"Doctor Free Practice": A Trend or a Temporary Measure?

Topic: “Physicians’ Independent Practice”: A Trend or a Stopgap Measure?

Participant: HuKun

Location: Dayi Cloud Valley

(Repost) “Physicians’ Independent Practice”: A Trend or a Stopgap Measure?

Everyone is familiar with the University of Texas MD Anderson Cancer Center in the United States, right? Last year, it was ranked as the number one cancer center in the nation by U.S. News & World Report. Over the past decade, it has claimed the top spot seven times. Some time ago, President Obama proposed the Cancer Moonshot Initiative, which had actually been launched at this center three years prior.

The success story of MD Anderson Cancer Center is undoubtedly a classic case in health administration, worthy of an entire book. However, its true “crown jewel” is singular: the “Multi-disciplinary Approach to Cancer Treatment.” For example, at this center, a breast cancer patient’s treatment plan is jointly developed and implemented by specialists from breast surgery, medical oncology, radiology, pathology, pharmacy, radiation oncology, and plastic surgery. The advantages of such a clinical approach are self-evident.

As the center’s influence continues to grow both domestically and internationally, “multidisciplinary comprehensive diagnosis and treatment” is increasingly gaining recognition among other medical institutions. For instance, Beijing United Family Hospital has shared its practical experience in implementing this approach. However, a prerequisite for the effective execution of “multidisciplinary comprehensive diagnosis and treatment” is a high level of teamwork among specialists from different disciplines. Since MD Anderson Cancer Center is an affiliate hospital of the publicly funded University of Texas Medical School, the majority of its physician team consists of faculty members who are salaried employees of the hospital. Consequently, their collaboration faces no administrative, informational, or financial barriers, a model similar to that of public hospitals in China.

In contrast, the traditional operational model—characterized by the independence of hospitals and physicians, as well as the siloed practice among specialists—presents significant barriers to the implementation of the “Multidisciplinary Team (MDT)” clinical care model. Consequently, strengthening “Clinical Integration” has remained a focal topic in U.S. hospital management circles in recent years.

The cover story of the first issue this year of Healthcare Executive, the official journal of the American College of Healthcare Executives (ACHE), was titled “Clinical Integration: The Future is Here.” The article attempts to explore, from legal and financial perspectives, ways to further strengthen the “integration” between hospitals and physician groups in pursuit of superior clinical and managerial outcomes. In summary, from a management standpoint, a high degree of integration between hospitals and physicians represents a more advanced and sophisticated operational model than one in which they remain separate and independent. “Clinical integration” and “multidisciplinary comprehensive diagnosis and treatment” are proven pathways to success in global clinical medicine. Weakening the ties between physicians and hospitals, thereby allowing physicians to drift away, will inevitably lead to a regression in clinical medicine.

However, in China, the situation appears to be exactly the reverse. Hospital employment of physicians has become the crux of prevailing systemic issues, while allowing physicians to “practice independently” is regarded as a panacea for reform. Is this truly the case? To put it bluntly, the root cause of negative phenomena in China’s healthcare service industry is that fee schedules for medical services fail to cover operational costs, as well as the compensation and living expenses of medical personnel. The solution should lie in further tapping into the health insurance services market, improving health insurance plans, advancing the marketization of healthcare services, and promoting market-based pricing for medical services and professional remuneration.

So, why has “physicians’ independent practice” been enthusiastically embraced by all parties? I believe physicians welcome it because reforms in public hospitals have progressed sluggishly; rather than suffocating in a sealed container, they would rather squeeze through any available crack to escape. The media champion it because healthcare reform has been stagnant—where else is there any excitement if not here? Capital enthusiasts embrace it because, well, as the saying goes, even a pig can fly if it stands at the eye of the storm. And the government’s enthusiasm? Well, let’s just say it has finally found a fig leaf to cover itself.

Can “Physician Independent Practice” Truly Go Far? First, I would like to ask the readers: does anyone know the corresponding English term for “自由执业” (literally “free practice”)? Probably not. While “Private Practice” is the English expression for this mode of practice, it does not convey the notion of “freedom.” In fact, physicians with clinical experience know that doctors cannot practice entirely freely. Regardless of the country, no doctor can simply set up a stall to provide medical care or walk into a hospital and perform surgeries. To practice independently, physicians must not only possess medical licensure but also obtain a business license from municipal regulatory authorities. If you wish to admit patients to a hospital under your care, you must undergo the necessary approval processes to secure clinical privileges at that institution. In short, the term “free practice” is inaccurate; “independent practice” is a more appropriate description.

