SHANGHAI — In early January last year, Li Futian’s stomach pains flared up again. The then 49-year-old peanut trader had felt them for several months, but always said he was fine. This time, though, Li’s son insisted on taking him to the nearest major hospital for tests.

The hospital was in the family’s home of Zhengzhou, a city of 10 million people in central China’s Henan province. There, after some tests, doctors said Li had a stomach ulcer. But there was another problem: Li’s liver. He took more tests. When the results came back a few days later, a doctor told Li that he had final-stage liver cancer, and it was inoperable.

When Li Futian’s son, the then 27-year-old Li Bei, heard the news, he felt his world cave in around him. Dad, with cancer? How could this happen?

No, seriously: How could this happen?

Four months prior, Li Bei had taken his father to a private center in Zhengzhou to undergo a full health check. The center belonged to Meinian Onehealth, China’s largest private health-check company, and the whole service cost 900 yuan (then $137). Li Futian had done a couple of liver tests — including cancer screenings — and a staff member who looked like a doctor assured him that there were no underlying problems.

Now, the doctor who said Li Futian had liver cancer was pointing at his test results. “It’s clear your father has had hepatitis for a long time,” the doctor told Li Bei. “He should have come to us much earlier.”

Putting a Price on Your Health

For many Chinese people, annual health checks at private clinics are the easiest way to make sure they’re fit and well. Public health insurance doesn’t cover general checkups, and for many, the country’s noisy, overcrowded hospitals are worth avoiding, unless absolutely necessary.

These days, health-conscious types tend to get checked at companies like Meinian. Compared with China’s crumbling public health institutions, private health-check centers are clean and modern, populated by engaged, helpful staff. The clinics aren’t hospitals: They’re not allowed to dispense medicine, and their services don’t count as formal medical diagnoses. But they look like hospitals, and that makes many customers trust their professionalism.

In big cities like Beijing and Shanghai, private providers are so popular that they often have agreements with individual employers, who in turn sign their staff up for health checks as part of their benefits packages. The practice buttresses a health-check industry that’s worth an estimated 200 billion yuan — nine times more than it was worth a decade ago.

But despite the industry’s breakneck growth, private health-check companies are under increasing scrutiny. In the past year, Chinese media outlets have published reports of patients undergoing unnecessary extra tests, receiving the wrong test results, or being told they’re sick when they’re not. Some people have undergone expensive follow-up tests, while others have delayed treatment for severe diseases, believing themselves to be well. Worst of all, some people have died following mismanaged care at health-check companies.

When he went in for an appointment at Meinian in late 2017, Li Bei found the experience so professional, he immediately made an appointment for his father. Despite a few minor irregularities, he was in peak health, the person who delivered the results said. Nonetheless, the two men later returned to the center to get a second opinion. Li Bei says a staff member claiming to be a doctor went through the report page by page and concluded that there were no major issues. Feeling reassured, the Lis went home.

By the end of 2017, Li Futian had thrown himself back into work. As a peanut trader, he frequently worked until midnight, chain-smoking all the while. His cancer diagnosis came just three years after he and his wife moved to Zhengzhou from Beijing, reuniting the once-impoverished family after 10 years apart. Life got even better in 2017, when Li Bei got married. “I thought the good times were just beginning,” he says.

The Li family are far from the only distraught customers of Chinese health-check providers. Richard Saint Cyr, who underwent three health checks at private centers operated by Ciming Checkup — a company since bought by Meinian — says he found the company’s medical services “dangerously misleading.” He should know: He’s a doctor who formerly worked at Beijing United Family Hospital, one of the Chinese capital’s foremost institutions.

Cyr grew suspicious when, during his first health check, no doctor at the center sat down and spoke to him about his risk factors — elements of age, sex, genetics, and lifestyle that determine to which ailments a patient is most susceptible. In clinical practice, risk factors help shape decisions on which tests best suit the patient. “But a great number of tests I did were completely non-evidence based,” Cyr says, adding that patients really only need a small or inexpensive part of the packages and there was little need for him to take the tests at all.

Meinian and other health-check companies seldom tailor their services to a customer’s individual needs. Instead, customers — or their employers — usually buy “packages” of tests. The packages are not recommended by doctors, but by the company’s sales personnel, who are paid a commission for every sale.

Many health-check providers sell packages through popular e-commerce platforms. On one of them — tech giant Alibaba’s Tmall — Meinian offers a range of around 80 packages containing various combinations of more than 100 tests. Shoppers can purchase packages including 12 “tumor-marker tests” that claim to detect a variety of different cancers, or so-called biomeridian tests rooted in traditional Chinese medicine. The cheapest package costs 99 yuan; the most expensive, 12,999 yuan.

Cyr is not the only customer to complain about health-check staff recommending him unnecessary tests. Zhang Jinpeng, a 30-year-old Shanghai-based automobile engineer, says his former company once paid for him to undergo a package of tests with China’s second-biggest health-check chain, iKang Healthcare Group.

