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Azure Health The Future of China’s Healthcare System

We arrive in Beijing to a city blanketed by new white snow underneath clear blue sky.

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The Future of China’s Healthcare System

Third Hospital Symposium, Peking University, Beijing, CN

Foreword April 22, 2013 Azure Health, LLC was created by mid-career health professionals in the Healthcare-focused executive MBA program at Yale. From March 18th to March 28th 2013, members of the Azure Health team visited with multiple stakeholders in the future of China’s healthcare system. We hoped to create a working knowledge of healthcare in China, form lasting friendships and explore opportunities for collaboration. Our itinerary included 5 major hospitals in China in the cities of Beijing, Xi’an, and Shanghai, the Ministry of Health, the Beijing State-owned Asset Management Company, multiple pharmaceutical, medical device and CRO companies, and a medical device incubator.1 Here we have recorded our impressions from the visit.

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Visit schedule: Appendix A.

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The Future of China’s Healthcare System

contents Foreword

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Background Introduction Healthcare Reform Patients & Providers Prepayment penalty Lack of primary care Specialty care dominance Private hospitals Pharma & Medical Devices Pharmaceuticals Innovation Intellectual Property Patient Outreach

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A Unique Healthcare System Subsidy shifting A hybrid model? Holding future costs in check

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Structural Considerations Patient demographics Government plans The 3 tiers of Chinese healthcare A harmonious provider ecosystem A nationwide health information network

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Future Collaborations Focused consultative services Reducing the prepayment penalty Addressing primary care need Competitive private hospitals Hospital brand management Healthcare IT Pathology and radiology services Conferences and training

25 25 26 28 28 29 30 31

Locations visited China Trip Contributors Final Words

32 33 34

Appendix Participant Profiles Trip Itinerary

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The Future of China’s Healthcare System

Background I. Introduction Mao brought health and Deng brought wealth to China. The Mao Era began with the formation of the People’s Republic in October 1949, and lasted 26 years until Mao Zedong’s death in 1976. Universal care based upon the collective, in the form of agricultural and industrial units, was instituted with emphasis on public health and preventive medicine. With immunizations, aggressive treatment of infectious disease with antibiotics, and preventive care using traditional Chinese medicines (TCM), China achieved the most rapid increase in life expectancy in global history, from 35-40 years in the early 1950’s to 65.5 years of age by 1980.2 China’s economy fared poorly in comparison until it finally emerged in the aftermath of the Cultural Revolution. As Mao dominated the first 25 years of the People’s Republic, the second 25 years would belong to Deng Xiaoping. After 1975, with Deng in control, China transitioned from centralized planning to a largely market-based economy. Although the communal system of healthcare had eroded, life expectancy and overall health continued to improve. By 2010, life expectancy reached 72.5 years for men and 76.8 years for women. This resulted from 2 major factors: a decreasing fertility rate combined with increasing per capita income (US $4000 in 2011, equivalent to > US $7000 in purchasing power parity)3. With China’s one child policy, greater capital invested in fewer offspring led to an upward march in both education and health standards for successive generations. With its increasing wealth, today China faces new challenges. Greater openness to the West has led to behavioral and dietary changes, with a consequent shift in China’s disease profile towards chronic illnesses familiar to the West. China’s population now matches the US in the dubious distinction that today, cancer, heart disease and stroke are its greatest killers.4

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Miller 2011 Peng, Xizhe “China's Demographic History and Future Challenges” Science 333, 581 (2011). 4 “Burden of disease in China in 2001,” Disease Control Priorities Project, www.dcp2.org. 3

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II. Healthcare Reform Increasing access, decreasing uncertainty After the Cultural Revolution through the 1990’s, healthcare costs were mainly borne by patients as out-of-pocket expense. To increase access, in 1999 China instituted healthcare reform. Basic Health Insurance, consisting of three plans, the New Cooperative Medical Scheme (NCMS) for rural areas, and the Urban Employees’ Basic Medical Insurance system (UEBMI) and Urban Resident’s Basic Medical Insurance system (URBMI) for urban areas,5 were rolled out from 2002 to the present, and coverage amounts have steadily increased. Yet as late as 2005, coverage reached less than 25% of the Chinese population.6 In 2009 the pace of reform accelerated greatly, and today China has near universal healthcare access covering 97% of the population.7 Local governments are now charged with implementing plans that are set at the central level through the management of local health care insurance systems and local providers. While health care access is wide, it is not deep. Due to the high cost of care for cancer and chronic diseases, including cancer drugs, radiosurgery, treatment for diabetes and dialysis for kidney disease, care may still require up to 50% or more out-of-pocket expense.8 Basic Health Insurance in China provides the population access to healthcare, but it falls short of acting as full health insurance. This is especially true given the behavior of providers, discussed in the next section.

People’s Hospital Symposium, Peking University, Beijing, CN

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Ministry of Health, Beijing, CN

Wang et al, 2009 Chen H and Lin Y, “The Rise of Private Health Insurance”, China Economic Review, March 27, 2012 7 Liu Y., “Great Progress but More is Needed” NY Times, Nov. 1, 2011 8 China National Health Development Research Center, 2011, Table 5, p.9. 6

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The Future of China’s Healthcare System

III. Patients and Providers i. Prepayment for hospital services: an obstacle to healthcare access The Chinese people have not adopted Western notions of a “right” to medical care. Hospitals in China, unlike their counterparts in the US, are therefore able to charge upfront for care that has not yet been delivered. The need for patients to pay large amounts of cash out-of-pocket at the onset of illness negates a substantial benefit that patients enjoy in national health systems in Canada and Europe, and from health insurance in the US, where hospitals are paid after care is delivered. Although government insurance in China allows patients to reclaim a portion of costs later, this “prepay” requirement remains a significant obstacle to care even when the entire cost of care will be reimbursed. The cost of this “prepayment penalty” is evident in recent data from 2012 as the savings rate in China climbed to 54.3%, the highest in the world.9 The country's total savings came to more than 20 trillion yuan (US $3.2 trillion), equivalent to an average per capita savings of around 10,000 yuan (US $1,600). This is despite the recent rollout of healthcare insurance to achieve near universal coverage, and suggests that even with health insurance coverage Chinese people continue to feel, as much as ever, the need to “self-insure”. If China’s policymakers hoped to encourage less savings and greater consumption to power its economy as part of the rationale for healthcare reform, they have not achieved the desired result.

