Sunday, August 2, 2009

What not to do

It has been great fun teaching a short course in comparative health systems/financing around the world to students taking the Peking University/Duke University Diploma in Global Health. 90 students from 44 Universities around China.

On friday, they asked me to talk a bit about health reform in the U.S. (I was surprised by how much some of the students were following this). They wanted me to identify some lessons regarding what China might do given their recently stated goal of moving toward universal coverage in China. I am not really sure what China should do. I don't know enough about their system. So, I focused on things they should probably not do based on experience from the USA. Here are five of those thoughts, that I thought the most important. I plan to write a bit more about my experience in China, later. I am returning back to the states on Monday.

1. Do not provide large subsidy for rich to get private insurance. All subsidies provided to stimulate insurance need to be clear.

2. Don’t deny the existence of limits for what medicine can do. This has to do with a cultural conversation about what medicine can do versus public health versus individual choices versus things that can't be fixed.

3. Pay attention to the incentives in how doctors and hospitals are paid. The incentives in the Chinese system are now confusing, and there is a good deal of corruption and 'under the table' payment. We talked a great deal this week about the tradeoffs and incentives inherent in using FFS, capitation, salary as payment means.

4. While there is not much evidence that markets for insurance reduce health costs, you can have some ‘market notions’ inside a system that may help improve quality.
Choice of doctor, hospital and information provided to patients can help keep any system honest.

5. Be careful with age-related insurance financed via payroll taxes, demographic changes will greatly affect such a system. China has recently reversed its one child policy, and a couple who were both only children can now have two children. Lets say they do this for 20 years and then change back to a one child policy....that pig in the python would make the baby boomers impact on medicare look like a little blip.

Finally, you can’t or shouldn’t copy another system. You can learn from them, but your job is to build the CHINESE health system. This is generic advice....all nations can see models and learn lessons from others, but must ultimately build a system that works for them.

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