1. An Analysis on Obstacles to Medical Professionalism in China: A look at the Practical Linying Hu Ph.D. Peking University Health Science Center

2. Problems and Background First fundamental principle of Medical Professionalism: Primacy of Patient Welfare First fundamental principle of Medical Professionalism: Primacy of Patient Welfare “ This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician– patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. ” “ This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician– patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle. ” ——Medical Professionalism in the New Millennium: A Physician Charter, ——Medical Professionalism in the New Millennium: A Physician Charter, Annals of Internal Medicine, Feb. 2002, Volume 136, 3.

3. “Primacy of Patient Welfare” in China Da Yi Jing Cheng Da Yi Jing Cheng Medical Moral Norm and Regulation, (1988, MOH); Medical Moral Norm and Regulation, (1988, MOH); Moral Norm and Regulation for Chinese Medicine,(1992, State Council) Moral Norm and Regulation for Chinese Medicine,(1992, State Council) Law on Licensed Doctors of the People’s Republic of China, (1998, the NPC Standing Committee ) Law on Licensed Doctors of the People’s Republic of China, (1998, the NPC Standing Committee )

4. Primacy of Patient Welfare Primacy of patient welfare means: Primacy of patient welfare means: Patient-centered, providing patients the most appropriate high qualified care that patient needs most. Patient-centered, providing patients the most appropriate high qualified care that patient needs most.

5. Investigation Subjects 1. Payment system 1. Payment system 2. Worries about potential risks 2. Worries about potential risks 3. Non-economic promotion 3. Non-economic promotion 4. Health care system 4. Health care system

6. Investigation Subjects Are above factors obstacles to medical professionalism in China? Are above factors obstacles to medical professionalism in China? How do these factors influence physician’s behavior of putting patient’s welfare first negatively? How do these factors influence physician’s behavior of putting patient’s welfare first negatively?

7. Methodology Literature Study Literature Study Papers published in important and influencial Chinese journals and major conferences from 2000-2008 Papers published in important and influencial Chinese journals and major conferences from 2000-2008 In-depth Interview In-depth Interview 31 doctors, including Internal, Surgery, OB. Pediatric, Shychatric; 31 doctors, including Internal, Surgery, OB. Pediatric, Shychatric; 70% from big comprehensive hospitals; 70% from big comprehensive hospitals; 20% from mid-level hospitals; 20% from mid-level hospitals; 10% from local community hospitals 10% from local community hospitals Interview outline Interview outline 2 hours/interview 2 hours/interview

8. Models of Current Payment System Model 1 ： Professorship and administrative position- centered payment system Model 1 ： Professorship and administrative position- centered payment system

9. Analysis of Model 1 Strong political administrative style Strong political administrative style Weak impulse to behavior ethically Weak impulse to behavior ethically

10. Model 2 Model 2: Profit-centered Payment system Model 2: Profit-centered Payment system

11. Case of Model 2: Bonus System of a Cardiovascular Division 1 head of doctor in out-patient, 3 attending doctor, 1 senior resident 。 Among them, 1 head of doctor in out-patient, 3 attending doctor, 1 senior resident 。 Among them, A earns 78,000 RMB ， operating 8 surgeries; B earns 58,000 RMB, 6 surgeries 6; C earns 49,000RMB, 2 surgeries, D earns 12,000. A earns 78,000 RMB ， operating 8 surgeries; B earns 58,000 RMB, 6 surgeries 6; C earns 49,000RMB, 2 surgeries, D earns 12,000. ① Head of clinician’s bonus: 3688 RMB ② Bonus sum for doctores:15000 － 3688 ＝ 11312RMB ； ③ Bonus distribution ： A with highest earning gets 70 score, other doctors’ scores are certain rates of 70; One score on average ： 11312/304.79 ＝ 37.11RMB ； ① Head of clinician’s bonus: 3688 RMB ② Bonus sum for doctores:15000 － 3688 ＝ 11312RMB ； ③ Bonus distribution ： A with highest earning gets 70 score, other doctors’ scores are certain rates of 70; One score on average ： 11312/304.79 ＝ 37.11RMB ； Result ： A ： (70+10+10+8+8)×37.11 ＝ 3934RMB ； B:3194RMB ； C:2754RMB ； D:1439RMB 。 Result ： A ： (70+10+10+8+8)×37.11 ＝ 3934RMB ； B:3194RMB ； C:2754RMB ； D:1439RMB 。

12. Model 2: Bonus System of a Cardiovascular Division （ Thous. RMB ） （ Hund. RMB ）

13. Analysis Negative effects of profit-centered bonus system on physician’s behavior: Negative effects of profit-centered bonus system on physician’s behavior: Deselecting patient Deselecting patient Overtreatment, increasing unnecessary medical cost Overtreatment, increasing unnecessary medical cost Preferring high-cost medical intervene, despite of low health benefit, neglecting health education Preferring high-cost medical intervene, despite of low health benefit, neglecting health education

14. Conclusion 1. Current bonus system is mainly hospital profit- centered, rather than patient-centered. 2. Profit-centered bonus system becomes an obstacle to medical professionalism, undermining trust between physician and patient. 3. Bonus system design needs more scentific prudence, for the result may be unwanted.

15. Suggestions ： How can patient-centered bonus system be possible? 1. Clearly setting final aim of bonus system Patient-centered, increasing high quality of medical care. Patient-centered, increasing high quality of medical care. 2. Developing objective measures for patient-centered bonus system, measure what is important to patient. Continuity, communication, respect for patient preferences and confidentiality, and access, and high- quality medical care should be included at least.

16. Suggestions ： How can patient-centered bonus system be possible? （ conti. ） 3. Set up a consistent bonus system guideline at higher level, ensure transparency and implementation. 4. Develop overall supportive system environment for patient-centered bonus system, including just macro health care system and efficient medical risk management system.

17. Thank you !