ii. Primary care in China Chinese healthcare lacks a substantive primary care component. Instead, patients self-refer to specialists. This has a direct and an indirect effect upon patient care. The direct effect is higher levels of chronic disease and cancer. It is well-established that high-quality preventive care is delivered most effectively by primary care physicians. Consider the problem of heart disease. Vast numbers of hospital beds and coronary units and a great amount of diagnostic and research time and money is spent to control hypertension and treat its complications. At best this effort is unrewarding; it is a relatively futile approach to the problem. Thanks to multiple studies10 we know that detection of raised blood pressure in 9

International Monetary Fund. The average savings rate in the rest of the world was 19.7% in 2012. 10 VA study, Framingham Study

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the healthy young, and its early treatment before symptoms appear, can prevent the complications of hypertension including ischemic heart disease. A similar situation exists with regard to cancer. Carcinoma of the cervix must be tackled primarily by cytology of healthy women, not by heroic surgery and superlative radiotherapy. Ultimately the most rewarding approach to disease involves the identification of those risks, preventing its development, and early detection and treatment. These are uniquely the skills of primary care. In highly-complex patients, primary care physicians are able to coordinate the care of multiple specialists to deliver more integrated and skilled care. This leads directly to better overall health and a higher quality of life. Therefore primary care, in addition to being cost-effective, is also the key to better health at both ends of the illness spectrum. The lack of an effective primary care layer will ultimately be costly both in terms of resources and effectiveness as the Chinese population continues to age and chronic diseases and cancers increase in prevalence.

iii. The dominance of specialty care at elite University hospitals: a lack of provider harmony Indirectly, the relative absence of primary care in China leads to a lack of harmony between healthcare delivery at different provider levels. In a competition between hospitals at different levels that all offer specialty care, the best specialists by default are not found at local community hospitals; they work instead at the elite institutions in the largest cities. Although new clinics and private hospitals are being built quickly in China, they lack the prestige of elite government hospitals. Hospitals are categorized, depending upon number of beds, as Level 3 (>500 beds), Level 2 (>100 beds), or Level 1, with further a, b, and c designations. The 3a teaching hospitals connected to medical schools in the largest cities, such as Beijing and Shanghai, enjoy the greatest prestige. We visited three such hospitals in Beijing, and clearly the healthcare delivered was on par with Western standards. Patients come from all of China to obtain care at these facilities. At the Beijing hospitals we visited, outpatient encounters numbered between 10,000 and 13,000 per day. Meanwhile, many local hospitals remain underutilized with spare capacity.

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The Future of China’s Healthcare System

iv. Private hospitals: meeting the needs of an enlarging middle class China’s economy has grown to become the second largest in the world; estimates suggest that it will surpass the US economy in size towards the end of this current decade. Its healthcare sector, however, has not kept pace. Economic wealth has created a large Chinese middle class whose medical needs are not well met by today’s Chinese health care providers. Currently in China, the vast majority of hospitals are government-operated. The Chinese government hopes that most of its medical needs can be met by growth in private sector hospitals. According to China’s health minister Chen Zhu, during the 12th Five Year Plan period (2011-2015) the proportion rates of hospital beds and patient volume provided at private hospitals should double, as the country pledged for both rates to reach 20%11. In October 2012, Beijing issued policies to help private hospitals develop, including favorable taxation, simplified registration procedures and priority to be given to private hospitals during new hospital planning.12 With better functional balance between elite and local providers, more middle class patients will seek care locally, and with the increase in private hospital beds, patients who need specialty care will have greater options.

Beijing Asset Management Company, Beijing AiYuHua Women & Children’s Hospital, Beijing, CN

Peking Union Medical College Symposium, Beijing, CN

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China encourages private investment in hospitals: minister. Xinhua news agency, 2012.09.17 http://news.xinhuanet.com/english/china/2012-09/17/c_131855535.htm 12 Health center a new model for reform. China Daily, 2012.09.18 http://www.china.org.cn/china/2012-09/18/content_26554475.htm

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IV. Pharmaceuticals and Medical Devices

i. Pharmaceuticals “The Chinese government has a vision: to move the pharmaceutical industry from one based on low-cost manufacturing to one that is a dynamic source of global innovation.”13 Goals include delivering 30 new drugs by 2015 and achieving first-tier R&D capabilities by 2020 to address Chinese medical needs especially oncology, diabetes, cardiovascular and respiratory disease. Chinese pharmaceutical market has expanded aggressively in the past decade, outstripping that of health expenditures overall. Currently the Chinese pharmaceutical market comprises 48% over the counter drugs (OTC), 42% prescription drugs and 10% Traditional Chinese Medicine (TCM).14 Sales have grown at a CAGR of over 25% from 2007-2010. With an aging Chinese population, a growing income and middle class and increasing government expenditure on healthcare, the Chinese pharmaceutical market is expected to continue strong but more modestly from 2010-2015, at a CAGR of mid-teen percent.15 During our visit to Chempartner, we learned that pharmaceutical sales in China have risen from 9th in the world in 2007 to 2nd in 2011 and are projected to be the largest by 2020. To capitalize, many multinational pharma companies including Pfizer, Merck & Co, GSK, Novartis, Roche, AstraZeneca, Merch Serono, Novo Nordisk, Sanofi and Eli Lilly have set up R&D centers, manufacture facilities and Asia & Pacific headquarters in China.

ii. State of Innovation: the haigui Much of this is driven by returning Chinese nationals, fondly known as Sea Turtles or Haigui (Chinese: 海归; pinyin: hǎiguī) who enjoy large incentives provided by the Chinese government including but not limited to grants, inexpensive facilities for business and personal rent subsidies, with escalating financial support as a venture demonstrates success. These individuals are uniquely positioned to bring western innovation and business practices to China

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Building an innovation-driven pharmaceutical industry in China. 2012 R&D-based Pharmaceutical Association Committee (RDPAC) 14 China’s pharmaceutical industry – Poised for the giant leap, KPMG, 2011 15 The next phase: opportunities in China’s pharmaceutical market. Deloitte, 2010

