China is in the midst of a comprehensive $178.3 billion health care reform that is arguably the most ambitious among a series of stalled, largely counterproductive post-1978 efforts to improve access and reduce inequalities between rural and urban areas within China’s regionalized health care system. Unless the health care reforms are accompanied by a reform of fiscal policies, however, the absence of good governance brought on by financial constraints and perverse cadre payment incentives at the sub-national level is likely to undermine efforts to create a robust primary care infrastructure, and will consequently result in reform failure.
The wide-ranging economic reforms of the 1980’s transferred the responsibility for funding health care onto China’s local governments. In areas of China where economic reform resulted in an economic boom – i.e. major coastal cities like Shanghai and the first of the Special Economic Zones in Guangdong and Fujian province – local governments were able to raise enough money from increased tax revenue to greatly counterbalance the withdrawal of Central Government funding. In most of the country, however, Central Government funding decreased while the tax base stayed unchanged or shrunk owing to outward migration to the urban centers and the just mentioned Special Economic Zones.
There are 900,000 people in the United States who reside in assisted living settings, at an average age of nearly 87. On average, these individuals pay privately between $3,000-$6,000 per month for services that often include room and board, medication delivery and pill box set-up, supervision, and assistance with activities of daily living. Assisted living facilities are an integral part of the health care delivery system for many of our nation’s frailest older adults. Despite the high quality care that is often provided, the assisted living environment can often leave healthcare providers scratching their heads about what they can and cannot order for their patients. My recent experience with such a facility involving a patient with possible influenza illustrates the complex middle ground these facilities occupy.
A phone call from an assisted living facility in town interrupted me from my afternoon schedule. The facility’s nurse introduced herself and began to give me a report about my 85-year-old patient with dementia.
“Mr. Smith has a fever to 102 and is coughing up some ugly looking sputum. I’d like to order some labs and perhaps a chest X-ray. We might also want to consider an antibiotic.”
I asked the nurse a series of questions. Was my patient’s blood pressure unstable? Was he short of breath? Was he confused or disoriented?”
In each case, she told me, “no.”
“He is sitting quite comfortably watching a talk show on television. His only complaint is the occasional cough.”
I asked a few more questions and was reassured that he was otherwise fine. I told her that her initial request for blood work and a chest X-ray sounded like a good idea. We would wait on the antibiotic until the results came back.
“I’ll call you later today with the results,” she said.