📄 medicine

From hospital availability to patient access: affordability-related barriers to clinician recommendation of innovative medical technologies in Shanghai, China

A 2025 cross-sectional survey of 824 clinicians in Shanghai reveals that affordability concerns frequently lead medical professionals to withhold recommendations for innovative medical technologies, highlighting the critical need for policies that reduce patient out-of-pocket burdens and strengthen institutional support to bridge the gap between hospital availability and actual patient access.

Original authors: Gan Wang, Biao Wang, Wenshan Zhang, Junyu Niu, Lengchen Hou

Published 2026-09-27

📖 4 min read☕ Coffee break read

CC BY 4.0

Original authors: Gan Wang, Biao Wang, Wenshan Zhang, Junyu Niu, Lengchen Hou

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Access to modern medicine is rarely a single moment of arrival; it is a long, winding path shaped by many hands. A new drug or a life-saving machine might be officially approved and sitting on a hospital shelf, yet a patient may never receive it. This gap between what is available and what is actually used is a central puzzle for health researchers. They know that a treatment's journey depends on more than just geography or the presence of a building; it relies on a chain of decisions made by doctors, the rules of insurance, and the financial reality of the person seeking care. When a doctor considers a new, innovative technology, they must weigh its medical benefits against the cost the patient will have to pay. If the price is too high, the doctor might decide not to suggest it at all, effectively blocking the patient from the option before the conversation even begins. This hidden barrier, where financial worry stops a recommendation from being made, is the focus of a new investigation into how medical care works in practice.

Researchers in Shanghai, China, set out to understand this specific moment of decision-making. They wanted to know how often doctors choose not to recommend new medicines or devices because they believe the patient cannot afford them. To find the answer, the team surveyed 824 practicing doctors across various hospitals in the city during late 2025. They asked these clinicians to reflect on their own behavior, specifically whether they had ever held back from prescribing a cutting-edge treatment due to a patient's economic situation. The survey was designed to capture not just whether this happened, but how often, and to explore what factors made doctors more or less likely to skip these recommendations. The study focused on the period when a doctor first considers a treatment option, looking for the point where money might stop the conversation before it starts.

The results revealed that this financial hesitation is widespread. More than one-third of the doctors surveyed admitted that they frequently refrain from recommending innovative medical technologies because of their patients' economic reasons. When the researchers looked at doctors who reported this happening even occasionally, the number rose to over four-fifths of the group. In other words, for the vast majority of clinicians in this sample, the fear of a patient's inability to pay is a regular part of their decision-making process. The most significant obstacle identified was the high price of the technology or the large amount of money a patient would have to pay out of their own pocket. Nearly two-thirds of the doctors rated this financial burden as a serious or very serious barrier. Another major factor was the doctors' belief that patients would not accept the treatment due to cost or a lack of understanding about the financial implications.

The study also examined what helps doctors overcome these barriers. It found that when hospitals provide strong support—such as clear procedures for approving new treatments, better training for staff, and helpful information about insurance coverage—doctors are less likely to skip recommendations. In fact, higher levels of institutional support were linked to a lower rate of doctors holding back on these suggestions. Interestingly, the doctors' own knowledge of medical evidence or their familiarity with government policies did not significantly change how often they avoided recommending treatments due to cost. This suggests that the issue is not a lack of medical knowledge or policy awareness, but rather a practical response to the financial reality facing their patients. Doctors who had participated in research involving new technologies were actually more likely to report holding back, perhaps because their deeper exposure to these innovations made them more acutely aware of the cost constraints in real-world practice.

These findings highlight a critical, often overlooked step in the journey of medical care. The research suggests that affordability acts as a filter long before a patient receives a treatment, shaping the menu of options a doctor presents. If a doctor anticipates that a patient cannot pay, they may simply not offer the most advanced option, even if it is the best medical choice. This means that improving access to new medical technologies requires more than just approving them or stocking them in hospitals. It demands a system that supports doctors in navigating the financial aspects of care, ensuring that cost does not silently decide which patients get to hear about the newest and most effective treatments. The study concludes that for innovation to truly reach the people who need it, health systems must address the financial burden on patients and provide doctors with the tools and support they need to discuss these options openly and without fear of causing financial harm.

Technical Summary: Affordability-Related Barriers to Clinician Recommendation of Innovative Medical Technologies in Shanghai

Problem Statement
While innovative medical devices and medicines are increasingly available in hospitals, formal availability does not guarantee patient access. A critical, yet underexamined, bottleneck exists at the interface between hospital availability and patient-facing recommendations. Clinicians often act as gatekeepers who may forego recommending clinically relevant innovative technologies if they anticipate that patients cannot afford them. This study addresses the gap in health services research regarding whether patient affordability constrains the service pathway before treatment options are even presented to patients. Specifically, it investigates the prevalence of "affordability-related foregone recommendation" among clinicians in Shanghai and identifies the economic, professional, and institutional factors driving this behavior.