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The Future of China’s Healthcare System

and bridge the cultural and political differences. It is also evident that there are tremendous resources for Westerners interested in the Chinese market. Approximately 90% of hospital equipment in use in China is currently imported. This, combined with enormous growth in the number of devices used in patient care, makes medical devices a large and important healthcare sector in China. The next 5-10 years have been designated China’s Medical Years, aimed at developing China’s ability to serve its own market. We visited Gateway Medical Innovation Center, which is also the project of a returnee - an accelerator/ incubator whose unique focus is on the preclinical development of medical devices. While the Center expected to serve the needs of foreign medical device development (while retaining the rights for the Chinese market) their current work is primarily supporting Chinese physicians in their innovations process by pairing them with engineers and funding. Dr. Hu, one of the founders of Gateway, stated that it’s easy to raise funds, but the need is for worthwhile investments. Innovation capabilities in China are behind what’s seen in the West, with most advances being incremental improvements or adaptations of already existing technology. Chinese physicians tend to work within the structure of what is available, and do not tend to think outside the box. Other barriers include government cost controls, regulatory processes and the related common Chinese business practices. A pharmaceutical compound must be invented in China in order for first in human clinical trials to be run in China. There is a significant tax placed on candidate pharmaceuticals imported for clinical trials. Furthermore, a biologic must be manufactured in China for the Chinese market. Pfizer China was therefore established in 2005. It now employs 550 people and it is also headed up by a returnee. Clinical operations are located in Beijing, the R&D Center is in Shanghai and an additional R&D center is being established in Wuhan. Except in clinical research, where there is a shortage of principal investigators, local talent was cited as an asset. Barriers included compliance, intellectual property (although improving), lower R&D productivity and rising costs. In terms of opportunities and challenges, Pfizer China’s model includes novel alliances and open innovation to advance R&D objectives. Their portfolio focuses on highly differentiated products, in particular targeted drugs as well as merger and acquisition opportunities. They are also shepherding the brand in this emerging market and seeking to gain deeper customer insights, including the leveraging of social media. Pfizer is on track to become the second largest biopharma company in China by 2015, with current revenues of $1B, 24 Chinese new

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chemical entities (NCE) in clinical trials, and lots of government interest: $12B in funding over the next 5 years toward new pharmaceutical development programs.

iii. Intellectual Property: the SIPO The Chinese government provides significant incentives to nationals filing patent applications with the Chinese State Intellectual Property Office (SIPO) which international onlookers suggest promotes quantity over quality.16 In 2012 with 1.26M issuances, the SIPO granted more patents than any other patent office worldwide. Of these, 80% were granted based on domestic applications. However, many international patent professions are quick to point out that there are significant differences between the majority of these patents and those granted in the US. The majority of patent applications the Chinese file with the SIPO are Utility Model (UM) applications, a category that does not exist in the US. This type of application has less stringent requirements and they generally pertain to features of existing innovations, for example new shapes or structural features. Furthermore there is no substantive examination and generally they grant within a year from filing. In 2011 there were 585,467 UM applications filed with the SIPO.

iv. Patient outreach Innovation by medical devices companies is going beyond research and development labs. At the Medtronic Patient Care Center in Bejing, China, an innovative approach to education and awareness has been established to respond to the unique patient healthcare needs in China. The education center is the first of its kind in China and worldwide. Patients and families meet with medical experts to learn about advanced technology options for treatment of chronic disease. In a center that resembles an Apple Store, patients obtain a hands-on approach to learning through exposure to advanced medical devices and anatomical models. The experience provides access to information that otherwise may never reach patients in China who may have limited time to discuss treatment options with their physician. This education center creates an opportunity for patients to learn enough about Medtronic’s devices to engage in 16

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China’s Great Leap Forward in Patents, International Technology Law Blog April 4, 2013


The Future of China’s Healthcare System

an informed dialogue with their physicians on advanced medical technology solutions. It advances Medtronic’s brand, delivers educational information, and hopefully will aid the Chinese patient community in the management of their chronic disease.17

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http://wwwp.medtronic.com/Newsroom/NewsReleaseDetails.do?itemId=1281039211471&lang =en_US

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Chang’an Cancer Hospital Symposium, Xi’an, CN

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The Future of China’s Healthcare System

A Unique Healthcare System i. Subsidy shifting: creating a dynamic healthcare market In a remarkable departure from other single payer national health care systems, at the onset of healthcare reform more than ten years ago, the Chinese government decided to shift resources from the supply to the demand side of health care.18 Direct subsidies paid to government hospitals and clinics were virtually eliminated over the last decade, and replaced by direct reimbursement to patients through expanded Basic Health Insurance coverage. The government switched dramatically from a seller to a buyer of health care services by subsidizing the buying power of patients. This is a distinctly different model from the national health care plans of Canada and Europe, and much more similar to that of the US. By giving choice to patients, the government has created a market for health care services that is similarly dynamic. Virtually overnight, government hospitals that previously received direct subsidy support suddenly had to act like individual for-profit entities that had to improve their healthcare product or fail. Evidence of strong competitive pressure was prominent in the presentations we heard in all five of the hospitals we visited, including three of the top-tier super-elite hospitals in Beijing: People’s Hospital and Third Hospital of Peking University and the Peking Union Hospital. In fact, arguably the Chinese healthcare market is more dynamic than that in the US. In China, there are less regional monopoly and oligopoly providers organized into hospital chains, and large third party commercial payers are absent. The healthcare markets we visited in the cities of Beijing, Xi’an and Shanghai were extremely dynamic and competitive, with hospitals offering unique products to patients not seen in the US. Overall, providers and patients seem to engage in a market free-for-all for patient volume and medical services. There is similar dynamism in other portions of the healthcare value chain. Many global pharmaceutical companies are in China to access its healthcare market despite heavy controls upon drug pricing by the government. Large CRO’s conduct research for healthcare products destined for the Chinese marketplace, and TCM (traditional Chinese medicine) is big business dominated by a few large Chinese companies. Medical device entrepreneurship is similarly alive and well, since hospitals are free to buy medical device products for patients who can 18

Eggleson K., “Health Care for 1.3 Billion: An Overview of China’s Health System”, Stanford APARC, 2012

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afford them. Global companies, including those in healthcare, are taking notice because while per capita income in China is still low, actual purchasing power is quite high due to the country’s savings rate (54% vs. 5% in the US) and the presence of a wealthy upper middle class with a size that approximate the population of the United States.

ii. A hybrid model: the best of US and Europe? National single payer health care systems in the West are good at guaranteeing a safety net and holding down costs. They typically excel at preventive and primary care but are poor at innovation and the provision of specialty care. On the other hand, the US market-driven system is not as good at primary and preventive care, but it excels at innovation and the provision of specialty care. As we all know, the US health care system is also extraordinarily expensive, taking up 17% of the US GDP. Arguably, with its quality of medical research, the US has the best health care system in the world if the patient happens to be both well-informed and wealthy. Given the opportunity, however, it is not a system any government administration would decide to devise today. China, by shifting subsidies from providers to patients while achieving universal coverage, is remarkably creating a model that may be combining the best of both worlds, on the cheap. With a large population that is still extremely poor in its rural regions, the government is still working to create a wide social safety net for its people with a preventive and primary care emphasis. While that effort is still ongoing, it has been able to control cost. During our visit to the private Chang’an hospital in Xi’an, we learned that since the local population is not wealthy, the local government had essentially de facto control over the prices the hospital could charge through the government’s reimbursement rates to patients. Yet the hospital, in competition with 10 other hospitals regionally, is making a good profit. In its richer eastern regions, these same market-oriented policies have created a dynamic booming healthcare environment that fosters competition. Every 3a hospital has all of the best equipment and technologies found in the world, with the most expensive MRI imaging, linear accelerators for cancer radiotherapy, and labs for genotype testing. Two 2a specialty neuroscience hospitals had PET, MEEG, video EEG, and EEG recording equipment with high sampling rates to detect ripples for epilepsy. The staff physicians and nurses are highly trained. What we are seeing is the creation of a healthcare infrastructure in eastern

