Public hospitals in China
Unlike many industrialized counties where only very ill patients are admitted to hospitals, patients in China can be admitted to public hospitals for chronic diseases and rehabilitation [
2]. On top of inpatient care, Chinese public hospitals are overburdened with the load of outpatient care. As there are no formal referral systems, patients can go directly to public hospitals to seek outpatient care even for minor conditions [
3]. The general public have low trust in the quality of care provided at primary care facilities; the demand for health services, consequently, increases and concentrates at large public hospitals [
39]. Government financing is one of the primary sources of revenues for Chinese public hospitals. But due to insufficient financing, hospitals mainly survive on service fees [
4]. Physicians’ salaries are also tied to hospital revenues in China. As a result, hospitals directors and physicians have been perversely incentivized to make up the gap of profits through over-prescriptions [
40]. Findings in this present study have resonated with those prominent issues of Chinese public hospitals mentioned above from the patient perspective and identified the aspects of hospital care that patients are most concerned with.
Aspects that patients care most about in public hospitals
Priorities of various aspects of hospital care have been determined in this study exclusively from the perspectives of patients rather than from the views of medical staff or health experts. To the best of our knowledge, this study is the first to explore what patients care about most in China’s public hospitals from a patient perspective by using individual interviews.
Of the nine key themes identified, four are concerned with the “structure” of hospital care, including environment and facilities, professional competence, hospital reputation, and morals of medical staff. Another four themes are classified into the “process” of hospital care, which are caring attitudes and emotional support, medical costs, communication and information, and efficiency and coordination of care. The remaining theme of health outcomes refers to the “outcome” of care in public hospitals.
For the theme of
professional competence, patients in the interviews expressed their expectations on nurses and other medical staff apart from doctors. This finding indicates that patients are aware of and could distinguish the different roles of medical professionals in providing health care services within a hospital. Besides, patients’ emphasis on nurses’ professional capacity found in our study also underlines the overall shortage of nurses. Nursing shortage in China is more severe than that of some developed countries [
41]. The particular low number of nurses makes the importance of this professional group even more salient.
Unlike previous findings, our study has disclosed a theme of
morals of medical staff. Patients commented on medicines in the interviews from different angles. In terms of professional capacity, patients emphasized doctors’ ability to prescribe appropriate medicines. As regard to hospital reputation, patients commented on the drug supply of hospitals. When it comes to the moral issues, patients highlighted doctors’ prescribing behavior from the perspective of medical ethics rather than professionalism. These findings suggest that patients who are not trained or have medical expertise do have the ability to assess whether medical professionals deliver treatment appropriate to their health problems [
42]. These results on the one hand reveal the moral issues in China’s public hospital, and on the other hand verify the importance of measuring patients’ experiences of care.
For the theme of
caring attitudes and emotional support, the categories described by patients cover the general attitude to more specific attributes, and patients in our study did not differentiate much between doctors and nurses in their serving attitudes. All the attributes mentioned were expected to be possessed by both doctors and nurses. These findings are in consistency with a previous study in Australian patients [
33]. Some interviewees also expressed their appreciation on respect and privacy protection. These results indicate that patients may seek a higher level of caring from medical staff than merely compassion and sympathy at public hospitals. Similar results have been observed in a qualitative study of Hong Kong patients [
43].
For the theme of
medical costs, patients in our study expressed their strong views on the costs of drugs, medical examinations, registration, surgeries, nursing and other costs. Although controlling health expenditure is a principal component of public hospital reform and a previous study has reported significant decrease in post-reform drug expenditures per visit [
11], patients interviewed in our study were still highly concerned about their medical costs. Besides, patients also repeatedly mentioned health insurance reimbursement in the interviews from the reimbursed items covered by health insurance to the implementation of real-time reimbursement. In China there are three major social health insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Rural Cooperative Medical Scheme (NCMS) [
44]. Payroll taxes are the primary funding source for UEBMI premiums, and government subsidies are the major source for URBMI and NCMS premiums [
44]. Each of the three insurance schemes has its own benefit package based on the scale of premium. UEBMI covers both inpatients and outpatient services, whereas URBMI and NCMS mainly cover inpatient services, with quite low proportion of outpatient services and selected chronic conditions reimbursed due to the small amount of premium [
4]. Besides, these three health insurance schemes have different reimbursement caps. Patients with different types of insurance schemes, therefore, may have to pay different proportions of out-of-pocket money for the same health care with the same quality [
44]. Due to variations in local government’s financial and management capacity and inequalities in benefit packages, although nearly universal insurance coverage has been accomplished in China since the initiation of the health-care reform, the benefits remain shallow [
45]. Another key barrier to insurance use in China is the mobility of insurance management [
4]. Currently, most patients have to go back to their registration city or county to get reimbursement, if they seek health care in other areas. Findings in this present study indicate that patients still suffer economic burden and barriers to insurance use when seeking care in public hospitals.
For the theme of
communication and information, patients highlighted the importance of medical staff providing information on various aspects of care and possessing good communication skills. Similar findings have been shown in previous studies [
46]. Participants in this study also emphasized their own involvement in decision making such as discussing treatment with doctors. This finding concurs with the results of other studies, suggesting that patients value their own engagement in hospital care and prefer individualized treatment achieved through collective decision making [
47,
48].
For the theme of
efficiency and coordination of care, relevant sections of interviews in this study were dominated by the topic of waiting time in public hospitals. Apart from time spent on waiting for seeing a doctor and taking the medical examinations, the waiting time for registration and paying fees were also commented on by patients, and even the waiting time for taking the elevator was mentioned. These phenomena might be probably caused by the fact that China has no strict referral system, and patients can go directly to public hospitals for all outpatient care [
4], including simple health problems [
3]. In China public hospitals serve the largest number of patients [
7], which in consequence leads to long waiting time for various health care services in public hospitals. Such long-time wait also lay heavy caseloads on doctors, which causes minimal individual consulting time. As a result, conflicts between patients and doctors occur due to insufficient communication [
4]. It is indicative that the referral mechanism and quality of primary care are in need of improvement in China’s health system.
For the theme of health outcomes, patients highlighted treatment effect and recovery length. Although this theme seems to be categorized as a PROM by name, its subthemes are more concerned with PREMs. The subthemes identified are relevant to evaluation of patients’ satisfaction with or experience of treatment effect and recovery length rather than the assessment of patients’ health status or health-related quality of life. These findings imply that the development and application of PROMs, and not only PREMs, could be improved in evaluation of public hospital performance in China.
Limitations
A limitation of our study is that some patients described the same concepts more than once in the interview. To avoid bias, the research group counted the repeating phrases of the same patient exactly as they appeared in the interview. In future research, attempts can be made to count the repeating concepts of the same respondent only once.
Another limitation is that the only personal information gathered about the patients was their sex, age and residence with some information missing. Since it was an exploratory study with the primary purpose to understand patients’ primary concerns about hospital care, the research group did not set strict rules prior to conducting interviews to gather information on personal data. However, it would be of great value to further explore the difference in perceptions about hospital care between patients of different backgrounds. Patients’ sex, age, education level, employment status and income level might exhibit variation in thematic enunciation which could not be investigated in the current study. This limitation should be addressed and investigated in future studies.
In order to ensure the representativeness of the sample in this study, we used mixed sampling methods to include both outpatients and inpatients from urban and rural areas in Jiangsu Province. However, the results of this current study cannot be generalized to other parts of China, as Jiangsu Province is a relatively prosperous region. But since Jiangsu Province is a health-care reform pilot site, this study could provide an example for similar studies conducted in other parts of the country.