Methodology

Study Design: A cross-sectional survey conducted in December 2025 among practicing clinicians in general and specialty hospitals in Shanghai.
Data Source: The "Survey on Clinical Adoption Behaviors and Cognitions of Innovative Medical Devices and Medicines in Shanghai."
Participants: 824 valid responses from clinicians holding practicing physician licenses. The sample included diverse departments (surgery, internal medicine, oncology, etc.) and professional titles (residents to chief physicians).
Instrument: A self-developed, psychometrically validated "Clinical Adoption Behavior and Cognition Scale" comprising 29 items across five dimensions: clinical evidence appraisal, policy environment perceptions, perceived barriers, attitudes/intentions, and support systems. The scale demonstrated high internal consistency (Cronbach's $\alpha$ = 0.91) and content validity.
Primary Outcome: "Frequent affordability-related foregone recommendation," defined as clinicians reporting they often refrain from prescribing or recommending innovative technologies due to patients' economic reasons.
Statistical Analysis: Modified Poisson regression with robust variance was employed to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). This approach was chosen to avoid the overestimation of association magnitude common in logistic regression for common outcomes. Three hierarchical models were fitted to control for hospital type, department, professional title, research participation, and use frequency, followed by adjustments for economic barriers, policy literacy, evidence orientation, and institutional support.

Key Results

Prevalence: Affordability-related foregone recommendation is highly prevalent. 37.1% of clinicians reported frequently refraining from recommendations due to economic reasons, while 82.3% reported this behavior occurring at least sometimes.
Perceived Barriers: High price or high patient out-of-pocket burden was the most significant barrier, rated as "serious" or "very serious" by 62.9% of respondents. Low patient acceptance due to economic or cognitive reasons was the second most cited barrier (56.6%).
Determinants of Frequent Foregone Recommendation:
- Economic Factors: Clinicians perceiving high price/out-of-pocket burden as a serious barrier were significantly more likely to frequently forego recommendations (aPR = 1.38; 95% CI: 1.09–1.74). Similarly, perceived low patient acceptance due to economic/cognitive reasons showed a strong association (aPR = 1.74; 95% CI: 1.39–2.17).
- Institutional Support: Higher levels of perceived institutional support (e.g., efficient review processes, adequate training, clear reimbursement info) were associated with a lower prevalence of foregone recommendation (aPR = 0.82; 95% CI: 0.70–0.97).
- Non-Significant Factors: After full adjustment, general policy literacy and evidence orientation were not independently associated with the frequency of foregone recommendations.
Sensitivity Analyses: Results remained robust across different outcome definitions (including "any" foregone recommendation), continuous variable treatments, and exclusions of clinicians who never use innovative technologies.

Key Contributions

Identification of a Hidden Access Barrier: The study shifts the focus from technology availability to the "recommendation interface," demonstrating that affordability concerns can restrict access before patients are even offered treatment options.
Provider-Mediated Access Dynamics: It provides empirical evidence that clinicians actively filter the menu of available technologies based on anticipated patient financial toxicity, effectively acting as a mediator of access.
Role of Institutional Support: The findings highlight that institutional processes (training, reimbursement clarity, committee efficiency) can mitigate the impact of affordability barriers, suggesting that system-level interventions are as crucial as reimbursement policy.
Methodological Rigor: The use of a validated scale and modified Poisson regression provides a robust estimation of prevalence ratios for a common health services outcome.

Significance and Claims
The paper claims that affordability-related foregone recommendation is a common phenomenon in Shanghai that creates a "less visible barrier" between formal policy support and realized patient access. The authors argue that health services policies aiming to improve access to innovation must look beyond regulatory approval and hospital entry. Instead, they must address:

Patient Out-of-Pocket Burden: Ensuring reimbursement coverage is sufficient to prevent affordability-based exclusion.
Clinician Support: Providing transparent institutional pathways, decision-support tools, and training on cost communication.
Service Delivery Coordination: Recognizing that high-value innovations may fail to achieve population-level benefits if they remain unaffordable for specific patient groups, leading to uneven distribution.

The study concludes that improving access requires a coordinated approach involving payers, hospitals, clinicians, and patient support programs to ensure that innovative technologies translate from hospital availability into patient-accessible options. The authors explicitly note limitations, including the cross-sectional design (preventing causal inference), self-reported data, and the study's restriction to a high-resource urban setting (Shanghai), cautioning against generalization to primary care or less-resourced regions without further research.

Technical Summary: Affordability-Related Barriers to Clinician Recommendation of Innovative Medical Technologies in Shanghai

More like this