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The Future of China’s Healthcare System

China that is on par with what we see in the best hospitals in the US. During our visit with the Beijing State-owned Asset Management Company, we were treated with a presentation of their first hospital venture, Beijing Ai Yu Hua 北京 爱育华, a new Women & Children’s Hospital in Beijing slated to come online in June 2014. The hospital will utilize a patient-centered model for care, designed to be on par with any similar first-class hospital in the US. Collaboration with Children’s Hospital of Philadelphia will ensure the best training for its staff and processes for its operations. The main difference between Chinese 3a hospitals and the best hospitals in the US is in the capacity to perform higher level hospital analyses and management. The best hospitals in the US continuously analyze patient data to seek improvement in operational and patient care processes, to decrease complications and increase efficiency using reporting functions from their IT systems and standing committees to analyze the reports and devise improvements.

iii. Holding future expenditures in check: drawing the line between confidence and excess Remarkably, China’s healthcare expenditure is 6% of GDP, lower than costs in even Europe and Canada. An important factor is the currently large out-ofpocket expense for patients and the need to pay for care upfront, which places a tremendous downward pressure on cost, virtually eliminating the moral hazard of healthcare insurance. There are other developed countries where a single payer system holds healthcare costs in line with a large patient deductible. Japan has been a relatively wealth country for decades, yet the Japanese maintain a 30% out-of-pocket deductible for health insurance with exceptions made for the elderly and poor.19 As a result, Japanese health care cost is 8.5% of GDP, half that of the US. A major policy rationale for increasing healthcare spending to decrease out-ofpocket expense is to enlarge the consumption portion of China’s economy by encouraging the population to spend more and save less. The question is where to draw a line that will give the Chinese people enough confidence and security for healthcare access so they may save less and consume more, without driving healthcare expenditures to a level that would be burdensome for China’s economy. 19

International Profile of Health Care Systems 2011, Commonwealth Fund, Japan, page 74

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Structural Considerations There are two drivers for the future of Chinese healthcare. The population profile of patients in China is changing rapidly, and the central government is clearly committed to meeting patient needs and improving healthcare services.

i. Changing patient demographics The patient profile in China is changing both in terms of demographics and expectations. An aging population20 of better educated and informed patients21 is undergoing rapid urbanization22. The burden of chronic disease and cancer will increase as the average age of the population increases. The literate, more educated middle class will continue to seek a higher level of care, which currently skews sharply towards urban University hospital centers. Rapid urbanization further exacerbates the pressure upon urban care delivery systems that are already over-utilized. Urban centers consume 80% of healthcare expenditures, while 70% of the country’s population resides in rural areas. Furthermore, the Chinese government health insurance system is currently administered by local governments rather than the central government. Movement of citizens and economic homogeneity will require an integrated health insurance system to allow the portability of health insurance, which will lead to greater stability of the labor market.

ii. Government commitment to healthcare China’s goal from 2011 to 2015 is to improve Basic Health Insurance by deepening coverage, making insurance portable, investing in more infrastructure and physician training, instituting operating standards for facilities and training 20

By 2020, 11.8% of China’s population will be over 65 years of age compare to 8.56% in 2004 “China’s population” China News Agency, January 1, 2005. 21 Consumption of vitamins and other health services like laser surgery has increase in China in past 5 years. Chinese government is encouraging voice of consumers.”Hangzhou patients participate in hospital evaluation” http://www.bjhb.gov.cn/ 22 Urbanization is happening in China at the rate of 1% every year. By 2020 60% of China will be urbanized. “Urbanization and spread of disease of affluence in China -- Health Econometrics And Data Group” http://www.york.ac.uk/res/herc/documents/wp/08_25.pdf

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The Future of China’s Healthcare System

standards for doctors, and encouraging the formation of a robust private health care sector.23 The government has been committed to addressing healthcare issues through candid acknowledgment, massive investment, and implementation of initiatives to improve hospital management and raise quality of patient care. In the past decade, the government has taken steps to improve customer focus in the Chinese healthcare system. Year 2005 was the “Year of Hospital Management Reform” with the key theme of “Patients come first, improve the quality of service”. Tianjin is an example of a local health bureau taking action to raise the quality of care. Instead of tying salary of physicians to productivity factors such as number of patients served, the Health Bureau of Tianjin ties the salary of physicians to job performance, of which an important component is patient satisfaction24.

iii. The Future Segments of Chinese Healthcare Through its policy statement Liu Xinming, a senior advisor on policy and regulations in the Ministry of Health, said: “The government will define provision of healthcare services as publicly funded industry…. Government hospitals and socially owned non-profit hospitals will become the main components of the healthcare sector, in order to demonstrate the public service nature of the healthcare sector. For profit hospitals will play a supplemental role, and we will set different policies.”25 In the drive to improve access to and quality of the healthcare system in China towards Western standards, we believe that the government will formulate strategy and policies to segment the healthcare market along three distinctive lines: public health, basic health services and specialty medical services. Each service segment will have a different funding mechanism, and allow different forms of competition (see Table 1 to follow).

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Summary of National Meeting on Health Reform, http://sub.ldws.gov.cn/xhx/ReadNews.asp?NewsId=617 24 MOH working conference April 18, 2005. Chinese Ministry of Health Website. www.moh.gov.cn 25 MOH Policy and Regulations Department May 2005.

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Service Category

Description

Delivery Mechanism

Funding Mechanism

Market Condition

Public Health Services

Control and prevention of infectious disease, STDs, AIDS, respiratory disease, mental illness, healthcare education.

Public, nonprofit government clinics and hospitals

Government direct, social insurance, and low patient out-of-pocket.

Closed Market, subsidized and controlled by the government.

Basic Health Services

Basic primary care medical services for treatment and wellbeing.

Non-profit clinics and hospitals.

Government direct, social insurance, and low patient out-of-pocket.

Mainly subsidized and controlled by the government, but open to for-profit institutions.

Specialty Medical Services

High tech care (equal to western countries & US), specialty elective procedures

University and for-profit hospitals based on free market principles.

