)
Verbal conflicts (N=204)
Physical assaults (N=64, 12.7%)
Reasons for medical disputes reported by
respondents
48
Hospital environment
82
Financial issues
118
Communication problems
110
Patients' mistrust
48
Medical harasser
164
Patients' unreasonable complaint
Medical error
26
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.
– 19.4% (N=98) never; 61.9% (N=312) sometimes; 18.7% (N=94) often
Regression results using ordered probit model
Variable
Model 1
-.132 (.111)
.029 (.010)**
Male
Age
Education
Master or above
-.151 (.491)
Bachelor
-.429 (.490)
Diploma or below
-.094 (.523)
Internal medicine
.135 (.150)
Surgery
.143 (.137)
Class III Hospital
-.480 (.148)***
Technical Title
Middle
-.385 (.143)**
Senior
-.462 (.215)*
Monthly payroll income (yuan)
8,001-10,000
-1.496 (.505)**
6,001-8,000
-1.579 (.499)**
4,001-6,000
-1.580 (.508)**
< = 4,000
-1.103 (.564)*
Workload
31-50/day
10-30/day
< 10/day
Frequency of disputes
1-3 times
0
/Cut1
-2.104 (.794)
/Cut2
-.243 (.792)
Log likelihood
-443.529
N
504
Model 2
-0.085 (0.113)
.033 (.010)***
Model 3
-.031 (.114)
.033 (.010)***
-.131 (.500)
-.366 (.504)
.034 (.540)
.318 (.158)*
.213 (.143)
-.584 (.153)***
-.002 (.499)
-.277 (.503)
.038 (.539)
.329 (.159)*
.182 (.144)
-.529 (.156)***
-.407 (.144)**
-.495 (.219)*
-.364 (.146)**
-.535 (.221)**
-1.632 (.501)**
-1.796 (.497)***
-1.848 (.507)***
-1.322 (.563)*
-1.552 (.499)**
-1.665 (.495)***
-1.760 (.505)***
-1.146 (.564)*
.567 (.153)***
.709 (.161)***
.303 (.281)
.550 (.154)***
.616 (.165)***
.182 (.285)
-1.615 (.800)
.309 (.800)
-432.696
504
.526 (.195)**
.770 (.195)***
-.815 (.882)
1.151 (.824)
-424.421
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.