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Financing health services in China: Adapting to economic reform
Soc. Sci. Med. Vol. 45. No. 10, pp. 1601-1603. 1997 Published by Elsevier Science Ltd. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
Pergamon
BOOK REVIEWS
The Secret(s) of Good Patient Care: Thoughts on Medicine in the 21st Century, by William Campbell Felch, MD. Praeger, 1996. 208pp., U.S.$49.95 (hardcover). Although titled "'The Secret(s) of Good Patient Care," this book is better summarized by its parenthetical title, "Thoughts on Medicine in the 21st Century." This work is a collection of loosely related essays on medicine as it is practiced in the United States. Dr Felch draws on his long and distinguished career in medicine to relay his thoughts and experiences on a variety of topics from euthanasia to how and why physicians choose medicine as a career. Many of the essays are linked by a common theme of ambiguity in medicine. For example, in his essay on Death Certificates, he describes not only the form, but also the process of filling out a death certificate in great detail. He also comments that different physicians use significantly different terminology, procedures and categories of information on these forms. Therefore, he finds it very unsettling that so much "scientific research" is based on analysis of these documents. A second theme Felch presents is that while medicine in the United States is at a technological high, patient satisfaction is at an all time low. He suggests that there are many reasons for this circumstance, including the negative influences of the government and third party payers, the lack of time doctors spend talking to patients, and a heavy
Financing Health Services in China: Adapting to Economic Reform, by S. L. Tang, G. Bloom, X. S. Feng, H. Lucas, X. Y. Gu and M. Segall, Brighton, Institute of Development Studies. IDS Research Report 26, 1994. The impact of the reform of health care financing on rural health services in China is the subject of a report by Tang et al. (1994). The report begins with a useful, if somewhat detailed and long, overview of the health system in rural China in terms of its organisational structure, complex three-tiered decision making hierarchy, main policy thrusts and financing mechanisms. This is set within the context of the frequent political and socioeconomic turmoils of the past five decades. The founding of the People's Republic of China in 1949 led to the creation of a public health system based on the principle of universal access. The right to basic health care was even written into the country's new constitution as one of "five guarantees" of social relief from the government to prevent destitution. The health system set up to provide universal care boasted many achievements, including a rapid expansion of infrastructure, effective mass public health campaigns and the deployment of the famous "barefoot doctors". At the same time, however, the system proved highly centralised and bureaucratic.
reliance on technology over the art of healing. Hence, he addresses the book to both physicians and patients in an attempt to repair their relationship. His solutions are less identifiable, but generally emphasize physicians' decisionmaking processes. The strength of this book is found in the diversity of topics and a down-to-earth approach to medicine. Felch strives to take the mystery out of the profession by providing many personal anecdotes, such as selling his blood for spending money during medical school. This diversity is also a major weakness in the book. Many of his ideas are lost or duplicated in what seems to be a rambling tour through the field of medicine. Another problem with the book is cost. While textbooks are frequently expensive, the intended audience of this book includes the general public, and $49.95 for a 200 page book is likely to discourage the casual reader. Overall, it is an insightful text about physicians, including how they are trained, how they make decisions, and the major issues they face on a daily basis. If read by his intended audience, this book could help to bridge the communications gap between doctors and patients. Maine-Dartmouth Family Practice Residency Waterville, ME 04901 U.S.A.