Social insurance, patient out-ofpocket and commercial insurance.

Competitive & open to local and foreign health insurance companies.

Table 1: A tiered services structure for the distribution and delivery of healthcare

In Table 1 above, the first two segments (light blue), Public Health Services and Basic Medical Services, effectively comprise a single layer of preventative and primary care that acts as a safety net for the entire population. It is a low-cost, high-quality product that ensures the overall health of the population, in the same mode as single-payer systems within national healthcare programs. The completion of this layer will require greater investment in primary care and new training, maintenance and certification protocols for physicians and local provider clinics and hospitals. The third segment (gray), Specialty Medical Services, will belong to the free market for healthcare that is already alive and well in the first-tier hospitals of eastern China. We believe that the Chinese healthcare market will soon see a surge of investment in commercial insurance funding for special health services that will allow patients to offset rising out-of-pocket expense with risk adjustment insurance premium payments.26 This insurance product will need to be designed specifically for the current Chinese healthcare landscape, or it will fail, as many already have. A properly formulated commercial insurance, stratified for different population incomes, will attract the younger, upwardlymobile population who are looking for improved healthcare with lower out-ofpocket risk. 26

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Similar views were shared by IBM Institutes for Business Value Analysis.


The Future of China’s Healthcare System

iv. A harmonious healthcare provider ecosystem The relative absence of high quality primary care in China leads to a lack of harmony between healthcare delivery at different provider levels. In a competition between hospitals that all offer specialty care, the best specialists by default are not found locally; they work instead at the elite institutions in the largest cities. The resulting imbalance in competition results in overcrowding at elite hospitals while local community hospitals may remain half-empty. A more harmonious relationship between local providers and elite 3a institutions would involve balanced complementary relationships based upon low-cost, high-quality primary care in the community, and referrals to regional centers of excellence for necessary specialty care. Elite hospitals would then send their patients back to the community for follow-up care.

v. A nationwide health information network Facilitating information sharing by building a common platform linking healthcare providers in a nationwide network is an inevitable task for the government if it seeks to create a global healthcare delivery model. Modest HIE networks are forming regionally in China, and People’s Hospital in Beijing is pioneering a more robust HIE effort in collaboration with the MOH. 27 A reliable, security-rich, nationwide network can form the backbone of a national health information infrastructure and facilitate information sharing between providers, patients and regulatory bodies in the government. In addition, with healthcare information, the central government can partner with private insurers to administer insurance plans and create competition between insurance carriers to offer the best service for the needs of the Chinese population.

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Beyond Regional Health Information Exchange in China: A Practical and Industrial-Strength Approach, AMIA Annu Symp Proc. 2011; 2011: 824–833.

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PuTuo Hospital Symposium, Shanghai, CN

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The Future of China’s Healthcare System

Future Goals of Azure Health in China Healthcare management services Our program, the Masters of Business Administration for Executives, Leadership in Healthcare Program in the School of Management at Yale University in the United States, trains our group to create organizational efficiencies and solve difficult problems in health care management. We would like to collaborate with you to take on your challenges and make contributions to solve the critical issues confronting your healthcare organization. There may be many opportunities to share knowledge and begin an ongoing dialogue that may lead to cooperative projects in areas of need and opportunity. For example, we have the ability to analyze and evaluate hospital service lines in the best hospitals in the US, and adapt them for implementation in China. In addition, after your hospital project is complete, we can continue on in a management or consulting capacity to provide or assist in the administration of your hospital, coordinate your clinical programs, and establish strong ties with hospitals in the US for your clinical and research programs so that they may continue to thrive.

Reducing the prepayment penalty for medical care If the goals of basic health insurance from the government are to increase access and decrease future uncertainty, then the need for patients in China to prepay medical expenses to hospitals prior to the delivery of healthcare works against these goals. The government provided social health insurance network with insufficient coverage provides a unique opportunity for private commercial supplemental insurance, but the insurance sector in China has not stepped up. The penetration of commercial insurance market is poor. This results in wide coverage gap for most of the citizens.. Most importantly, no available insurance product offers to “prepay” the cost of care to hospitals for the patient. With the Ministry of Health as well as hospitals, we can explore the creation of financial and insurance products that could alleviate the need for the Chinese people to “self-insure” against unexpected medical cost. This must be accomplished with either a financial or insurance product that will “prepay” the

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cost of care for the patient. This can be accomplished with a pure financial service product that prepays the entire cost of care upfront in return for reimbursement from Basic health insurance after care is delivered and a claim is filed, with the patient paying for any difference in cost vs. reimbursement. An alternative commercial insurance option would also guarantee blanket coverage of all care upfront so that the patient will no longer have to pay out-ofpocket at the onset of illness. A coinsurance is then charged to the patient by the insurance company after care delivery is completed. The amount of the coinsurance may range from zero to a calculated percentage of the total cost of care, depending upon the level of insurance premium paid by the patient and the reimbursement obtained from Basic health insurance. It is possible to design a financial services prepayment product directly with hospitals who are interested in this option. Designing a supplementary insurance prepayment product would require discussion with the government and with hospitals to allow the sharing of patient health information that would proper establish risk and determine premium prices for what would be a very unique insurance product. This will require an IT infrastructure to access each patient’s government-provided Basic Insurance information to determine the liability that would be covered by Basic Health Insurance. An insurance product which eliminates the upfront pre-pay from the patient’s out-of-pocket expense will increase access to care, improve healthcare quality and in long run reduce the costs.

Addressing Primary care need High-quality primary care service is required for the creation of a three-tiered structure for the distribution of healthcare in China (Table 1). Indeed, during our visit to the Ministry of Health, Dr. Li Da Chuan described China’s efforts to create this type of primary care layer. The two most important factors in the creation of strong primary care centers in the western and southern parts of China are the establishment of high standards in staff training and hospital operations in the community, and the education of primary care physicians from regional medical schools and the elevation of their wages so that they will decide to stay and work in their local healthcare regions. Trained physicians from Beijing will want to return to Beijing even if they are told to work for a period of time in the countryside. If students are chosen from rural

