Patients in China: the Silent Stakeholder

This month Mary Assimakopoulos, talks about the issues around healthcare access for patients in China and highlights some of the adherence issues unique to the region.

As a person living in China, a socialist country, you might expect healthcare to be offered free of charge or at least heavily subsidised. The truth is, according to a study published in the Lancet, patients in mainland China in 2010 self-paid 60-70% of their outpatient costs and at least 50% of the cost of inpatient treatment. The implications of this are that the patient and their immediate family need to be considered as key stakeholders in treatment decisions for three key reasons:

  1. In the absence of a formal primary care system, patients are free to present to any health facility/doctor specialty that they choose.
  2. Patients typically have to pay out of their own pocket for a significant proportion of their healthcare costs.
  3. As payers, patients decide their own duration of therapy and adherence to treatment.

The impact of having no formal primary care

Some patients in China are suspicious of doctor’s prescribing decisions, referring to them as “white wolves.”

Currently only around 10% of healthcare spending is delivered at a primary care level. Effectively this means that there are no General Practitioners and no formal referral process. In the absence of a classic screening and referring model, patients are free to present to any hospital they want to (or more correctly where they can afford).

How does a patient decide where to go? Patients who want the best treatment must educate themselves as to which is the best doctor/hospital to attend. So they actively seek out information to make an informed choice. They turn to the internet, searching both domestic and international websites, and to friends and family, valuing personal recommendation. As a consequence, patients in China are arguably more health aware than patients in other countries. They are also more engaged and play a more proactive role in their treatment decisions.

Patients typically pay 60% of the cost of their treatment out-of-pocket

Patients and their family must bear a significant cost of healthcare even if they are covered by social insurance. As a result, many patients cannot afford anything more than basic treatments. Those who can afford them must decide whether they are willing to pay. The hospital system makes money by marking up the cost of medicines and some believe this creates an incentive for doctors to prescribe more costly treatments. Consequently, some patients in China are suspicious of doctor’s prescribing decisions, referring to them as “white wolves”.

However, the healthcare system is now being overhauled and (slowly) moving towards a fee per service. The patient will be able to decide what level of specialty they want to see (42 RMB for the equivalent of a GP up to 106 RMB for a specialist) and will still play an active role in their treatment decisions.

Duration of therapy

If [traditional Chinese medicines] are thought to be mild and gentle, then the opposite is true of western style medicines, which are thought of as being very strong and possibly detrimental to the patient’s long-term health.

As many patients are footing their own healthcare bill, the duration of therapy is impacted by affordability and willingness to pay. This is especially true for chronic conditions, and even more so for asymptomatic illnesses such as hypertension. However, there is a concept of patient reluctance that goes beyond just money.

In Chinese philosophy when a patient becomes ill because their body is out of balance. Traditional Chinese Medicines (TCMs) are thought to gently restore the body to balance and therefore bring the patient back to health. However this does not hold for allopathic medicines and many patients are concerned about the impact of taking medication over an extended period. If TCMs are thought to be mild and gentle, then the opposite is true of western style medicines, which are thought of as being very strong and possibly detrimental to the patient’s long-term health. This perception can have a negative impact not only on the duration of therapy but also on adherence to ongoing therapy. Patients are known to reduce doses or skip doses altogether. They don’t refill their prescriptions on time and take drug holidays. Obviously this behavior can impact the efficacy of treatments and if a patient’s condition is not improving then they question the drug’s effectiveness.

In China, the patient is a very important stakeholder. They decide when and where to present, whether to start a treatment, how much they are willing to pay and for how long. All of these factors have a direct impact on brand uptake, treatment adherence and the duration of therapy. If pharmaceutical companies want to understand the treatment flow and the buying process then they are strongly advised to include the patient in China.

We have seen a willingness on the part of patients to be actively involved in their treatment journey, from information seeking all the way through to paying for medicines. We would suggest that Chinese health consumers have a greater health awareness than in other countries and engagement in their treatment decisions, not because they want to but because they have to. In the absence of primary care, patients must be actively involved if they want to ensure the best treatment.

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