Headlines about foreign companies establishing a foothold in China only to fail years later no longer surprise anyone. But why does this keep happening? Kenneth Wilcox, former CEO of Silicon Valley Bank (SVB) from 2001 to 2010 and author of The China Business Conundrum: Ensure that Win-Win Doesn't Mean Western Companies Lose Twice, argues that the answer comes down to mental models and preparation.

In a recent lecture hosted by the Stanford Center on China's Economy and Institutions, Wilcox explained that we all develop mental models — internal frameworks that help us interpret and navigate the world around us. We carry these models with us wherever we go, applying them instinctively to new situations and environments. The trouble, Wilcox argues, is that a mental model only holds up if the new environment resembles the one it was built for. And American mental models, more often than not, simply don't hold up in China.

Wilcox knows this firsthand. After a decade leading SVB, he and his wife moved to China in 2011 to open a Chinese branch of the bank. Things started smoothly enough — he secured a partnership with Shanghai Pudong Development Bank and obtained the necessary license — but it quickly became clear that the rules he'd spent his career following no longer applied. The license, for instance, permitted him to open the bank but barred him from conducting any business in renminbi, China's national currency, for the first three years. For a bank, this created an obvious problem: how do you pay staff, let alone operate, without access to local currency? The government's solution was a subsidy to cover operating costs during that period, along with an invitation to meet regularly with other banks and business leaders to share SVB's model and approach. After many such meetings, Wilcox's Chinese partners told him they had been so impressed with what they'd learned that they planned to open their own bank modeled on SVB's approach.

This, Wilcox explained, is a pattern that plays out with striking regularity in China. Foreign companies are lured in with the promise of a vast new market and eager local partners. They are then entangled in regulations and bureaucracy, kept afloat with subsidies while they wait for permission to operate more freely — all while their technology and intellectual property are quietly absorbed. Eventually, the foreign company is left with little choice but to close up and leave. Some companies see it happening but look the other way. Others don't recognize it until it's too late. Many never fully understand why they failed at all.

Wilcox traced all of this back to the limitations of mental models. American businesses tend to arrive in China assuming the environment will function more or less like home: keep your head down, stay out of politics, focus on the business, and you'll be fine. But that assumption doesn't hold in China, where the government and the Communist Party exert control over virtually every aspect of commercial life. The most powerful players routinely hold simultaneous roles — party member, bank executive, government official — all at once. It is precisely these unexamined assumptions, Wilcox concluded, that set so many Western ventures up to fail before they've even begun.

Despite advances in healthcare delivery, access to high-quality medical care remains uneven in many countries. In systems where medical resources are limited and physician quality varies widely, patients must make important decisions about where and from whom to seek care. These choices can shape not only individual health outcomes but also the efficiency of healthcare systems.

Yuli Xu, a postdoctoral fellow at APARC’s Asia Health Policy Program, has made these questions central to her research on how institutional structures shape individual behavior and inequality in labor and health markets in both China and the United States. “I examine how policy reforms and institutional arrangements influence outcomes for families, workers, and patients, using large administrative and survey datasets,” she says

At a recent webinar, Xu presented new research examining patients’ preferences for physician continuity in China’s healthcare system. Her work explores whether patients prefer to return to the same physician even when institutional barriers to switching providers are minimal.

Watch her talk on our YouTube channel.
 

Physician Continuity in a Flexible Healthcare System

Much of the existing research on physician continuity focuses on healthcare systems in developed countries, where institutional rules strongly shape patient behavior. In those settings, referral requirements, insurance networks, and primary care gatekeeping often limit patients’ ability to switch doctors easily.

China’s healthcare system offers a very different context. “My interest in this topic was initially motivated by observing the stark differences between healthcare systems in China and the United States,” Xu says.

“In China, patients can often choose doctors directly with relatively few formal barriers, while high-quality medical resources remain scarce,” she explains. “This contrast made me interested in understanding how patients value continuity of care in a setting with fewer institutional switching frictions but greater variation in physician quality.”

