Establishing Appropriate Agency Relationships for Providers in China

Liu, Yu; Saltman, Richard B.

As the base of a health care system, a physician's professionalism can be traced to the Oath of Hippocrates. 46 In the United States, the Flexner Report in 1910 was an important landmark in the development of a modern medical profession, and some scholars further defined its physician professionalism framework based on Flexner's perspectives. 47 In an increasing complex health care delivery system, physician professionalism may be defined in various frameworks with multiple ways. To be sure, physicians in China with their Confucian-based culture may not interpret or fully practice exactly the Western standard of physician professionalism. 48 However, China's health system development has demonstrated that market mechanisms alone do not have the capability to create a high-functioning professionalism structure for physicians. 8 A comprehensive physician professionalism system tailored to Chinese culture and social background may need the engagement and collaboration of government, professional physician associations, health care facilities, and physician leadership representatives. However, almost no efforts for physician professionalism have been implemented as part of the newest round of health care reform. 49 The development of a comprehensive physician professionalism system should be implemented at macro, meso, and micro levels, a multipronged approach which has proved to be an effective health care reform strategy in a number of countries. 50 At the macro level, the Chinese government should design a high-level legal framework and regulation to prohibit hospitals using measures related to volume or contribution of profit to incentivize physicians. The US Stark Law and Anti-Kickback Statute provide examples of how Western legal systems keep the autonomy and professionalism of practitioners separate from health care facilities. A professional physician association, for example, the Chinese Medical Association, should assume a larger role in developing, monitoring, and supervising high-level physicians' professional values and behaviors. Such professional values and behaviors should also be incorporated into the competencies of physician accreditation. The Chinese Medical Association may consider some of the standards designed by its Western counterparts. 51 In addition, physician professionalism will require broader social awareness, support, and an alliance between society and the medicine profession. 52 (See Table 2 for summary of "Stakeholder," "Major Responsibilities and Goal," and "Example," for the 3 levels.)