Patient satisfaction is increasingly recognized as an important research area that significantly affect the hospital reputations and ultimately, affect the hospital revenue [1; 2; 3]. Literature emphasizes the positive relationships between patient’s satisfaction and quality of technical services, (medical treatment). they received [4; 5; 6; 7]. Satisfaction is a necessary element that motivates patients to accept the treatment, follow medical instructions and then accelerate health recovery [2; 8].
Satisfaction also influences the behavioural intention of patients. Satisfied patients are more likely to be loyal to their hospitals and recommend the hospital to other patients, friends and families [9; 10; 11]. From this perspective, hospital management looks to positive patient’s behavioural intention as the ultimate aim from satisfying their patients . In this research we consider both patient satisfaction and patient behavioural intention.
Despite the obvious correlation between satisfaction and treatment, patients may have no adequate education on medicine and the question arises as to whether patients can provide valid and reliable evaluation of the clinical treatment . However, there are other domains allowing patients to evaluate indirectly the hospital technical services, including interactive care, (interaction between patients and technical healthcare providers), Administrative aspects, and the environment within which the treatment is provided [14; 15; 16]. Administrative and environmental aspects comprise a wide range of managerial activities that facilitate the delivery of services. This research considers interactive care and the functional elements of administrative and environment aspects that are directly associated with, or facilitate the interactive care.
The reputation of an organisation reflects the perception of organisation’s customers, employees, and the general public . Literature points out to hospital reputation as a variable influencing hospital selection and affecting patient satisfaction [18; 19; 20]. Jung et al.  show that perceptions related to a hospital’s reputation plays major role in the selection of the hospital. Abd-El-Salam et al.  state that hospital reputation is correlated with service quality and customer satisfaction.
Another area affecting the patient satisfaction is the hospital costs or billing system . Healthcare costs system is one of the patient’s consideration in selecting a hospital . Studies shows that higher expensive hospitals are perceived by patients to provide better healthcare [3; 25]. Limited research indicates correlation between satisfaction and behavioural intention, reputation, and costs [24; 26]. From research point of view, correlation between variables is a necessary condition indicating potential role of a variable on its relationships with other variables. However, correlations don’t show the type and magnitude of the variable’s role. That is, whether a variable mediates or moderates relationships of other variables. According to our best knowledge, the roles of hospital reputation and costs on the relationships between interactive care and patient satisfaction and behavioural intention have not been investigated in the current literature. Our research is an attempt to fill this gap in literature. It considered four large teaching hospitals located at Zhejiang Province in China as a case. A questionnaire was designed and distributed among 1441patients. SPSS, AMOS software and PROCESS tool  was used to analyse data.
The effect of service quality on patient satisfaction has been widely researched in the literature [2; 8; 22; 28]. There are several approaches for defining service quality. Grönroos  considers the work of Swan and Combs  and express the concept of service quality into two dimensions; technical dimension (knowledge and skills) and functional dimension (interaction between customer and service provider). Parasuraman et al.  proposed two service quality dimensions, namely ‘outcome’ and ‘process’ which correspond to the the dichotomy proposed by Grönroos . Another service quality model is known as SERVQUAL . It defines the quality into five dimensions; tangibles, reliability, responsiveness, assurance, and empathy . Mangold and Babakus  classify service quality into two stages; front-stage, and back-stage. The former refers to the interaction of customer with the service provider and the later considers interactions with the other service activities .
Glushko and Tabas  distinguish between the interactions of the customer and provider that are part of the service encounters (or front-stage activities) and other activities that precede those encounters (back-stage activities) and make them possible. Glushko and Tabas stress that the focus in the service quality is on the interaction between employees and customers, and the service quality is mainly determined during the final “service encounters” that takes place in the front stage. According to Parasuraman et al.  these encounters are the service from the customer’s viewpoint. Mangold and Babakus  emphasise that service providers' back-stage perspective may limit their ability to understand customers' expectations, because “the customer has a front-stage perspective, he is usually unaware of many of the activities and problems that occur behind the scene”. Based on the above argument, the technical and functional dimensions of service quality proposed by Grönroos  are within the concept of front-stage service quality.
