David's Health Policy Blog

The US and China have a similar problem: getting patients to use less expensive locations for routine medical care. Consumers in both countries with choices want the “best”. Regulators and payers in both countries are struggling to find a mix of incentives that will convince patients to use lower cost facilities.

Every government official, academic researcher, and medical staff person I have met so far in China has emphasized the critical importance of getting more Chinese citizens to use local community health centers for their primary and routine care. Many hoped something like the British primary care gatekeeping system would emerge to contain costs, increase quality, and provide greater equity. They fear that unless care seeking patterns change health system costs will become unsustainable.

When I asked my interviewees what they and their families do when they need any medical care every one of them said they go directly to the highest level teaching hospital. Every other person I met from tour guides to high government officials said the same thing. Not feeling well? Head for the biggest hospital, even though the wait might be long, the doctor impolite and rushed, and the cost high. It’s a problem.

Like most institutions in China for the past 5000 years, there is a hierarchy in the medical care system. At the base are primary health centers located in most urban neighborhoods and rural communities. They have doctors, often both “western” and traditional Chinese Medicine, nurses, and other health professionals. The facilities include outpatient clinics, pharmacies, again often western and traditional medicines, basic labs, xray, and often a small number of beds that provide rehabilitation and palliative care. They are owned by the local governments. The staff are government employees.

In the middle are community hospitals that provide maternity, pediatric, medical and general surgery services organized by specialty. They have inpatient and outpatient services. They often have emergency rooms that are open at night. These hospitals are staffed by full time doctors, nurses and other personnel. The hospitals are owned by the local and district governments but are not formally affiliated with a medical school. I was told many are underutilized.

The top tier are tertiary hospitals affiliated with a medical school. These are almost all in cities and can have more than 1000 beds and large outpatient clinics. They are owned by the local or province government. The medical staffs are organized by specialty departments. The most senior doctors often have both hospital and medical school appointments but all are government employees. Some of the senior physicians have ways to supplement their incomes, including through informal gifts and payments from patients.

Patients in China are free to go to any health facility at any time. There are no gatekeepers. A majority of Chinese citizens, I was repeatedly told, go the to teaching hospitals, bypassing health centers and community hospitals to get there. Repeat visitors usually know the clinic or doctor they want to see so they go to the appointment window to get an appointment (hopefully that day). New patients or a patient with a new problem start at a triage desk where a doctor or nurse hears why the patients came and tells them the clinic they should use. Patients go to a window to make an appointment and then to another to pay the physician and testing fees in advance, some of which are now covered by insurance. They pay again at the end of the visit for the medications they need and any treatments they received during the visit. (More on the evolution of insurance and out of pocket costs in another post).

Despite the large numbers of people at the hospitals, patients expect to be seen without delay. The waits they encounter increase tension between doctors who feel overworked and harried by the heavy patient loads and the patients and family members who expect to be seen immediately. I witnessed several heated exchanges even during brief visits to community centers and hospitals. Doctors told me confrontations are very frequent. Nevertheless, the tertiary hospital is the place of choice in China.

Why? There appears to be an almost total lack of confidence in the quality of care at the community centers. To understand why, anecdotes may be more important than statistics. One student told me: “Whenever I or one of my friends went to a community center, all they did was send us to the hospital to see a specialist, so why bother to go there first?” Another said: “Only old people use the community centers because they can get their medicine there for less money and it is convenient. But they go to the hospital when they are sick. “ (Doctors at the community health centers I visited confirmed this.)

A middle aged former teacher said: “Of course we all go to the hospital. Everybody knows the doctors at the health centers aren’t any good. The best doctors are always at the tier three hospitals”. Several academics explained why this perception is so widely held. Admission to medical school is based on one national exam. The students with the highest grades are admitted to the highest ranking medical schools where the focus is entirely on training specialists. Who will work in tertiary care hospitals. Students with lower grades on the exam go to regional medical colleges and usually do not get admitted to the specialty training programs. They staff the lower tiered facilities where they get low pay and little respect.

The Chinese government is using financial incentives to get people to select community health centers first. It is simultaneously lowering fees for prescriptions, especially when bought at a community health center, and raising fees for physician visits. In theory the changes are supposed to net out as little change for the patients but there is broad skepticism this is true. I was told by both doctors and academics that higher fees will bring higher respect for physicians and cover some of the loss of profits they have been making on prescription markups. The lower prescription prices are related to new government requirements that prohibit hospitals and doctors from marking up medicine prices as a way of raising revenue for the hospitals and doctors.

The government is also encouraging teaching hospitals to develop “networks” of care with local hospitals and community centers to increase collaboration among them and to get better trained physicians into the community centers, at least part of the time. My sense is the policy makers hope some form of gatekeeping will emerge without having to mandate it. These changes have been talked about for several years but they were formally enacted and start dates announced in early April, 2017. The information systems needed to operate an integrated system do not exist. At the moment, almost all records are still on paper and there is almost no communication back and forth across levels of the system.