Michelle Steele Rebelsky
Since the early 1980s, there have been efforts to implement fundamental changes to health care financing. To a large extent, these changes have been initiated in response to macrolevel restructuring of the Chinese economy which put increased pressures on public expenditure. Yet, reforms have also been introduced to pay for the rising costs of health care for a rapidly growing and ageing population. The changes have included the collapse of cooperative medical schemes, decentralised decision-making, introduction of the household responsibility system and levying of user fees for a wide range of services. The impact of the above changes on rural health services is the focus of the final chapters of the report based on survey research carried out from April-May 1988. While the study may be already out of date, given the remarkable pace of change in the ensuing years, its findings correspond to more recent evidence from other countries with similar reforms. Most notable have been the growing inequities of access to health care between rural and urban areas, different regions, and socioeconomic groups. This study also found a weakening of preventive and promotive health services, and a lack of effective regulation of health workers and their training. Alternative financing mechanisms have also been initiated but, at the time of the report, did not account for a substantial part of resources. The study
1601
1602
Book Reviews
concludes that "'a market for health care does not automatically provide a cost-effective mix of preventive and curative services ... [but] needs to be supplemented by third party payers, agencies which plan and coordinate local health services, a management and regulatory framework for the sector as a whole, and systems to ensure that health workers are accountable to the community" (p. 140). The final chapter of the report puts forth a strategy for rural health services to adapt to the profound changes based on three linancing mechanisms household contributions,
extrabudgetary revenue of township governments and village administrative committees, and government (p. 140).
Psychiatric Malpractice, by J. L. Kelley. New Brunswick,
For example, Johnny Moore committed suicide after being discharged from Charter Hospital of Winston-Salem, Massachusetts, a private institution. The malpractice case centered around the question of whether or not Charter discharged him prematurely. Dennis Gould, who was diagnosed with paranoid schizophrenia was also released from a Massachusetts state hospital, and, acting on perceived orders from God, killed a young woman with whom he previously had a romantic relationship. Although the Moore case is discussed under the heading of suicide, and Gould under the heading of violence toward others, both concern premature release. In the Moore case premature release occurred because of termination of insurance benefits. In the Gould case, he was moved from private hospitals to state hospitals, in one instance because of unpaid bills and in another because of insurance limits. Gould's story might also be placed under the heading: the role of religion in the promotion of violent behavior. The story of Leonard Avery, a Vietnam veteran suffering from PTSD who killed one person and wounded tk~ur others, all of whom he did not know, reveals that despite Avery's history, he was given Haldol, a controversial antipsychotic drug (now banned in the United States), but not admitted to the VA hospital. Although Avery's story is told under the heading of violence against others, I would place it more appropriately under the heading of the hold that insurance companies and the military have on the treatment of mental illness, as well as tile role of the military in promoting violent behavior, then defined as psychiatric illness. A number of psychiatric issues resulting in litigation issue from antiquated notions about how women should be treated, including the Tarasoff case, resulting in the "'duty to warn" doctrine, the Gould case, and all the cases listed under "sexual misconduct". II1 almost all the litigation Kelley discusses, the expert witnesses is the fulcrum upon which winning or losing is based. Because delinitions of mental illness, appropriate treatment, and standards of care stemming from diagnosis and treatment are "'grey areas," the status and credibility of the expert witness is of paramount importance in selling a case to the jury. The theme of this book is that psychiatrists at times fail their patients, who are a danger to themselves or others. One remedy is to take the psychiatrist to court. There are important undercurrents in Kelley's message, however. One undercurrent is the lack of clarity of "'mental illness". The second undercurrent is that the definition and treatment of various mental illnesses are often not in the hands of psychiatrists. They might be determined by drug companies, insurance companies, bottom line economic considerations of hospitals, and whatever category is available to psychiatrists at the time they are seeing the patient. These t:actors can lead to misdiagnosis and inappropriate treatment as well. Third, it is very difficult to predict what a ~'mentally ill" person will do: psychiatrists are not psychics. Finally. many actions taken by people who are
