Happy new year!! We are starting year 2 in Guangzhou. My family deserves credit for putting up with many harships and frustrations - even as we enjoy the overall good QOL in Guangzhou.
Trump and North Korea: It’s like watching a train crash in slow motion. From “over here” next to North Korea but in a country with some influence and perhaps some understanding of what is really going on there, I imagine it is easier to see my own country at risk. At the very least, North Korea is an enormous distraction. Diverting the attention of our military and parts of our government. Using much of our geopolitical influence to ask everyone else to try and reign in this tiny country.
The China strategy seems to be to ignore the internal politics of all countries equally. They are interested in trade and an opportunity to export their ability to design and deliver huge infrastructure projects – now that the domestic economy can no longer be poweredthis way. They are willing and able to invest billions in infrastructure projects that enable local economic development which naturally orients toward the country and the people who brought them the railroad, the port, or the refinery.
I am not finished deciding how I feel about this somewhat “amoral” approach to international relations. “The Chinese Way” has brought opportunity to millions of people in places we can’t seem to penetrate. At the same time, they steadfastly refuse to get involved in the judgement of unsavory leaders and regimes. Are we doing so much better? The US tries to pick “winners” and makes a big fuss over “defending liberty” and protecting human rights. Those are worthy causes to be sure, but on balance over the past 20 years, have we succeeded in advancing those causes? Are people in Columbia, Iraq, and Afghanistan better off? What helps more: moral leadership or economic development?
Healthcare: On the domestic, medical front there is another train crash that I am watching in slow motion: the Chinese public health care system. I have outlined some of the struggles in previous posts. None of them are unfamiliar to us in the US. Overtesting, overtreatment, lack of trust, poor health literacy, worship of technology, demoralized doctors and nurses, nearly absent primary care. My challenge is to teach what I can, without getting too preachy and losing my audience. I know some very wise and knowledgeable people who insist that changing the costly behavior of doctors (and it really is mostly in our purvue) is not all about money – but really, let’s call a spade a spade. I am all for professionalism, satisfaction, joy, etc, but how many people reading this would choose to cut their income by 20-30%, while creating difficult conversations with patients who want technology and their problem fixed NOW and watch the guy or girl in the next office suite doing well operating on anything that moves (and has insurance) while the hospital fawns all over them?
Doctors are highly trained professionals who go to school and train for a decade or more after college, work long hours and sometimes (or always, if you work, for example, in the ED, OR, oncology ward, Labor and Delivery) cope with very upset people in very stressful situations. They expect to earn enough to keep their families solidly in the upper middle class. That doesn’t mean exactly the same thing to everyone, but I think most feel they should be able to live in a comfortable community with access to good schools when their kids are young, be able to afford to send their kids to college, and retire at a reasonable age. They expect comparable earnings to lawyers who also work hard and have challenging work interactions at times. In the news we see the highly successful folks who work in finance and who grow businesses from scratch to billion dollar exits. We think everyone with an MBA makes that kind of money.
Another part of the puzzle is the payment system. Basically, in the US, CMS and the AMA’s RUC sets payments for 95% of the services for 95% of patients. Yet, we continue to insist that medicine is a “free market”. Huh? What kind of free market has fixed payments?
If a doctor feels entitled to something between 200-300k/year (pre-tax) then they will figure out how many procedures and office visits it takes to get them near their goal. Note that this is not hugely different between those in true private practice and those who are “employed” by larger organizations. Most of these “employed” docs have a “salary” that is fairly tightly tied to productivity. This reality is easy to spot. Studies show that the number of procedures done in a community is largely dependent on the number of doctors who provide that procedure. If you reduce the reimbursement for a service, doctors respond by doing more of them and spending less time on each one.
Anyway, this same incentive system and expectation system is driving the same trend to joyless, thoughtless, expensive, overtesting and overtreatment here in China. But I believe we need to acknowledge that we can’t fix the process of medical services and then expect doctors and hospitals to behave as if prices are a function of equilibrium in a free market.
Enough pontificating for now. Stay safe everyone.