On the day of his appointment, Zhang moved from room to room, where medical staff in white coats performed each test on him. In one room, a staff member cursorily ran an ultrasound machine across his neck, told him that the readings looked unusual, and suggested that he take several follow-up blood tests to eliminate any thyroid problems. A concerned Zhang paid 300 yuan out of pocket for the extra tests.

At another station, Zhang was told of irregularities in his digestive system and strongly encouraged to get screened for colorectal cancer — a service that cost an extra 1,500 yuan. “When I said no, the doctor tried to shock me into accepting the test with statistics about China’s colorectal cancer rate, assuring me that the exam was quick and painless,” Zhang recalls.

Cyr chuckles when he hears about Zhang’s experiences. “No, that’s not necessary,” he says, adding that the tests must be age-appropriate and doctors shouldn’t jump to conclusions based on irregular results of one-off tests. Otherwise, he says, “there’d be a massive number of false positives.”

Having never had digestive problems, Zhang decided against the colorectal exam. But later, while chatting with his co-workers, he discovered that many of them had been told to get the additional blood tests. Some had even forked out the money for the cancer screening, too.

Cyr says that many private health-check centers rely on test results that aren’t always accurate or necessary when preparing their reports. He recalls feeling surprised that many private physicians at Ciming conducted preliminary screenings using ultrasound. “We only use ultrasound as a follow-up test, when we suspect there is something wrong or a blood test comes back and looks weird,” Cyr explains.

Additionally, health-check centers often mischaracterize the real uses of tumor-markers, doctors say. Wang Yuandong, an oncology surgeon at Guangzhou’s Fuda Cancer Hospital and the executive director of the Chinese Society of Clinical Oncology, says that most tumor-markers have limited accuracy in cancer screenings: A positive result may indicate that the patient has the disease, but also may not. “Even if the readings are higher than a healthy range, it doesn’t necessarily mean that you have cancer,” he says.

Cyr is more worried about staff at companies like Meinian and iKang misleading patients with health risks or underlying conditions. Because of the emphasis on selling tests and packages, serious conditions — like Li Futian’s liver cancer — might get missed, even as staff claim that everything’s fine. “They heavily rely on the machines and the numbers, but they don’t ever review you as a person. Because they don’t know the patient, they only see customers,” he says. “They do all these tests, maybe including the cancer screenings, but a six-year smoker could just walk away thinking everything is fine and continue to smoke.”

An Industry in Rude Health

Many of the problems with health-check companies have emerged during the industry’s rapid expansion over the past decade.

Since China began its market reforms in the late 1970s, access to the country’s public health system has become increasingly unequal. Nowadays, medical resources are concentrated in large, urban hospitals, leaving rural and community-level clinics — which are intended to provide primary care — understaffed and underfunded. Larger hospitals, struggling to cope with the sheer volume of patients, have all but excluded primary care from their services.

To fill this void, private health providers have aggressively expanded their reaches. Meinian was established in 2004 and recorded 150,000 visits four years later. Following a series of mergers and acquisitions, the company now has more than 600 centers in around 200 Chinese cities and boasted 30 million visits last year. A similar story has taken place at iKang, which was acquired by Alibaba Group and Suning last month and currently has 120 centers.

The private sector boom has been felt most keenly in China’s cities. Although national statistics show that most Chinese people still choose public hospitals for health checks, more people in larger cities are going to private providers. In Beijing, for example, over half of all health checks carried out in 2017 took place at commercial health-check centers. And because employers increasingly purchase health checks on behalf of their workers, group purchases account for over 70% of such companies’ business.

But as private health-check companies have grown, they’ve faced a litany of punishments related to patient safety and medical ethics. In 2018, local health authorities found that Meinian had used CT scanners without permission from China’s health authority; forged doctor’s signatures on health reports; and used unlicensed staff, resulting in errors and inconsistencies.

In a public notice published in March 2018, Meinian warned potential investors that “as the volume of business increases, clients may receive misdiagnoses due to varying health conditions, the complexity of diseases, medical staff negligence, and medical equipment malfunctions.” The notice added that legal disputes with patients pose one of the greatest threats to the company’s future growth.

Company business models arguably elevate these risks. Meinian, for example, employs so-called health consultants who earn commissions by selling standardized health-check packages to individuals, private companies, and work units. Health consultants are rarely medically trained, sometimes ignore their clients’ current health status, and seldom provide adequate safety warnings. When Sixth Tone posed as a healthy potential customer in their mid-20s, an online consultant suggested we buy a cancer-screening package that included a full-chest CT scan. They offered no explanation about the test’s inherent radiation risks.

After making a sale, health consultants make arrangements with health-check centers for appointments. Many consultants promise face-to-face meetings with doctors, but experts question the qualifications of medical personnel at private centers. Online recruitment listings show that most private health-check centers in China — including Meinian and iKang — only require vocational university degrees for positions as doctors. As long as applicants hold medical licenses, this practice is legal. But it does mean that private companies frequently hire either medical staff with minimal clinical experience or retired doctors looking for a windfall.