New Jersey: Rutgers University Press, 1996. 229 pp. Attorney James L. Kelley's very readable book is about people in the United States who sought out psychiatric help, and then for one tragic reason or another, sued their psychiatrist for malpractice. The book reads like an annotated novel although the stories are real. Through the experiences of the litigants, the book moves across four legal/psychiatric issues: suicide, violence against others, standards of psychiatric care, and sexual misconduct by mental health providers. Some of the cases Kelley discusses are well-known to North Americans; others are more obscure. All are well-documented through Kelley's use of court documents and other available research. Kelley's struggles with his own manic depression, years of misdiagnosis, and inappropriate prescription of medication serve as an experiential basis for his interest in psychiatric malpractice as well as his bias in the writing of this book. This, of course, is not necessarily a fault. Many of our intellectual interests stem from our own personal experiences. Further, I would contend that it is not often enough that the views of victims and survivors of various forms of psychiatric abuse are given voice. To set the stage for these stories, Kelley begins with the history of the law of psychiatric malpractice. Beginning with the Code of Justinian in 600 A.C.E., which protected slaves against improper doctors" care, a charge of "'mala praxis'" or bad practice provided ['or remedies lk)r inappropriate invasions ot" a patient's body by a physician whom the patient had trusted. Although psychiatric malpractice evolved from this concept, problems arise in interpretation of bad practice given the lack of clarity in definitkms of mental illness. Kelley lists five elements that a ~'typical psychiatric malpractice case must prove" to make a case: ( I t the existence of a psychiatrisF patient relationship, wherein the patient or his/her guardian is the litigant and the psychiatrist is the defendant; (2) the requirement of a standard of care stemming from a particular diagnosis and treatment: (3) a breach of this standard of care: (4) a strong cause and effect relationship between a breach of a standard of care and the plaintiff's alleged injuries: and (5) a monetary value attached to the future care of the patient/plaintiff or his/her survivors, if the patient has committed suicide. Although the book is divided by kinds of psychiatric malpractice, one could easily view the contentious issues leading to litigation in terms of other critical [actors, including whether the plaintiff was in a public or private hospital; the vulnerability/powerlessness of the patient plaintiff: the hold insurance companies have on the definitions and treatment of mental illness; the role of religion and the military in violent behavior then labeled as psychiatric; hatred of women; problems of expert witnesses; and the lure of litigation.
International Health Policy Programme Kelley Lee Health Poll O ' Unit London School ~f 14vgiene and Tropical Medicine Keppel Street London W C I E 7HT U.K,
Pergamon
BOOK REVIEWS
The Secret(s) of Good Patient Care: Thoughts on Medicine in the 21st Century, by William Campbell Felch, MD. Praeger, 1996. 208pp., U.S.$49.95 (hardcover). Although titled "'The Secret(s) of Good Patient Care," this book is better summarized by its parenthetical title, "Thoughts on Medicine in the 21st Century." This work is a collection of loosely related essays on medicine as it is practiced in the United States. Dr Felch draws on his long and distinguished career in medicine to relay his thoughts and experiences on a variety of topics from euthanasia to how and why physicians choose medicine as a career. Many of the essays are linked by a common theme of ambiguity in medicine. For example, in his essay on Death Certificates, he describes not only the form, but also the process of filling out a death certificate in great detail. He also comments that different physicians use significantly different terminology, procedures and categories of information on these forms. Therefore, he finds it very unsettling that so much "scientific research" is based on analysis of these documents. A second theme Felch presents is that while medicine in the United States is at a technological high, patient satisfaction is at an all time low. He suggests that there are many reasons for this circumstance, including the negative influences of the government and third party payers, the lack of time doctors spend talking to patients, and a heavy
Financing Health Services in China: Adapting to Economic Reform, by S. L. Tang, G. Bloom, X. S. Feng, H. Lucas, X. Y. Gu and M. Segall, Brighton, Institute of Development Studies. IDS Research Report 26, 1994. The impact of the reform of health care financing on rural health services in China is the subject of a report by Tang et al. (1994). The report begins with a useful, if somewhat detailed and long, overview of the health system in rural China in terms of its organisational structure, complex three-tiered decision making hierarchy, main policy thrusts and financing mechanisms. This is set within the context of the frequent political and socioeconomic turmoils of the past five decades. The founding of the People's Republic of China in 1949 led to the creation of a public health system based on the principle of universal access. The right to basic health care was even written into the country's new constitution as one of "five guarantees" of social relief from the government to prevent destitution. The health system set up to provide universal care boasted many achievements, including a rapid expansion of infrastructure, effective mass public health campaigns and the deployment of the famous "barefoot doctors". At the same time, however, the system proved highly centralised and bureaucratic.
