ALL expats face the issue of where to seek medical care: international-standard clinics or far more affordable but very different Chinese hospitals. Nancy Zhang weighs the pros and cons.

Expats sick of high "expat" prices for Western food and products can choose to go local - and enjoy it. In most cases local alternatives are just as good.

But when it comes to medical care, it takes a big leap of faith to trust unfamiliar Chinese systems and doctors, and this leaves the option of significantly more expensive international clinics. But are these concerns about one system and the higher prices in another system justified?

It's complicated. This article arose from two earlier pieces: One about expats complaining that they were unfairly charged "expat prices" (November 19, 2008); another about the difference between "Chinese prices" and "expat prices" across the board (December 3, 2008).

We found there was so much to say about medical care alone that it deserved its own article, and this just scratches the surface.

For expats, internationally run hospitals such as ParkwayHealth (the largest private health provider in the city), Shanghai United and Shanghai East might appear to be the safest choices.

Their high prices are based on internationally accredited doctors, English-language service and systems designed to interface smoothly with expat needs, such as insurance companies and even doctors back home.

It's a package that ParkwayHealth terms "culturally and linguistically appropriate" for expat patients.

But after a visit last November to an international clinic, Singaporean restaurant owner Lee says the care, though competent, was overpriced. It was treatment for his wife in an emergency, a bleeding ulcer.

"The bill came to 100,000 yuan (US$14,621) for three and half days' stay," says Lee, asking that his full name not be used. "How can it cost that much? Even with insurance, I still don't think I deserve this treatment."

Lee, who has lived here for 10 years, feels the service overall was too profit-centered and says some nurses were inattentive and more concerned with paperwork.

Nurses did tell him rooms were 6,500 yuan a night, but he says they did not tell him he would be charged for each doctor's visit.

His wife was seen by four doctors, who "asked the same questions and got the same answers," says Lee, and each visit cost 1,000 to 3,000 yuan.

Another long-term expat, Regina Von Waahl from Germany, observers that international clinics can go overboard with costly tests and precautions. Von Waahl, an entrepreneur, has lived in Shanghai for more than six years, and in China for more than 15 years.

"They are trying to be safe, but it's quite obvious all these tests aren't necessary. When my son broke his arm, World Link suggested we fly to Hong Kong for surgery ?? I thought if I have to fly out even for this, how can I live in Shanghai'?" says Von Waahl. "I feel a bit cheated."

Von Waahl now goes to Chinese hospitals, though she has insurance.

Dr Jeffrey Staples, the new director of ParkwayHealth's North Asia Division, comments, "ParkwayHealth strives to practice medicine to the highest international standards while ensuring that all tests and consultations are both necessary and appropriate. Medical service is not like ordering food off a menu ?? every physician practices medicine differently. It's an art as well as a science. In order to practice medical excellence, doctors order tests, or refer to colleagues for second or more opinions as they feel appropriate, and this is always done with the patient's best interest in mind.

"Regarding surgical procedures for the expat market, while we do offer some surgical services within Parkway, some of our patients prefer to go abroad for surgery."

Commenting on concerns such as Lee's (not at Parkway or World Link), Dr Staples says, "Billing transparency and consistency is important, doctors should explain what they are doing and why, so that the patient's expectations are managed appropriately. Transparency and consistency is a struggle for everyone, everywhere, but it is a goal that we will continue to strive for."

Another major drawback is that international hospitals here often lack certain specialists. When complications arise, patients are transferred to Chinese specialists at Chinese hospitals.

Sharon Pantoja is a Canadian mother of two, and a school nurse, who had her first baby in Shanghai in 2003. She went to World Link for prenatal care but when she showed abnormalities, she was transferred to Huashan Hospital.

Though an English-speaking nurse accompanied her to the hospital, thereafter care from World Link was limited to a few visits from her former doctor. Even then, says Pantoja, her doctor's substantial medical involvement ended.

This situation is quite common among foreign clinics, says Roxanne Michaude, a US registered nurse who used to work for a foreign clinic. She has been here for more than four years and founded First Aid China.

