The doctor–patient relationship, defensive medicine and overprescription in Chinese public hospitals: Evidence from a cross-sectional survey in Shenzhen city
Introduction
Studies on provider behaviors occupy the central stage of health economics and policy research. A particular strand of the literature focuses on medical malpractice and its effects on provider behaviors. Defined as medical practice based on fear of legal liability rather than on patients' best interests, the concept of defensive medicine describes physicians' distorted behaviors in response to potential threats stemming from malpractice litigation (Kessler et al., 2006). In the global escalation of health care costs, defensive medicine has been increasingly recognized as a perverse engine as it motivates physicians to provide lots of unnecessary services. Explanations for physicians' defensive behaviors, however, vary. Many studies especially those based on the US context attribute defensive medicine to medical malpractice litigation systems whereas others have sought to explain it from physicians' internal emotional mechanisms rather than from external modifier of behaviors (Cunningham and Wilson, 2010).
This article joins the debate with a fresh case from China, where empirical studies analyzing defensive medicine are scant. Based on the rich body of literature on the country's health system, this article notes that defensive behaviors in the Chinese context mainly take the form of overprescribing diagnostic tests, procedures and drugs, a problem plaguing the country's health system for long. Defying the traditional explanations for defensive medicine, this study, with a survey of physicians in a Chinese city, reveals that in a country where medical malpractice lawsuits are rare, physicians' self-perceived threats from patients may constitute a major reason for defensive practices. Echoing the target income hypothesis, this study also reinforced the finding that low remuneration continues to drive Chinese physicians towards overprescribing. Despite its nature as a city-level case study, this article represents the first attempt that examines the escalating tension between doctors and patients in China and its effects to medical practices.
Section snippets
Literature review
According to the US Office of Technology Assessment (1994), “[d]efensive 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.” There is a rich body of literature encompassing both theoretical modeling and empirical evidence which demonstrates the wide practice of defensive medicine not only in the US but also in other countries (Hershey, 1972,
Research question
China is in the midst of carrying out an ambitious program of national health care reforms. Launched in 2009, this initiative is intended to overhaul a system which has deteriorated significantly in the past three decades, and build a comprehensive and universal replacement by 2020 (Chen, 2009). An extensive literature documents the sorry condition of China's health care since the 1980s. Double-digit inflation in health expenditure and reduced access to care are the main symptoms of decline (
Background
Chinese health care after the foundation of the People's Republic was structured to resemble the Soviet system. Private practices were quickly eradicated as capitalist. All hospitals were virtually public. Governments funded capital investment while hospitals' operational costs were recovered by heavy subsidies (Gu, 2001). Patients' fees were set at nominal levels to ensure accessibility. Health workers in hospitals were state employees entitled to quasi-civil service status, receiving fixed
Methodology
While the defensive practice of medicine is clinically unnecessary and inflates cost, there are major methodological challenges involved in measuring it. Firstly, medical decision making is a complex function of various factors. It is difficult in practice to single out the effect of the threat of malpractice suits. Secondly, since not all practices motivated by considerations of liability will result in poor-quality medical care, it is difficult to draw the line between where good medicine
Results
The survey firstly measured physicians' income and workload. Respondents were asked about their monthly payroll income including basic salary and bonus, as well as their satisfaction with this level of income. Extra income from sources such as red packets (hong bao; bribes from patients), kickbacks, and other under-the-table payments was not included. On average, 80.5% of physicians in the sample were paid between 4001 yuan and 8000 yuan per month (equivalent to US$650 to US$1300). Those paid
Conclusion and policy implications
This article presents empirical findings from a survey of Chinese physicians. It has examined the widespread phenomenon of overprescription in Chinese hospitals from the perspective of defensive medicine and provided an alternative explanation for this behavior. Drawing on the literature, this study broadens our understanding on the nature of defensive behaviors and argues that even when malpractice litigation is rare, physicians may still practice defensively because of self-perceived threats
Acknowledgment
This study is funded by the Dean's Research Funding (ECR04012) of the Faculty of Liberal Arts and Social Sciences, Hong Kong Institute of Education. Part of the preparation for this project received financial support from the Early Career Scheme Project (ECS 859213) funded by the Research Grants Council of the Hong Kong SAR Government. Constructive comments from Wei Yang, Jay Pan, Xun Wu, M Ramesh, Jiwei Qian and Asad Singh Bali are much appreciated. The research assistance of Ms Jieyi Luo and
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