Patients in China can often select physicians directly through hospital appointment systems and may visit specialists without referrals. This flexibility allows researchers to observe patient preferences more clearly, since continuity with a physician is less likely to be driven by institutional constraints.

Xu’s study draws on administrative medical claims data from residents enrolled in China’s Urban and Rural Resident Basic Medical Insurance program. The dataset includes detailed information on outpatient visits, diagnoses, expenditures, and physician identifiers. These records make it possible to track how patients choose physicians over time and whether they repeatedly return to the same doctor.

Evidence of Persistent Physician Choice

Xu’s first question is whether patients maintain consistent relationships with physicians when switching is easy. The data show that many do. Patients with chronic conditions frequently return to the same physician over multiple visits, suggesting that continuity of care remains an important factor in medical decision-making.

To analyze physician choice more systematically, Xu estimates a discrete choice model that examines how patients weigh factors such as physician experience, consultation fees, and prior interactions with the doctor.

The results reveal that prior relationships strongly influence patient decisions. Patients are significantly more likely to return to physicians they have visited in the previous six months.

The study also finds variation in preferences across patient groups. Female patients and patients with lower socioeconomic status are more likely to maintain long-term relationships with physicians. At the same time, patients respond to financial incentives. Higher consultation fees reduce the probability of selecting a physician.

These findings suggest that even in a flexible system where patients can easily switch providers, many still value stable relationships with physicians.

To estimate the causal value of physician continuity, Xu examines what happens when these patient-physician relationships are unexpectedly interrupted.

The results show clear behavioral changes. When their regular physician is absent, patients reduce visits to that department and spend less on medical care. The decline extends beyond the physician’s own department. Patients also reduce visits to other departments within the same hospital.

This pattern suggests that many patients organize multiple appointments during a single hospital visit. If a trusted physician is unavailable, patients may delay or cancel other appointments. The study also finds little evidence that patients compensate by seeking care at other hospitals. Instead, many appear to postpone care until their regular physician returns.

Implications for Healthcare Utilization and Policy

By examining how patients navigate healthcare systems with limited resources and flexible provider choice, Xu’s research offers new insights into how institutional design shapes healthcare access and efficiency.

While Xu finds no evidence of worsening short-term health outcomes within months after physicians’ absence, the research indicates that physician continuity can reduce costs for certain patients. Individuals with more severe conditions incur higher medical spending when they must see unfamiliar physicians, suggesting that established relationships may improve efficiency by facilitating information sharing and familiarity with medical histories.

“One strand of my work during my postdoc focuses on the Chinese healthcare system, where medical resources, especially high-quality physicians, are scarce and unevenly distributed,” Xu notes.

Her findings highlight the importance of stable patient-physician relationships in healthcare systems where provider quality varies. Even when patients have the freedom to choose among providers, many still demonstrate strong preferences for continuity with trusted physicians.

Research Community and Future Directions

Xu says her time at APARC has played an important role in advancing this research. “My time at APARC has provided an incredibly supportive and stimulating research environment,” she says. She credits the guidance of Karen Eggleston, director of the Asia Health Policy Program, whose expertise in health economics and Asian health systems helped shape the project.

She also highlights the broader intellectual community at Stanford. “I have had the opportunity to connect with many wonderful scholars across the Freeman Spogli Institute and Stanford more broadly,” Xu says, noting that conversations with economists and health policy researchers have helped refine her work and expand her perspective on healthcare systems.

Looking ahead, Xu plans to continue studying healthcare systems across different institutional settings. “I would encourage young scholars not to focus on only one country, but instead to study broader research questions and examine how they play out across different institutional settings,” she says. “Comparing institutions across countries can generate new insights and help identify mechanisms that might not be visible in a single context.”
 

Key Takeaways
 

• Patients in China demonstrate strong preferences for continuity with physicians despite minimal institutional barriers to switching providers.

• Physician absences lead to significant reductions in healthcare utilization within the same department and across other departments in the same hospital.

• Patients do not substitute toward other hospitals when their regular physician is unavailable, and many return to their original physician once they resume practice.

• The findings suggest that stable patient-physician relationships can improve efficiency and reduce costs in healthcare systems with flexible provider choice.