By Hongqiao Fu, PhD (School of Public Health, Peking University)
Background
Telemedicine and telehealth hold promise for reducing access barriers, improving quality, and containing health expenditure. As Internet companies enter the healthcare market, a rising number of online healthcare platforms have emerged worldwide. These platforms primarily use telephone and videoconferencing software to provide on-demand remote health care, giving patients fast and convenient access to doctors.
Like Teladoc in the United States, DocOnline in India, and Halodoc in Indonesia, a rising number of online healthcare platforms have emerged in China. The outbreak of the COVID-19 pandemic has further increased the demand for telehealth services on these platforms. A growing number of Chinese doctors are providing direct-to-consumer telemedicine services via these platforms; among them, the majority are full-time employees of Chinese public hospitals. This combination of public hospital doctors and privately funded online healthcare platforms creates a new form of dual practice: online dual practice. However, to the best of our knowledge, no studies have investigated online dual practice before.
Our recent article in Health Policy and Planning measures the prevalence of online dual practice by public hospital doctors in China, and examines how physicians allocate time for online work, and their motivations. We conduct this study by using web-crawled data from the four largest online healthcare platforms in China (Haodf.com, Wedoctor, Chunyu Doctor, Ping’an Doctor) and through interviews of public hospital doctors who are actively working on these platforms.
What did we find?
Throughout China, at least 16.5% of public hospital doctors were engaged in online service provision. The prevalence varied across physician seniority. Senior doctors were more likely to undertake online work as compared to their junior colleagues: no less than 33.5% of chief physicians and 21.5% of associate chief physicians rendered online healthcare services on at least one of the four leading platforms, compared with 14.8% of attending physicians and 8.0% of resident physicians. Moreover, we found that the prevalence of online dual practice in most of these hub cities was higher than the national average. For example, the estimated prevalence of online dual practice for chief physicians in Beijing, Shanghai, and Guangzhou was around 70%.
Most interviewed doctors said that they mainly used small pockets of time during working hours and after-hours to render services on the platforms. For example, an interviewed young ophthalmologist answered “I would check the apps between outpatient visits, when I am on the subway after work, or when I am at home on weekends.” The transaction data from Haodf.com confirms our findings from the interviews. 48.7% of the phone-call consultations on the platforms occurred between 6 pm and 11 pm. A larger share of phone-call consultations took place during the off-hours for senior doctors than it did for junior doctors.
The respondents gave five reasons for providing online services on third-party online healthcare platforms. “Efficiency improvement” was one motivation that was frequently mentioned by senior doctors. For example, they mention that they could inform their patients in advance by sending them guidance through the platforms and then doctors could save time on repetitive tasks and make the most of their working hours. “Personal control” was another word that was frequently mentioned by senior doctors. A doctor said “it brings us many complicated cases… I don’t want too many simple cases in outpatient visits; I would like complicated ones.”
Junior doctors, however, cared more about career developments and financial rewards. Some doctors noted that they wanted to build their reputation by providing online services. Other junior respondents were candid about their pecuniary motivation. For example, an interviewee in Beijing talked about the excessively high housing price when explaining her motivations for online dual practice. Furthermore, more than two-thirds of respondents mentioned that they used online platforms to better serve patients.
What are the potential effects of online dual practice on health systems?
The positive impacts on access to public hospital care are straightforward. Given that doctors use small pockets of time during working hours and after-hours to render online services, it increases the total labor supply of physicians and thus improves healthcare access. Moreover, it enables patients to access remote healthcare providers and may reduce access barriers due to travel distance.
Online dual practice may also improve the efficiency of service delivery at public hospitals. The Internet enables doctors to serve patients with minor conditions and reduce unnecessary visits. Public hospitals can therefore reserve more resources for patients with severe conditions. It also contributes to alleviating the crowdedness and reducing waiting time at public hospitals. All these results would be conducive to improving the efficiency of public hospitals.
However, there are some scenarios in which online dual practice can potentially worsen equity in access to public hospital care. For example, patients who seek private online consultations first can secure appointment slots that are scarce at public hospitals. The payment for online consultation is equivalent to an informal payment that permits high-income patients to access public hospital care more easily. It may also result in a deterioration in quality of care at public hospitals if dual providers overuse the Internet tools and opportunistically manipulate the quality of care to direct patients into private hospitals.
Overall, the net effect of online dual practice on health system performance remains an open question. The benefits and costs of online dual practice may depend on the specific contexts of health systems and regulatory policies on it should be health-system specific. It is important to assess how it affects the health system performance, particularly on key domains such as access, efficiency, quality of care, and patient satisfaction. Rigorous monitoring and evaluations can inform any mid-course policy adjustments, ensuring that countries can achieve their stated goals of the health system.