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The Future of China’s Healthcare System

areas and are well-trained in regional medical schools, they are more likely to want to stay near home. Regional medical schools must attain the same high educational standards as their counterparts in Beijing and Shanghai, and they must emphasize the training of 5-year primary care physicians in family medicine, pediatrics, obstetrics-gynecology, and internal medicine over the creation of physicians in other specialties. Training certification for physicians and nurses, and JCAHO-type standards for hospital operation should be established to ensure that high-quality standards are met throughout the healthcare continuum. Local clinics and community hospitals should be certified by the government as delivering the best in primary and preventive care when they attain adequate numbers of well-trained primary care physicians and proficiency in operational processes. With patient education regarding the importance of primary care and generalized implementation of the highest standards in community healthcare, the Chinese populace will learn over time to trust their local hospitals and clinics instead of trekking to the nearest mega-city for their care. The critical concept is that each provider layer must serve a unique role in the healthcare continuum. If these roles are clearly established, then patients will be efficiently distributed across provider levels in accordance to the level and type of service needed. Patients should visit primary care clinics and community hospitals for minor ailments and preventive care. They should visit secondary and tertiary hospitals based upon the seriousness of their conditions. The 3a specialty tertiary hospitals will focus upon treating the most unique and difficult cases. As patient recover and require only monitoring health services, they are referred back down to lower level layers of care to recuperate or receive rehabilitative services. Creating the infrastructure to train staff and the operational processes to manage clinics and hospitals to build the highest quality primary care facilities is something we can work on collaboratively with the MOH. A large part of this work will be the establishment of clear standards for both the training process for staff, and the operational guidelines for the management of the clinic or hospital. IT systems must be used to analyze data effectively, and quality systems must be in place to identify and correct problems with patient care. A certification process is necessary to ensure that personnel and facilities maintain their high level of performance. It is possible to create a high-quality functional infrastructure, or a primary provider “franchise�, that is generally applicable to

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all regional clinics and hospitals with an emphasis on primary care, and to then adapt it for individual implementations in different local regions of China that may have specific and unique characteristics that must be taken into account, much like the creation of restaurant chains such as Kentucky Fried Chicken.

Competitive private (and public) hospitals To compete successfully with elite University hospitals, private hospitals in China must offer a different value proposition to patients. The value must be immediately palpable once you enter the hospital, and the distinction should be clear through the entirety of the patient’s stay until they leave the front door. It must be value that elite public hospitals cannot offer. To overcome the reputational disparity between elite public hospitals and new private hospitals, private hospitals must treat patients as family or honored guests. In Western medicine, there is a concept called “patient-centered care.” Thinking about medicine as a service industry, with the patient at the center of any process or program you devise, is patient-centered care. Private hospitals need to dedicate themselves to the compassionate, holistic, and effective treatment of patients, providing care from the viewpoint of the patient. They should set as a goal to heal and restore the patient’s mind, body and spirit before the patient leaves the hospital. The elite hospitals are so crowded with patients that they would not be able to fathom how to even begin such a program, and since they have so many patients, they do not need to do so. We can work with private hospitals to establish the highest standards of operation for any hospital. We intend to work with national and local governments to identify and design the best training and operating guidelines for private hospitals. We can partner with local medical schools to institute training programs to produce physicians, nurses, and management personnel designated for each private hospital. Most importantly, we can work with private hospitals to institute the correct culture to become a patient-centered deliverer of healthcare.

Hospital brand management Today's Chinese consumer is brand-driven and loves Western brands, especially those from the US. In response, some private Chinese hospitals attempt to differentiate themselves via collaborative agreements with well-known US

28


The Future of China’s Healthcare System

hospitals such as Massachusetts General Hospital, Children's Hospital of Philadelphia, and MD Anderson Cancer Center. However, recent studies suggest that Chinese patients trust the hospital recommendations of friends and family the most, more so than branding efforts. They also tend to distrust hospitals that advertise in the media. Cobranding using famous US hospitals may attract patients in the short-term, but these brands will quickly erode if differentiation based on the borrowed Western image of hospitals is not matched by a differentiated patient experience and healthcare value delivery. It is likely that creation of hospital brand-equity in China will require a real and lasting value proposition. It is also important for China to develop its own brands that reflect high medical care and technology quality. Brand management in healthcare is about delivering two things: maintaining the highest quality of care possible, and differentiating your healthcare experience from your competition. Healthcare is extremely complicated, and differences in implementation can easily exist on a hospital-by-hospital basis. Our MBA-e group members possess a wealth of knowledge in the practical application of standards in healthcare operations. We have the background and believable credentials for such a role. We know how medicine is practiced, how staff is trained, and how hospitals are managed in the US. We understand the healthcare landscape in China well enough to adapt US practices to the realities of healthcare in China. We can also, based upon your hospital’s size, strengths and weaknesses, devise a strategy for creating a unique brand for your hospital that delivers a different value proposition to patients than your competition.

Healthcare IT Most hospitals have electronic medical records (EMR) software. We can help you use the right medical records software program to help you with patient management, to allow you to analyze patient data to look at health care quality, to examine the efficiency of healthcare delivery, to help improve the management of hospital resources, and to improve physician clinical work flow. In addition to medical recordkeeping, other physician order entry software allows you to enter orders directly, where they are stored and accessed by nurses and other staff for patient care. This software is available now on portable platforms such as the iPad and even the iPhone, so patient data entry and order entry may be performed anywhere.

29


Data can be entered as the doctor sees the patient, or even from home later in the day. Software on portable platforms also provides access to patient data, so that you can check on a patient’s laboratory or imaging result from anywhere. One of the most important uses of EMR software is the ability to help make clinical decisions using tools for evidence-based medicine and chronic disease management. Another important use of software is to create health information exchanges that share data between different hospitals and the government to enable policy makers to determine if implemented health policy is effective. We can assist you with these projects and more.

Pathology and Radiology Services The demand for quality healthcare is quickly rising in China. This demand requires the highest-quality capabilities in diagnostics and supplemental clinical information for treatment. We can provide a digital platform and advising/training services to hospitals that address these issues. Our platform enables image and information sharing between China, the US, and anywhere in the world, that can take the form of either real time communication or academic and literature sharing. It allows “web-ex� service for continuing education and meeting attendance. It also incorporates the ability to use coded diagnoses operation to let two physicians of different languages review cases in real-time, even during off hours. Currently, Chinese hospitals treat high-net worth patients who request additional opinions, and pathology requests are sent to the US for workup. Our platform will allow the instantaneous transmission of the highest quality data to any location in the world for real-time consultation with the surgical team in China, even if the patient is on the operating table in the OR awaiting an opinion. Even the general population can take advantage of these services, since rapid consultations will no longer depend upon the location of the radiologist or pathologist. There are other services that may perform similar functions, but they may not understand the Chinese landscape. We are not interested in simply providing a service. We hope to collaborate with hospitals to achieve continual growth in diagnostic excellence. US trained pathologists and radiologists can aid in continuing education, and create efficiencies to reduce waste in money and other resources in hospital, academic, and commercial imaging facilities and

30


The Future of China’s Healthcare System

laboratories. Sharing a digital platform inevitably increases throughput, decreases waste, and increases diagnostic capabilities by allowing multiple professionals to view cases and engage in discussion when data is difficult to interpret.