"There are very few foreign specialists here," says Michaude, now a school nurse. "Some hospitals may have state-of-the-art equipment but not the expertise to operate it."

Once transferred to Chinese hospitals, expats have to deal with Chinese practices that may clash with their expectations.

Pantoja was given no pain medication after the birth. "I really suffered," she recalls. "But when I talked to the Chinese doctors they said, 'You just had a baby, it's supposed to hurt'."

Procedures, such as an epidural, were also not explained to her, and the parents were kept from the baby while it was in intensive care.

Chinese alternatives

Would approaching Chinese hospitals directly cut unnecessary costs?

Apart from a different approach to aftercare, nurse Pantoja says that the quality of doctors at the Chinese hospital is surprisingly good, and her case was handled well overall. Once in a Chinese hospital, patients also pay according to that hospital's fees. And expats pay more than Chinese.

Pantoja's treatment at the international department of Huashan Hospital with ICU care for the premature baby cost US$10,000 ?? amazingly low, she says, compared with foreign hospitals in Shanghai or back in Canada.

Expats may doubt the quality of Chinese doctors and facilities, but Michaude comments that Chinese healthcare is in fact very good. Dealing with a large volume of patients every day, Chinese hospitals are very experienced at many routine procedures.

Some Chinese specialists are world-class, especially in particular types of bone reconstruction. But it's hard to get the same level of service such as aftercare and second opinions. Foreign clinics also tend to have more state-of-the-art equipment and hygiene control.

But the problem is finding the right doctors for your needs and navigating the Chinese system. That's where a referral from an international clinic is invaluable, according to Michaude.

"International clinics will refer you to people they have checked out and used, which you may not know about because the situation changes. They will also take care of logistics ?? that's all part of the price," says Michaude.

Staples adds that part of ParkwayHealth's responsibility is to transfer patients to "culturally and medically suitable doctors" at the Chinese end, such as doctors who speak English and who understand the expat's cultural needs.

ParkwayHealth doctors try to refer to physicians with whom they have worked. They have established relationships with Ruijin and Huashan hospitals and maintain these relationships.

Approaching Chinese hospitals directly without this referral has its pitfalls ?? not only are you responsible for finding the right doctor, but price negotiations can also be tricky.

For a routine hernia operation, American Michael Connolly, founder of shanghaiexpat.com, approached several local hospitals. Without medical insurance, or great personal wealth, this was his only option. He relied heavily on his Shanghainese wife and her family for recommendations and personal connections to find reliable doctors.

Still, he was quoted vastly different prices ?? all of them higher than locals pay.

"The doctor at Renji Hospital was very candid. He said the operation would cost me 15,000 yuan, whereas for locals it was 5,000 yuan," says Connolly. "I don't think it's an issue of fairness ?? it's just market economics."

Despite being charged a premium for being foreign, Connolly is happy to pay extra at international departments of Chinese hospitals ?? they offer crucial advantages like English language, priority over long queues, privacy and better facilities. Moreover, they are still significantly less expensive than foreign clinics.

However, Connolly did not appreciate the huge price variations among hospitals. The highest price he was quoted was 40,000 yuan at the VIP section of Huashan Hospital.

He says he was reluctant to bargain over medical services. "I don't want to make the doctor unhappy if I'm going under his knife later," Connolly says.

Through family connections, Connolly found a small, private clinic which charged 6,000 yuan. But at the last minute the hospital said no as "they feared responsibility and had a lot of reservations."

Connolly eventually had the surgery at a hospital in Shenzhen, Guangdong Province. He says facilities looked dingy and below Western standards, but the surgery went well. He first was quoted 8,000 yuan, then 11,000 yuan with medication. He bargained.

"Chinese hospitals also want to make money," says Connolly. "It's just not on the same scale as international hospitals."

Michaude says the choice between international or Chinese hospitals is not cut and dried. "It really depends on what you're comfortable with. If you can't navigate the Chinese system or have trust issues, then the foreign clinics are absolutely worth it. And if you have insurance then, heck, why not?"

But an exception is emergencies ?? do not travel across the city to a foreign clinic, she says. "Find the nearest emergency room and go there straightaway."