A brand new highly innovative hospital I visited is using a home grown application on “We Chat” (the ubiquitous web/phone engine for everything) to post patient’s lab and test results. Patients can download the information to their personal account to show doctors at other facilities. The government has announced a plan and timetable to create a single nationwide medical information/insurance information network for everyone, but the people I met think it is years away.

The US is using similar approaches to get people to use generic medicines, primary care instead of emergency rooms and local hospitals instead tertiary centers through differential co-pays and co-insurance and gatekeeping rules. So far, the results in the US have been modest and mixed. Consumer reaction has been mostly negative, especially on restrictions on using tertiary hospitals. It is far too early to know what the effects will be in China. Jointly examining these policy incentives might be a very interesting way to learn more about both Chinese and American consumer health behavior. Every academic I met was keenly interested in knowing if or how American financial and behavioral incentives work.

Sometimes seeing an entirely new situation clarifies something you have been looking at for years. That is what is happening to me as I got a glance of South Africa and India. All these countries share conditions that make implementing universal health coverage very challenging. (Brazil has these same factors so may face the same problems.)
• They are all federal systems in which individual States/provinces have real political power and significant control over health care delivery.
• They all have parallel public systems for the poor and better funded, private systems delivering care to people who can use private insurance or pay out of pocket.
• They have relatively unequal distributions of wealth.
• People and groups with political influence have easy access to the private delivery system and lack confidence in the public delivery system, especially at the primary care and routine hospital levels.
• People and groups using the private sector have the political clout to prevent efforts to redistribute resources to serve poor or other ethnic groups.

Obamacare will stay in place in the US, at least for a while but I think these factors may limit the country from reaching its goal of universal health coverage and may explain why some of the opposition has been so intense

India and South Africa recently announced major health reforms they hope will lead to universal health coverage over the next few years. Both intend to use an insurance mechanism, controlled at the national level to leverage significant changes in their primary care and regional hospital systems, especially around access, breadth of service and quality. The national governments have limited control over the delivery systems now. They hope the purchasing power they get by controlling insurance payments to the providers will give them more control. Obamacare includes major provisions that try to leverage change in the delivery system both directly and indirectly through its insurance reforms. Obamacare certainly tried to force big changes in State Medicaid programs until the Supremes said no. India and South Africa (and China as well) are trying to layer an insurance system on top of existing publicly owned and budgeted provider organizations. Neither country has yet developed an implementation plan to achieve the systems reform goal and neither has gone far enough down to path to know what kind or form of opposition from local forces will emerge. While insurance reforms have certainly affected provider behavior in the US, it is not clear—to me at least—that they have been particularly effective in improving quality or containing cost. In recent years employer based insurance has actually limited choice and braod access and shifted cost to employees. Private insurance has had very little impact on price or quality around the country.. The public insurance programs like Medicare and Medicaid have had marginally more impact on changing behavior. It is a constant cat and mouse game but the providers have beaten the insurers repeatedly. I wonder what will happen in other countries that rely on insurance mechanisms to change their delivery systems.

The ASHA program in India

Many countries, including the US, are struggling with the issue of how to make better use of lesser trained community health workers to improve effective access to care for poor and socially isolated individuals. India has a program in villages and poor urban areas called the ASHA program. I got to visit an ASHA and one of her clients on a recent visit to a rural health center near Nagpur. I have a wonderful picture but the computer gods are not letting me copy it.

The program is tantalizingly simple. A woman is recruited (the selection process and criteria differ by location) in each village and urban neighborhood. For example there were 17 associated with the rural center I visited and about 40 linked to an urban maternity hospital I visited in Kochi. They get days to weeks of training on very basic issues of pre-natal, maternal and infant care, including how to do a basic pregnancy screen and register pregnant women with the health center. Their major goal is to get women registered for pre-natal care very early in pregnancy and to agree to deliver in a health center or hospital. ASHAs often accompany the women to visits and to the hospital for support. ASHA’s are paid for productivity, not time. They get paid for registering women and for getting them to deliver at a health center or hospital. They can also be paid to conduct specific health outreach or education campaigns that are part of a government initiative. Virtually all ASHA’s are part time, about two hours a day. Some get further training that enables them to take on more health tasks in the village or at the health center.

Birth outcomes have been improving in India and a higher percentage of deliveries are occurring in health centers and hospitals. ASHA’s get some of the credit for this trend. One of the advantages of early and more frequent pre-natal visits is classifying a pregnancy as low or high risk. Women who are high risk are urged to deliver at the higher level hospital. Many health centers now have basic ambulances to transport the women—and those accompanying her—to the hospital when she is due.