Traditionally, hospitals and physicians in the United States have operated as separate and independent entities. Hospitals provide the premises, facilities, and ancillary nursing staff but do not employ physicians; instead, physicians refer patients to hospitals while utilizing their venues, facilities, and support staff. This division of labor fosters a complementary relationship between the two parties. Consequently, “independent practice” has become the predominant mode of medical practice for physicians in the U.S. However, under the Chinese system, hospitals directly employ physicians, meaning that, theoretically, there is no fertile ground for “independent practice” in China. Fortunately, the presence of some small foreign-funded hospitals adopting the American model, along with private hospitals facing shortages of medical personnel, has provided a narrow niche for a small number of independently practicing physicians to survive. Nevertheless, such opportunities are extremely limited, constrained by factors including the number of physicians they can accommodate, the scope of services they can offer, and the pool of patients with adequate payment capacity.

It is estimated that, under the Chinese system, the capacity for “independent medical practice” will not exceed 1%. “Independent practice” is like a pizza floating in mid-air—reserved for the plates of a fortunate few and largely irrelevant to the majority of physicians. Therefore, “free medical practice” is merely an expedient measure, not a trend. Excessive hype and overly aggressive promotion have deviated from “clinical integration,” leading to a regression in clinical medicine.

Note: Critical illnesses require a multidisciplinary collaborative model, such as that employed by MD Anderson. However, for relatively mild common and chronic diseases, individual clinics that are more community-oriented and convenient for patients still have room to play a significant role.

Topic: Diverse Perspectives on Scalpers Snatching Appointment Slots

Participants: Jiang Lei, Li Chaoren

Location: VCBeat Doctor Group

Why Do Developed Countries Not Have Appointment Scalpers? Why Are They Endemic in China, with Slots for Top Specialists Always Snatched by Fake Scalpers? There Is Only One Reason: It Is Damnably Easy to Book Appointments with Specialists in China! No medical records are required, no description of the patient’s condition is needed, no referral certificate from lower-tier hospitals or physicians is necessary, and not even a real ID card is mandatory. As long as you queue up, you can secure an appointment with a top specialist! People may pay lip service to the idea that it is unnecessary to seek out renowned experts and that seeing an ordinary associate chief physician would suffice, but when presented with these two options, anyone knows which one they would choose! Therefore, the fundamental solution to the scalper problem is to abolish direct booking for all professor-level appointments! To see a professor, patients must first consult with a physician within that specialty before gaining access to the professor’s appointment scheduling system. In this way, how could scalpers, who have no genuine need for medical care, find any room to survive?

First, continue to promote the tiered diagnosis and treatment system.

Currently, the vast majority of diseases can be effectively managed at the prefecture-level city level. A portion of severe and critical cases can be diagnosed and treated by provincial hospitals. In reality, there is a limited need for experts from national-level hospitals. Moreover, the expertise of professors and specialists in provincial hospitals and affiliated hospitals of key medical universities has already reached a very high standard. Therefore, it is advisable to implement a policy whereby direct registration for expert consultations and special-needs outpatient services at national-level hospitals is prohibited. Access to these services should be granted exclusively through referrals from lower-tier hospitals or general practitioners within the same institution. Specifically, patients would only be referred to specialists after being evaluated by lower-tier hospitals or general physicians who determine that the condition exceeds their capacity to treat. Patients must obtain a referral ticket before registering for an expert consultation. The price of referral tickets should be set higher than standard registration fees but remain below black-market scalper prices. Some may raise concerns about potential bribery of lower-tier physicians. This issue can be addressed through a rating system: if a specialist determines that patients referred by a particular physician do not actually require expert care, or if a physician’s referral rate is disproportionately high, the physician will receive negative points. Accumulation of excessive negative points will result in the revocation of the physician’s referral privileges.

Second: Hospital management must keep pace by cracking down on scalpers who hoard appointment slots.

This requires police cooperation, as hospital staff or security personnel lack law enforcement authority and can only monitor or issue warnings; it is the police who must apprehend scalpers. Furthermore, if scalping were criminalized, similar to how "medical disturbances" have been made a criminal offense, I believe the number of scalpers would decrease significantly. Meanwhile, hospitals must strictly enforce real-name registration for appointments. Appointments not registered under the patient’s own identity card will be neither honored nor refunded.

Third: To address the difficulty of securing medical appointments, registration fees must be increased.

Current consultation fees are too low. The registration fee for a general practitioner’s outpatient visit is only a few yuan, while that for a specialist is merely 300 yuan. Thus, for the cost of a single meal, why not consult a specialist? If the specialist’s registration fee were raised to 5,000 yuan (this is purely hypothetical; I do not actually recommend setting it this high), patients would carefully consider whether their condition truly warrants such an expense. This would likely divert some patients who could be effectively treated by general practitioners. Furthermore, higher consultation fees would boost physicians’ motivation, encouraging more doctors to diligently refine their clinical skills and advance their expertise to reach specialist levels in order to earn higher fees. High-achieving, high-IQ students from the college entrance examination would also be more willing to pursue medical careers. As the number of highly competent physicians increases, greater competition would naturally drive down registration fees, ultimately stabilizing at a price point acceptable to both doctors and patients.

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