Conferences and customized management training We can serve as a bridge to information that you may not find in China, and we can continue to be a focal point for future bilateral exchanges of information and ideas. Azure Health consults with the research faculty of the best institutions in the United States, including business management, public health, as well as medical institutions, for high level strategy and planning. Azure Health is the best source for elevated management leadership in the highly complex landscape of healthcare. Azure manages healthcare complexity and optimizes healthcare delivery.

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Locations Visited

The Ministry of Health (International Health Exchange and Cooperation Center)

Hospitals Peking University People’s Hospital Peking University Third Hospital Peking Union Hospital Beijing Women & Children’s Hospital (Ai Yu Hua, Presentation) Tsinghua University Yuquan Hospital Capital Medical University Xuanwu Hospital Capital Medical University SanBo Brain Hospital Chang’an Hospital (Xi’an) Shanghai Putuo Hospital

Companies Medtronic Patient Care Center (Beijing) Beijing State-Owned Asset Management Company Chempartner Boehringer Ingelheim Pfizer CDRC Medtronic Regional China HQ (Shanghai) Gateway (medical device incubator, Shanghai) Mozi Healthcare (IT Radiology)

Other Shanghai University of Traditional Chinese Medicine Shanghai Traditional Chinese Medicine Museum

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The Future of China’s Healthcare System

China Trip Contributors Yale School of Management Administration, MBA for Executives: Leadership in Healthcare David Bach, Senior Associate Dean Howard Forman, Director Ellen Skinner, Executive Director

Faculty Advisors Arthur J. Swersey, Professor of Operations Research Richard Foster, Senior Faculty Fellow

Consulting Faculty Advisors Lorenzo Caliendo, Assistant Professor of Economics Ingrid Nembhard, Assistant Professor of Health Policy and Administration, and of Management Martha Dale, Coordinator of China Programs

A special thanks to Jianyu Yang and Concord Medical Services (CCM)

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Final words

We left a short time ago, but we already miss you. We have been honored to visit your amazing country and the magnificent cities of Beijing, Xi’an, and Shanghai. You have all been wonderful hosts to us. We feel that we have created everlasting friendships. We hope you will continue to have future contact with us, academic and educational exchanges, and opportunities to collaborate with you in your areas of need and opportunity in healthcare. Most of us had never been to China and we have been extremely touched by your kindness. Thank you for an incredible experience, and we will continue to stay in touch...

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The Future of China’s Healthcare System

Appendix

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The Future of China’s Healthcare System

Azure Health Member Profiles Azure Health is a new company created by members of the Yale M.B.A. for Executives: Leadership in Healthcare program, a 22 month program designed for professionals in healthcare. 1. Brandon A. Banks Nationality: American Current Position: Aetna Business Project Program Senior Manager Specialties: Health Insurance Reform; Business Strategy; Health Information Technology Education Background: Undergrad: Bentley University; Waltham MA. USA 2. Xiaoli Chen, M.D. Nationality: Chinese American Current Position: President of Medical Staff, Forest Health Medical Center of Bucks County Clinical Professor of Pathology and Medical Director of Pathology Diagnostics Lab, Drexel University College of Medicine Specialties: Hospital accreditation by Joint Commission and laboratory accreditation by College of American Pathologists Hospital operation and business management Hospital quality improvement Clinical diagnosis, research, and teaching Education Background: Beijing Medical University School of Medicine Medical College of Pennsylvania Residency and Fellowship American Board of Pathology in Anatomic and Clinical Pathology and Cytopathology 3. Ming L. Cheng, M.D. Nationality: American Job Position/Title: 2008 – 2012 Brown Medical School, Assistant Professor of Neurosurgery 2010 – Current President & CEO, NuroRestore Inc. Areas of specialization Functional Neurosurgery – Academic Research Laboratory Director – Parkinson’s disease, Epilepsy, Major Depression, OCD Education Background: UC Berkeley (undergraduate) BA, College of Arts and Sciences, Major: Molecular Biology & Biochemistry BS, College of Chemistry, Major: Chemistry BS, College of Natural Resources, Major: Nutrition Stanford Medical School Graduate Degree: MD, Medicine Stanford Institute for International Studies Post-graduate Fellow, Asia-Pacific Research Center Barrow Neurological Institute Neurosurgery Residency UNC Chapel Hill Neurosurgery Residency Harvard Medical School (Massachusetts General Hospital) Functional Neurosurgery fellowship 4. Pravin A. Chougule Nationality: American and India Current Position: Director Fixed Income, Currencies and Commodities (FICC) IT, UBS Investment Bank Specialties: Front office trading systems' development for FICC Extensive knowledge in business analysis, design, development and delivery of IT solutions Education Background: Undergrad: Shivaji University, India

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5. Marc A. Chung Nationality: American and Hong Kong Current Position: Principal (Consultant) - Quintiles Consulting Specialties: Life Sciences - pharma & biotechs Strategic Planning Process Reengineering & Optimization Organizational Redesign Education Background: Johns Hopkins University - BA Yale University - MPH 6. Wendy L. Davis Nationality: American Current Position: VP IP and Diagnostic Portfolio Management, HistoRx Specialties: intellectual property (IP) i.e. Patents and Licensing and business development in biotech startup companies Education Background: Undergrad: Swarthmore College, USA 7. Sarah B. Destephens Nationality: American Current Position: Manager of Financial Planning and Analysis- Covidien Specialties: Financial Planning, Accounting, Internal Controls for Commercial Manufacturing Operations Education Background: Louisiana State University- Masters in the Science of Accounting Louisiana State University- Bachelors of Science in Accounting 8. James B. Destephens Nationality: American Current Position: Corporate Director Business Development & Licensing, Covidien Specialties: Medical Devices & Diagnostics, Pharmaceuticals Education Background: North Carolina State University, BS Economics, BS Computer Engineering, BS Electrical Engineering 9. Michael A. Garvey Nationality: American Current Position: Principal Sales Representative, Medtronic Specialties: Sales and Marketing, General Management, Business Development Education Background: Georgetown University, Washington, DC, B.S. in Foreign Service 10. Rajkishore Gorla Nationality: American Current Position: Director, Health Informatics, Informatic Inc. President, Suraksha (Non-Profit working to empower disabled girls in South India) Specialties: Health Informatics, Non-Profit Strategy, Health Mobility/Analytics, EMR/EHR implementation Education Background: University of New Hampshire, Durham, NH, USA Masters in Computer Science JNTU University, Hyderabad, India Bachelors in Computer Science 11. Mohammed A. Jaffry Nationality: Indian Current Position: Senior Strategy Advisor – IT investment, WellPoint Inc Specialties: Health Insurance Education Background: Undergrad: Mumbai University, India