Since the incentives paid to ASHAs are very modest, it is fair to ask if money is the only motivating factor. Some observers think it is not about money. Rather, they argue that the ASHA program has been an empowerment program for poor women in villages and urban areas. The ASHA has status in the village. The pregnant women gain both new information about how to safely have a baby and how to seek what they need. An increasing number of women, for example, are demanding to be transferred to the larger hospital for their delivery. The ASHA also plays a major role in breaking the social isolation of rural women by accompanying them to the city hospital, where many would have been afraid to go on their own.

As India moves to implement its new national health policy the prospect of expanding the training and roles of ASHA’s in both individual and village population health is being discussed.

It is well worth reporting that the ASHA and young pregnant woman I visited are participating in a double blind clinical trial. Yes, a full blown high quality clinical trial in a village without electricity or plumbing. They are part of large multi-site study to determine the effect of low dose aspirin taken daily during mid pregnancy will lead to fewer pre term births, low weight babies and lower rates of eclampsia and pre-eclampsia and prenatal mortality. The site leader for the research is Archana Patel and the team at the Lata Medical Research Institute in Nagpur. They are longstanding BUSPH partners with Pat Hibberd and were wonderful hosts for my visit.

The courts may have stopped the Feds from enforcing a ban but it seems the US Consulates either haven’t gotten the word that there is no ban or they have been instructed to put one into effect. India is not on the banned list and has never been a source of anything but people who have made great contributions to the US. Nevertheless, young Muslim physicians I recently met have gotten a clear message: “Muslims need not apply”. Stories are circulating in the medical community about visa applications that were formerly routinely approved are now being denied. As a result, Indian Muslim doctors who were planning to come to the US to complete advanced training or go into practice are already considering going to Canada or Europe. One young physician I met was very interested in coming to the US for a Masters in Public Health. He is going to wait to see if the fever of Muslim hate passes, but he is also now looking hard at alternatives. We should not underestimate the damage that is being done by the Trump led attack on the Muslim religion around the world.

AND ON THE FAILURE TO REPEAL/REPLACE

Word quickly reached even the most remote part of India where we are at the moment. Seen from afar the substance of the repeal effort was about the redistributive intents and effects of health reform. Ryan and Trump seemed perfectly willing to take resources from old people and poor people and give them to rich people. The Freedom Caucus wanted to shift benefits to lower middle income people through lower priced insurance. (They have their facts wrong and their solution won’t work but that is what they are trying to do.) The few moderate Republicans realized that a lot of their constituents were getting subsidies under the existing law and they wanted to preserve them. The Democrats got to sit back and make no choices. Different elements of the public figured accurately that the bill would take resources from them and all these pieces added up to huge majority opposed to the bill.

As I noted in an earlier blog, the Republicans needed the “savings” from killing Obamacare to fund part of their tax cuts for the rich plan. The money isn’t there now and Ryan/Trump are wounded. Out rich friends shouldn’t start spending their new money yet.

The US, South Africa and India have at least one thing in common. In all three the States or Provinces have great influence on health care and public health. Granting or leaving significant State power was a key element in the political compromises that enabled each of these countries to be created in their current form.

States in the US assumed primary responsibility for health from the start. Federal involvement, especially in financing health centers and partnering in Medicaid financing is relatively new and the Supreme Court reinforced the power of the States to say “No” when it slapped down the mandatory Medicaid expansion in the Affordable Care Act.

In South Africa and India primary responsibility for health care and public health were assigned to the existing states or provinces or tribal strongholds. The South African national government provides general per capita grants that are used in part to fund province level care and also provides restricted grants for specific programs such as HIV testing and care. The Indian national government also provides earmarked funds for specific national priorities but the individual States carry a greater total burden for financing health care.

As a result, national population health outcome measures are almost useless as indicators of health system performance or guides for national policy action. It is health outcomes at the State level that really tell the stories. In each of these countries the rates vary dramatically from State to State (Province to Province).(Note to readers: When I am not on the road I will create a chart showing the range of population outcomes in each country as a starting point for more detailed examination of reasons for differences.)

In all three countries there are important State/Province level differences in total population and geography, current income and wealth distribution, education, gender inequality, political leadership, ethnic diversity and religion. The quantity and quality of trained personnel varies greatly by State/Province as does the infrastructure for public health and healthcare. However, listing the differences is only a starting point  from which I will need to pursue answers when time and access to more material allows. However, it is going to become clear pretty fast that explanations for the differences are likely to found upstream in social and economic factors. The question will become why social and economic inequity persists among the States in these countries.

Health care is redistributive. Those of us who are healthier and wealthier always subsidize the care—in some way—of those who are sicker and poorer. (Students in my courses hear me say this dozens of times every semester.) What happens when the gap between those who have wealth and access to care is vast? Will those with the resources share with those who lack them? South Africa is the test case. Wealth in South Africa is less equitably distributed among the population than in almost any other country. The Gini Coefficient is about .69 (the higher the number the less equitable the distribution of wealth).

