There is an increasing global interest in optimising health care delivery and improving the quality of care 47. However, previous research has primarily focussed on reducing underuse and the failed delivery of needed services 48, while its counterpart, overuse, is comparatively less studied 49. To our knowledge, this is the first study using a standardised patient audit-study design to examine the patterns of overuse and quantify its financial impact in primary care in China. We found a high incidence of overuse among physician-patient interactions in a real-world scenario, and that the overuse led to a significant increase in healthcare expenditure. Compared to the non-overuse group, overuse increased the total cost by 118.8%, the exam cost by 60.0% and the drug cost by 100.2%. Also, we showed that in China public hospitals provided as many unnecessary services as private hospitals did in China, leading to a significant increase in health care expenditure. The financial impact of overuse was driven by interactions with female patients rather than male patients.
Using the SP method to measure overuse offers a unique opportunity to explore physician practices and accurately estimate overuse. Our results are comparable to other studies in China and other developing countries. For example, the prevalence of overuse in this study was overall higher than that in rural China 17,40, and similar to the level overuse found in India and Kenya 44,50. One typical difference of this study was the focus on community health centres in China. Community health centres are generally well equipped with medical equipment. For example, more than half of community health centres in China provided inpatient care in 2017 and even had specialist departments 51. Moreover, in our study setting community health centres can provide (almost) all the essential medical tests for the two tracer conditions 52. Therefore, we identified pervasive overuse of unnecessary medical tests, which were generally absent from the earlier investigations in (comparably poor) rural areas 17,40,41 and less developed regions 50,53.
The high prevalence of overuse in the study was dominated by physician behaviours rather than patient behaviours. In theory, overuse can be influenced by hospital, physician and patient characteristics. For example, patients may prefer better technology and medical tests for reassurance 54; may demand more services than those needed when covered by health insurance and not bearing the entire costs 55; and may request costly medications due to the direct-to-consumer marketing strategy for new drugs 56. However, in our setting, SPs were required not to request any service initially and therefore, we had a clean estimation of overuse that is only derived from provider behaviour. The reasons why physicians overprovide services are multifold. For example, physicians may be trained to identify (to exclude or confirm) all possible diagnoses using medical tests when they were medical students 57. Furthermore, physicians may show so-called second-degree moral hazard when patients are covered by health insurance 23. Also, physicians may prefer to be paid and do something in a fee-for-service system, even although these services did not add much value for patient health 58. Also, concerns about uncertain malpractice lawsuits in the future may also lead physicians to do more to defend themselves 59–61, especially for physicians with experience of previous medical disputes 62.
We provide new evidence on the physician-induced demand theory and a clean quasi-experimental estimation of the economic significance of overuse. Physicians tend to prescribe more services in response to either an increase or a decrease in the related reimbursement rate 25,27,63−65. The economic significance is impressive, but similar to findings from other credence good markets 66. In 2018, there were 4.41 billion outpatient visits in the primary care, accounting for 53.04% of total outpatient visits in China, and the outpatient healthcare expenditure per capita in primary care was 156.8 CNY 67, representing a market of 691.5 billion CNY (≈108.6 billion US dollars). The average cost of SP visit in the study was 35.0 CNY, with a standard deviation of 41.3. The relatively low cost is reasonable because we only used two non-complicated and common chronic diseases. We estimated the financial burden incurred by the overuse on the specific population that is affected by the two chronic diseases by considering the prevalence and the increased cost. In our sample, it was estimated that the overuse led to a 56.59% increase in total cost, a 54.50% increase in exam cost, and a 61.20% increase in drug cost in the population with the two chronic diseases. Our results strongly suggest that overuse can potentially place enormous costs on patients and whole economies. Eliminating the use of unnecessary medical tests and drugs would substantially reduce physical harm and the risk of poly-pharmacy 11, and simultaneously reduce the financial burden on the population.
In general, the unregulated provision of health care by the private sector is not socially desired 50, since providers may over-respond to demand, leading to socially inefficient provision. Alternatively, the default policy approach to delivering health care, especially primary care, is through public hospitals. In this study, we found that the overuse rate in public hospitals was as high as that in private hospitals. Moreover, the financial impact of overuse was driven by interactions in public hospitals rather than private hospitals. This may suggest that financial incentives in the public health sector in China are as strong as in the private health sector, or even stronger. Previous research indicated that financial incentives among public hospitals in China originated from market-oriented reforms since the 1980s 68. From that time, 1) health care professionals did not receive a wage from the government anymore; 2) the prices charged for physician service time were strictly capped by the government; 3) hospitals were permitted to earn profits from prescribing new drugs and high-tech examinations 69 and physicians received substantial bonuses from hospital profits. This context led to the pervasive over-prescription of unnecessary and expensive drugs and high-tech examinations 18.
Many studies suggest that physicians are substantially underpaid in public hospitals of China 70 due to the regulation on prices of physician service time. Physicians often have no legally mandated social benefits in primary care 51, and are commonly burned out 71. However, the last decade witnessed a significant increase in the health care workforce in China, including the physician numbers in primary care 72. The expansion of primary care under an underpayment system might be explained by the pervasive overuse in China 73. Overuse led to a significant increase in healthcare expenditure, which may proxy for an underlying market price to compensate for physician nominal wage. The financial incentives persisted after the latest health system reform in China, including the introduction of an essential medicine list and a zero-markup drug policy 74,75. The consequence is likely that physicians used more unnecessary medical tests when drug prescription was heavily regulated, as we found in the study.