Zhou Shenglai, the chairman of the Disease and Health Management Committee at the Chinese Hospital Association, divides doctors at health-check companies into two types: fresh graduates without clinical training and retired doctors. “The rapid expansion of these companies has led to a decrease in the quality of (medical) staff,” he says.

Nonetheless, health-check companies continue to rake in huge profits. In 2016, Meinian’s gross revenue was 3.1 billion yuan; the following year, it doubled to 6.2 billion yuan. In 2018, the company announced plans to build 200 new centers per year.

Out of Control

In December, iKang’s chairman, Zhang Ligang, gave a speech at the 2018 China Entrepreneur Summit in Beijing. In the uncharacteristically frank speech, Zhang admitted that “both real and fake health checks exist in our industry,” adding that certain unnamed companies were employing “fake doctors.” “Some companies in our industry draw the customers’ blood, but don’t bother to test it — they just make up the results. Why can they fake it? Because there’s only a 3-in-1,000 chance that the customer has cancer.”

Zhang’s speech, which came amid a slew of industry scandals, renewed public demand to regulate commercial health-check providers. Experts say that China’s current legal punishments for health-check violations are too low to compel the billion-yuan companies to change their ways. One private center in Shanghai was fined for three consecutive years from 2016 to 2018 for having staff carry out medical procedures without a license. The highest fine they paid was 4,000 yuan. Several companies, which used radioactive machines without a license, received a fine of 3,000 yuan.

Last year, following public pressure, China’s National Health Commission issued the first new national regulations on private health-check providers since 2009. Now, health-check centers must establish quality-control departments, and local authorities must perform random inspections of at least 3% of the health-check centers under their jurisdiction on a “regular basis.” However, the new regulations do not include specific changes to the penalty system.

Zhou, of the Chinese Hospital Association, doubts that new rules will effectively curb violations. “Even if the inspectors find violations, the punishments are just too low for these companies to care,” he says.

In addition, when customers take action to report negligence and defend their consumer rights, companies use creative means to thwart them. When Zhang, the Shanghai-based engineer, received his test results from iKang, he noticed that his self-paid thyroid exam was missing from the report. In addition, the report contained basic errors: For example, his diastolic blood pressure reading was given as “609 mmHg” — a virtual impossibility, given that the normal range is between 60 and 80 mmHg.

Frustrated, Zhang shared his experience with iKang on reviews platform Dianping, China’s equivalent of Yelp. Soon after, Zhang says, iKang’s customer service team called him to apologize, claiming that an intern and an elderly doctor were responsible for the errors on his report. Zhang says iKang offered him more than 5,000 yuan to delete his Dianping comment. When he declined, a woman Zhang had never met called him in tears, claiming to be the intern in question and begging him to delete the comment or she’d lose her job.

Zhang deemed his issues with iKang too small to take legal action. But Li Bei, who blames Meinian’s negligence for his father’s late cancer diagnosis, says he has considered suing the company. However, he worries that he would be unable to obtain enough solid evidence to take on the health-check giant, and the family has spent most of their time and energy on his father’s treatment. “It’s not easy for common people like my family to sue a massive company like Meinian,” he sighs.

For Zou Weigao, a lawyer at Shandong Zhongying Law Firm who specializes in medical disputes, private health-check center medical dispute cases are some of the toughest. “It’s difficult to prove that the company bears responsibility for the outcome of their medical evaluations,” Zou says. “Usually they provide an exemption clause in their report saying that the results don’t constitute a formal medical diagnosis.” Zou estimates that around half of his plaintiffs in lawsuits against private health-check companies receive compensation, and they generally receive less money than those who sue public hospitals. In one of Zou’s recent cases, Meinian was forced to pay compensation to the family of a deceased former customer who also had liver cancer, which went undiagnosed for two months due to negligence. The family had originally hoped to claim back 186,000 yuan; they ended up with 45,000 yuan.

In a written response to Sixth Tone’s questions about the quality of its health-check services, Meinian said: “As China’s leading preventive medicine provider … our fundamental requirement is to meet national standards (for care).” Meinian’s company standards far exceed existing industrial standards in China, the company added.

iKang did not respond to Sixth Tone’s interview request.

Li Bei’s father, Li Futian, remains seriously unwell, although his condition has stabilized. He has had surgery to remove some of the cancer in his liver and takes medication to slow the spread of the disease. To date, the family has spent 700,000 yuan — their entire savings — on Li Futian’s care.

Li Bei never expected his father to live this long and cherishes every moment with him. But the experience has left him angry and suspicious. “I hope other people will treat these health-check companies more cautiously. I really don’t know who I can trust with my health now,” he says. “I don’t know anything about medicine. The doctor said all the numbers on Dad’s report looked fine. Thinking back, I was stupid to ever trust them.”

Editor: Matthew Walsh.

(Header image: Liu Xin/CNS/VCG)