reliance on technology over the art of healing. Hence, he addresses the book to both physicians and patients in an attempt to repair their relationship. His solutions are less identifiable, but generally emphasize physicians' decisionmaking processes. The strength of this book is found in the diversity of topics and a down-to-earth approach to medicine. Felch strives to take the mystery out of the profession by providing many personal anecdotes, such as selling his blood for spending money during medical school. This diversity is also a major weakness in the book. Many of his ideas are lost or duplicated in what seems to be a rambling tour through the field of medicine. Another problem with the book is cost. While textbooks are frequently expensive, the intended audience of this book includes the general public, and $49.95 for a 200 page book is likely to discourage the casual reader. Overall, it is an insightful text about physicians, including how they are trained, how they make decisions, and the major issues they face on a daily basis. If read by his intended audience, this book could help to bridge the communications gap between doctors and patients. Maine-Dartmouth Family Practice Residency Waterville, ME 04901 U.S.A.
Michelle Steele Rebelsky
Since the early 1980s, there have been efforts to implement fundamental changes to health care financing. To a large extent, these changes have been initiated in response to macrolevel restructuring of the Chinese economy which put increased pressures on public expenditure. Yet, reforms have also been introduced to pay for the rising costs of health care for a rapidly growing and ageing population. The changes have included the collapse of cooperative medical schemes, decentralised decision-making, introduction of the household responsibility system and levying of user fees for a wide range of services. The impact of the above changes on rural health services is the focus of the final chapters of the report based on survey research carried out from April-May 1988. While the study may be already out of date, given the remarkable pace of change in the ensuing years, its findings correspond to more recent evidence from other countries with similar reforms. Most notable have been the growing inequities of access to health care between rural and urban areas, different regions, and socioeconomic groups. This study also found a weakening of preventive and promotive health services, and a lack of effective regulation of health workers and their training. Alternative financing mechanisms have also been initiated but, at the time of the report, did not account for a substantial part of resources. The study
1601
1602
Book Reviews
concludes that "'a market for health care does not automatically provide a cost-effective mix of preventive and curative services ... [but] needs to be supplemented by third party payers, agencies which plan and coordinate local health services, a management and regulatory framework for the sector as a whole, and systems to ensure that health workers are accountable to the community" (p. 140). The final chapter of the report puts forth a strategy for rural health services to adapt to the profound changes based on three linancing mechanisms household contributions,
extrabudgetary revenue of township governments and village administrative committees, and government (p. 140).