However, financial incentives may not be the main issue since overuse can also be influenced by physician knowledge 17,76,77, professional ethics 78, altruistic behaviours 79, and practice norms 80. Our study is limited in that we did not measure physician knowledge and other characteristics at the data collection 17. However, the financial impact of overuse was similar across high-competence and low-competence physicians. Since physicians may have given a correct diagnosis by luck but no other service, we estimated the predicted probability of giving a correct diagnosis for each physician-patient interaction (Table S6). We found that the overuse was proportionately distributed among the continuum of predicted probability of providing a correct diagnosis (Fig. 4), and the continuum should serve as a more precise proxy for physician competence in the study. Also, we found similar results using physician age as a proxy for experience in medical practice. These results suggest the pervasive overuse and its associated cost in our study is unlikely to be attributable to physician incompetence.
We did not find that the overuse and its financial impact varied across female and male physicians, although recent studies suggest female physicians did better in metrics of physician-patient relationships and health outcomes. Surprisingly, the financial impact of overuse was driven by interactions with female patients rather than male patients. Theoretically, the overuse-associated physician agency problem is related to information asymmetry between physicians and patients. It is a relative position because patients varied in health literacy for making informed decisions 25,27, and therefore physician behaviours changed correspondingly. Women and girls in China are more vulnerable, less educated and earned less compared to their male counterparts 81,82, especially among the older cohorts like our setting. These disadvantages were finally manifested as low health literacy among female adults 83 and therefore physicians could become more aggressive in the provision of unnecessary medical tests and treatment.
This study has several limitations. First, the main limitation of the SP method is that only a few types of diseases (two in the study) can be presented. However, the SP method has good external validity when the detection rate (zero in the study) is reasonably low. For example, physician behaviours are consistent between SPs visits and real patient visits 50,53. Our results were robust across the two diseases, but more evidence is needed in the future. Second, the SP method focuses on actual medical practice rather than physician knowledge 40,84. Although the pervasive overuse in our study seems unlikely to be attributable to physician incompetence, more research is needed to understand how physician knowledge affects overuse. For example, growing evidence indicates a gap between physician knowledge and practice 84–86. Third, we present the evaluation for one-time new patient interactions with different physicians, and the situation perhaps will change when the continuity of care for the same physician-patient model is promoted. Further research could assess patient preference for specific physicians after his/her initial interaction. Finally, whether and how the overuse would influence physician decision making in improving other metrics of quality of care and patient wellbeing is beyond the scope of this study, and these remaining questions will be evaluated in follow-up projects.
Overall, the study has important implications for health system reforms in China. China has undergone tremendous demographic and epidemiological transitions during the past thirty years 5. The increasing burden from chronic diseases and an ageing population have presented great health care challenges for the country 87. Recent health system reforms encouraged the first contact with lower-tier health care providers and primary care providers 88, which may substantially affect patients with chronic diseases. Our study shows that overuse of health care is pervasive in the primary care of China and leads to a significant increase in health care expenditure. These findings shed light on the cost escalation of primary care in China, where overuse is a form of medical inefficiency and low quality of care that should be urgently addressed.
First, while we cannot exclude many factors incurring overuse from the physician side, overuse in this study seems unlikely to be attributable to physician incompetence. Thus additional clinical training does not seem to be an effective policy intervention because its impact on the quality of care depends on how much the additional training increases physician competence; and how much the (increased) competence, in turn, is reflected in practice. Previous studies indicated that both effects could be minimal in medical practice 53,84. This may also help explain why a previous study did not find a positive impact of clinical training on the quality of care in the same setting 89. Similar to the case in India, overuse among qualified physicians with sufficient knowledge is as common as that among unqualified providers 50. The clinical training significantly improved the quality of health care provided but failed to reduce the adverse effect of overuse 53.
Second, we show that overuse of medical tests and overuse of drugs are partial substitutes. We find that physicians provided fewer drugs (/tests) if they offered too many tests (/drugs), and overuse of drugs (/tests) was associated with a decrease in test (/drug) cost. We use a consultation-treatment transaction model to understand physician behaviour (Fig. 5) 50,77. The main insight from the model is that 1) physicians can induce patients to consume more services either at the consultation stage (medical tests) or the treatment stage (drugs), and 2) physicians can shift efforts and medical resources between the two stages to make the global budget seemingly balanced 60. Therefore, the consultation stage could be as expensive as the treatment stage in practice, but the consultation stage has been comparably less studied in the previous literature 18,77. The good news of this finding is that, in a sense, even without government regulation, market accountability (i.e., competition, reputation) can motivate physicians to keep the total health care expenditure to a particular upper bound. The cost indicator could be easily observed by patients and compared within their social network, especially for common diseases. It is well possible that patients would be unsatisfied if the health care expenditure is somewhat too high and absurd. In this case, the overuse leads to a significant but finite increase in health care expenditure.