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The Future of China’s Healthcare System 12. Chang-Berm Kang Nationality: Korean Current Position: Account Supervisory, DraftFCB Healthcare Specialties: Healthcare Marketing Education Background: Undergrad: Johns Hopkins University 13. Zhong Yang Belinda Ker, M.D. Nationality: Singapore Current Position: Attending Hospitalist, Rhode Island Hospital, Brown Medical School Specialties: Internal Medicine Education Background: Trinity College of Dublin, Ireland 14. John J. Kim Nationality: Korean American Current Position: Chief Medical Dosimetrist, Yale-New Haven Hospital Specialties: Radiation Oncology and Medical Physics Education Background: Memorial Sloan Kettering Cancer Center, Radiation Therapy School, NYC Fordham University, BA Biology, NYC 15. Suzanne P. Lagarde, M.D. Nationality: American Current Position: Partner, CT Gastroenterology Consultants (gastroenterologist) President, Board of Directors, Project Access-New Haven Specialties: Gastroenterologist, area of greatest interest is access to quality health care Education Background: Fordham University BA mathematics Cornell University Medical School MD 16. Erich S. Lee Nationality: African American Current Position: Owner/C.E.O. of WellWater Capital Consulting LLC Specialties: Installation and mitigation of clinical medical systems in hospitals and physician offices Education Background: Clark Atlanta University - Master of Science in Computer Science Clark Atlanta University - Bachelor of Science Computer Information Systems 17. Robert M. Lincer, M.D. F.A.C.S Nationality: American Current Position: Chairman, Department of Surgery, Lawrence and Memorial Hospital, New London, CT, U.S.A. Specialties: General Surgery, Surgical Oncology Education Background: M.D., Boston University School of Medicine, Boston, Massachusetts, U.S.A. B.A., Boston University, Boston, Massachusetts, U.S.A. 18. Junjian Liu, Ph.D. Nationality: Chinese Current Position: Group Leader, Abbott Laboratories Specialties: Drug R&D, Biotherapeutics, Outsourcing Licensing/acquisition for pharma and biotech Education Background: PhD in Biology, Peking University, Beijing, China BS in Biology, Shanxi Normal University, Xi’an, China

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19. Robert A. Martin Nationality: American Current Position: Vice President, Learning Outcomes and Metrics, Scientiae LLC, New York, New York Specialties: Continuing Medical Education and Accreditation Learning Assessment and Outcomes Analysis Adult Learning Practices and Human Performance Improvement Learning Technologies and E-Learning Management Systems Data Mining, Data structures, Normalization Education Background: Bachelor’s Degree in Drama/Literature/Dance, Dartmouth College, Hanover, New Hampshire, United States Certified Continuing Medical Education Professional (CCMEP) 20. Blake T. O’Shaughnessy Nationality: American Current Position: Senior Account Executive and Field Trainer Specialties: Pathology, Hospitals, Private Practice physician office, business development Education Background: Undergrad: Dickinson College, USA 21. Letty H. Ten Kate Nationality: Dutch Current Position: Independent business consultant healthcare development Specialties: Healthcare business development in emerging countries Feasibility studies healthcare development Education Background: Leiden University, Medicine, Undergrate, the Netherlands Technical University of Delft, Master Industrial Design Engineering, Medical Design, the Netherlands 22. Jianyu Yang, Ph.D. Nationality: Chinese Current Position: Chairman and CEO, Concord Medical Services Holdings Limited Specialties: Corporate strategy and restructuring, corporate governance, and corporate transactions Education Background: Liaoning University – Ph.D. in Economics

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The Future of China’s Healthcare System

Azure Health China Trip Travel Itinerary

Monday (3/18)

Tues (3/19)

1:05 pm Newark Airport

3:00 pm Beijing Airport

United Non-stop to Beijing (13 hours 50 minutes)

Beijing Sunworld Dynasty Hotel check-in

Kickoff Dinner Party (YJY)

Wed (3/20)

Thurs (3/21)

Friday (3/22)

Saturday (3/23)

Breakfast

Breakfast

Breakfast

Breakfast Hotel check-out

8:30 am - 12:00 pm Peking University People’s Hospital

9:00 am - 1:00 pm BSAM (Beijing StateOwned Asset Mngmnt Company), AiYuHua Hospital presentation; Olympic Village

9:00 am - 11:30 pm Ministry of Health: International Health Exchange and Cooperation Center

Group Lunch

Group Lunch (BSAM)

1:00 pm - 3:00 pm Medtronic Patient Care Center ----------------------Tiananmen Square; Forbidden City; Shopping Silk Market

2:00 pm - 5:00 pm Peking University 3rd Hospital

Group Dinner

2:30 pm - 5:00 pm Peking Union Hospital

Dinner with Karaoke (YJY)

Hou Hai Bar

Great Wall

Group Lunch (YJY)

7 to 9 pm Beijing to Xi’an Tangdi Hotel check-in

Healthcare institution visits in blue.

Sunday (3/24) Breakfast Terracotta Warriors and Horses

Ancient Xi’an City Wall

Monday(3/25)

Tuesday (3/26)

Wednesday (3/27)

Thursday (3/28)

Breakfast Hotel check-out

Breakfast

Breakfast

Breakfast Hotel check-out

9 am - 11:30 am Shanghai Putuo Hospital

9am -12 pm Boehringer Ingelheim -----------------------Shopping – Chenghuang Miao

11:30 am - 1:30 pm Group Lunch (Putuo Hospital)

Lunch

10 am - 12:30 pm Chang’an Hospital

Group Lunch (JJL)

Big Wild Goose Pagoda

Group Dinner

1:30 pm - 4:30 pm Shanghai U of TCM & Shanghai TCM museum -----------------------2:30 pm to 5:00 pm Chempartner 5:15 to 7:15 pm Xi’an to Shanghai Group Dinner & Hotel check-in (Putuo Hospital)

Pudong New Area Group Dinner Shanghai Oriental Pearl (Putuo Hospital)

12:30 pm – 3:00 pm Gateway Medical Device Incubator 3:30 pm - 5:30 pm Pfizer CDRC -----------------------Shopping - Nanjing Road Group Dinner (Putuo Hospital)

9 - 11 am Medtronic Regional China HQ Group Lunch (Putuo Hospital) Meglev Train 4:20 pm Shanghai Pudong Airport United Non-stop to Newark (14 hours 25 min) 6:45 pm Newark Airport

Xintiandi Bar

------------------------- denotes choice of activities

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