Psychiatric Malpractice, by J. L. Kelley. New Brunswick,
For example, Johnny Moore committed suicide after being discharged from Charter Hospital of Winston-Salem, Massachusetts, a private institution. The malpractice case centered around the question of whether or not Charter discharged him prematurely. Dennis Gould, who was diagnosed with paranoid schizophrenia was also released from a Massachusetts state hospital, and, acting on perceived orders from God, killed a young woman with whom he previously had a romantic relationship. Although the Moore case is discussed under the heading of suicide, and Gould under the heading of violence toward others, both concern premature release. In the Moore case premature release occurred because of termination of insurance benefits. In the Gould case, he was moved from private hospitals to state hospitals, in one instance because of unpaid bills and in another because of insurance limits. Gould's story might also be placed under the heading: the role of religion in the promotion of violent behavior. The story of Leonard Avery, a Vietnam veteran suffering from PTSD who killed one person and wounded tk~ur others, all of whom he did not know, reveals that despite Avery's history, he was given Haldol, a controversial antipsychotic drug (now banned in the United States), but not admitted to the VA hospital. Although Avery's story is told under the heading of violence against others, I would place it more appropriately under the heading of the hold that insurance companies and the military have on the treatment of mental illness, as well as tile role of the military in promoting violent behavior, then defined as psychiatric illness. A number of psychiatric issues resulting in litigation issue from antiquated notions about how women should be treated, including the Tarasoff case, resulting in the "'duty to warn" doctrine, the Gould case, and all the cases listed under "sexual misconduct". II1 almost all the litigation Kelley discusses, the expert witnesses is the fulcrum upon which winning or losing is based. Because delinitions of mental illness, appropriate treatment, and standards of care stemming from diagnosis and treatment are "'grey areas," the status and credibility of the expert witness is of paramount importance in selling a case to the jury. The theme of this book is that psychiatrists at times fail their patients, who are a danger to themselves or others. One remedy is to take the psychiatrist to court. There are important undercurrents in Kelley's message, however. One undercurrent is the lack of clarity of "'mental illness". The second undercurrent is that the definition and treatment of various mental illnesses are often not in the hands of psychiatrists. They might be determined by drug companies, insurance companies, bottom line economic considerations of hospitals, and whatever category is available to psychiatrists at the time they are seeing the patient. These t:actors can lead to misdiagnosis and inappropriate treatment as well. Third, it is very difficult to predict what a ~'mentally ill" person will do: psychiatrists are not psychics. Finally. many actions taken by people who are
New Jersey: Rutgers University Press, 1996. 229 pp. Attorney James L. Kelley's very readable book is about people in the United States who sought out psychiatric help, and then for one tragic reason or another, sued their psychiatrist for malpractice. The book reads like an annotated novel although the stories are real. Through the experiences of the litigants, the book moves across four legal/psychiatric issues: suicide, violence against others, standards of psychiatric care, and sexual misconduct by mental health providers. Some of the cases Kelley discusses are well-known to North Americans; others are more obscure. All are well-documented through Kelley's use of court documents and other available research. Kelley's struggles with his own manic depression, years of misdiagnosis, and inappropriate prescription of medication serve as an experiential basis for his interest in psychiatric malpractice as well as his bias in the writing of this book. This, of course, is not necessarily a fault. Many of our intellectual interests stem from our own personal experiences. Further, I would contend that it is not often enough that the views of victims and survivors of various forms of psychiatric abuse are given voice. To set the stage for these stories, Kelley begins with the history of the law of psychiatric malpractice. Beginning with the Code of Justinian in 600 A.C.E., which protected slaves against improper doctors" care, a charge of "'mala praxis'" or bad practice provided ['or remedies lk)r inappropriate invasions ot" a patient's body by a physician whom the patient had trusted. Although psychiatric malpractice evolved from this concept, problems arise in interpretation of bad practice given the lack of clarity in definitkms of mental illness. Kelley lists five elements that a ~'typical psychiatric malpractice case must prove" to make a case: ( I t the existence of a psychiatrisF patient relationship, wherein the patient or his/her guardian is the litigant and the psychiatrist is the defendant; (2) the requirement of a standard of care stemming from a particular diagnosis and treatment: (3) a breach of this standard of care: (4) a strong cause and effect relationship between a breach of a standard of care and the plaintiff's alleged injuries: and (5) a monetary value attached to the future care of the patient/plaintiff or his/her survivors, if the patient has committed suicide. Although the book is divided by kinds of psychiatric malpractice, one could easily view the contentious issues leading to litigation in terms of other critical [actors, including whether the plaintiff was in a public or private hospital; the vulnerability/powerlessness of the patient plaintiff: the hold insurance companies have on the definitions and treatment of mental illness; the role of religion and the military in violent behavior then labeled as psychiatric; hatred of women; problems of expert witnesses; and the lure of litigation.
International Health Policy Programme Kelley Lee Health Poll O ' Unit London School ~f 14vgiene and Tropical Medicine Keppel Street London W C I E 7HT U.K,