The Constitution of South Africa includes an explicit right to health care for all as a core responsibility of the government. In 2011 the government set the country on a 14 year path to National Health Insurance. The plan has been most completely described in an official White Paper issued in 2016. The goal is to provide equitable access to quality care for everyone by pooling all the money now spent for health care into a National Health Insurance Fund controlled at the National level. All citizens will be required to enroll in the program. Care will be largely free at the point of service. The White Paper calls for the National Fund to purchase clinical services through contracts with reorganized primary care and hospital networks. Public primary clinics that are now run entirely by nurses are expected to expand their scope of services to meet new national standards by hiring or contracting with physicians now in the private sector. The clinics  will be paid capitation fees for the individuals who select them. Hospitals, both public and private, will be paid on a uniform DRG based system. The effect will be an increase in resources for public clinics and hospitals and a significant decrease in prices to private doctors and hospitals who will be expected to make up these losses by serving many more people. The current private insurance companies will have no or minimal roles in future according to the White Paper. Costs will be managed and quality improved through implementation of a sophisticated electronic medical record system. The White Paper includes calls for greater attention to upstream determinants of health and prevention, but the focus is on curative medical care because, as one senior official said: South Africa has an extraordinarily high burden of disease.The tone of the White Paper is aspirational. It calls for a huge transformation but provides no details on how to get from here to there.

Some economists and public health experts think South Africa spends about enough money and has enough health professionals to care for the population if resources can be reallocated.  South Africa spends  8.8 % of its GDP on health, which is about the average for OECD countries. However, 84% of the population relies on a public sector delivery system that consumes about 4.1% of GDP. 16% of the population relies on an entirely separate private insurance and delivery system that consumes 4.4% a bit more than the public sector.

This inequity plays out in stark terms and is the core of the current debate about national health reform in South Africa.  Virtually every conversation, policy paper, newspaper or taxi-cab interview starts with some version of this inequity. For example the Minister of Health recently noted that 80% of medical specialists are in private practice, serving only 16% of the population. He said that one private hospital in Johannesburg has 30 affiliated gynecologists while the entire province of Limpopo in the Northern part of the country has seven South African gynecologists for its 40 public hospitals. (Cape Times, Feb 21, 2017) He said the private gynecologists earn more than five times what the public sector specialists earn but that under National Health Reform, their excessive fees would be reduced and they would take care of more poor people.

How reallocation is supposed to happen is completely unsettled. There are small government sponsored work groups developing specific proposals but none of the issues of governance, finance, operations or professional autonomy have been settled. New policy development is already stalling out in anticipation of a national election that will bring new leadership to the country in 2019.

Every government official and professional level person I met in my recent trip to South Africa has private insurance and uses the private system exclusively. Some shuddered at the thought of their doctors’ offices and hospitals being crowded with new patients. These senior people had considerable sympathy for the plight of those who rely on the public system but in the same breadth indicated that they didn’t want to give up what they now had.

Virtually all public employees and their dependents have some form of private medical insurance. Public employees will have to implement national health insurance policies but  concern for themselves and their families may be more powerful than political appeals for “solidarity” in health reform. They are already moving very slowly on health reform.

Not one of the craftspeople, workers, and small business owners I met has private insurance. Almost all said they “don’t get sick” or use the public system. They said it was “ok”. Spending the whole day waiting on lines was just part of going to clinic or hospital. Residents of a shanty town in Soweto told me they would go to a clinic nearby or to the big hospital—but they have to walk the several miles to get there because they can not afford a taxi. Only one uninsured person told me he had a private doctor whom he paid out of pocket. There was virtually no awareness that the government had proposed something called national health insurance and therefore no expectation that their own access to care might change. For them, South Africa has universal health care. It just doesn’t work very well. My questions to experts about consumer expectations for health reform were met with blank stares.

There is deep and mutual distrust between the public and private sector leaders at the national and provincial levels. However collaboration among the actors is a core component of the proposed reforms. High level government officials argue the distrust can be managed and resolved through stringent contracts. Academics who have studied provincial and district operations on the ground dismiss the possibility of writing and enforcing sophisticated contracts. One of them said: “The people promoting contracting have no idea what actually goes on at the operating level. They have never been there.”

All of the people I interviewed were deeply skeptical that progress would be made toward national health insurance anytime soon. One very senior official who was a prime author of the White Paper suggested I stop thinking about health insurance. Rather, think about delivery system reform. Nevertheless, there was a very strong feeling of optimism that  health equity could be improved among most of my interviewees. They pointed to the successful implementation of HIV/AIDS testing and treatment throughout the country in the public sector. We did that, they all said, so maybe we can fix health equity as well. I hope they are correct.