The technical and functional dimensions of service quality are applicable to healthcare services as they directly relate to the treatment, determine the correct diagnosis and satisfy patient needs for comfort and safety [14; 15; 36; 37]. Some adaptation, however, is necessary, mainly because the patient is a customer as well as the subject matter for services, in which the treatment is directly related to the patient’s wellbeing. Patients are trying to search for information from social media, family, friend, and other patients. The rapid evolution of Internet facilitates such search and change the way medical practitioners communicate and educate themselves and their patients . This gives patients general knowledge on the technical service, but such knowledge does not mean that patients have adequate education and ability to evaluate the technical dimensions of the clinical services they received. However, patients may no longer ready to accept treatments, especially for serious illness, without clear and convincing explanation from the medical professionals. Ong et al.  review the literature and assert that physicians’ information provision has been significantly related to patient satisfaction. It follows that physician-patient interaction plays major role in creating patient satisfaction [14; 40; 41]. Jacobs et al.  recognize physician-patient interaction to be of diagnostic import and therapeutic benefit. Dagger et al.  widen physician-patient concept to interactive care which is a reference to the care provided by any professional staff (physician, nurses, pharmacist, etc.) of the service provider. Gupta et al.  find that patient satisfaction with interactive care they receive is a predictor of survival in server illness such as breast cancer. Interactive care encourages patients for more engagement in their healthcare [43; 44] which, in turn, enhances patient satisfaction [8; 42; 45].
In addition to interactive care, Ware et al.  add two additional elements to the functional dimension of the service quality. These elements are administrative aspects and environment aspects. McDougall an Levesque  suggest an element referred to as ‘enablers’ which is analogous to administrative aspects. Environment element represents the general features that shape the patient services perceptions [42; 47].
Patients interact and influence with services that are delivered (front-stage activities) rather than managerial activities administrating the delivery of services (back-stage activities). In addition, our study was taken in China and considering the major public hospitals at Zhejiang Province. These hospitals are governed by the same local government of Zhejiang Province and have similar physical appearance and environment. This make the apparent physical environment aspects of these hospitals are less effective in the patients’ selection and their satisfaction. Unlike other research works [32; 42; 48; 49], this research considers the functional elements of administrative and environment aspects that are directly associated with the interactive care. That is, activities patient experienced inside the examination rooms and wards where the interactive care with professional staff take place, including privacy during diagnosis and telephone and staff interruptions at the time of patient’s examination.
Patient satisfaction and behavioural intention
Much of marketing literature looks to the satisfaction as the meeting of customer expectation with the perceived performance [32; 50]. Rust and Oliver  describe consumer satisfaction as the degree to which the consumer believes that provider services educe the positive feelings. On other words, satisfaction reflects the consumer royalty and influences his/her behavioural intention and retention . Recent research works consider patient satisfaction from the royalty and behavioural intention perspective [9; 12; 52; 53]. Healthcare literature points out to the interpersonal relationship or interaction between patients and healthcare providers as the most important factor of customer satisfaction [1; 14]. As early as 1996, Zeithaml et al.  associate behavioural intention with saying positive things about service providers, recommend the services to families and other friends, and royalty. So it is important to associate patients’ satisfaction with behavioural intention to reflect the degree of association of the consumer satisfaction, or feelings, with the service providers [12; 52]. For simplicity, we use the term ‘patient satisfaction’ to reflect both satisfaction and behavioural intention of the patients.
Considering the above argument, we predict the following hypothesis.
(a – c): Patient satisfaction will be positively and directly influenced by; (a) interactive care, (b) reputation, and (c) costs.
The positive effect of reputation on both healthcare and satisfaction leads us to hold that the effect of interactive care on satisfaction can better be explained through reputation. Accordingly, we propose the following hypothesis (Fig. 1A):
The hospital’s reputation will mediate the relationship between interactive care and patient satisfaction.
Literature refers to the cost of healthcare as major factor influencing the patient’s selection of healthcare organisation as well as their satisfaction [23; 24; 55]. Several studies indicate healthcare providers with higher expenses are perceived by patients to provide better care . Low-income families, however, may use hospitals associated with lower costs . On the other hands, DiCenzo and Freedman , examine the costs of healthcare providers in Massachusetts and stress that the highest paid providers do not necessarily provide the highest quality of care. DiCenzo and Freedman stress that provider price, not utilization of health care services, remains the biggest health care cost driver and administrative costs can burden the system and impede transparency . In this regard, Baji et al.  stress that to assure the costs acceptance, hospitals should provide real improvement on care noticeable for patients. Satisfied patient improve physician satisfaction and then functional quality [59; 60] which, in turn, improve interactive quality. Kenagy et al.  show that poor services usually comprise wasted effort and materials and, accordingly, significant reduction in the costs could be achieved with improved services. This argument may suggest that healthcare costs may specify conditions under which the healthcare relate to satisfaction. We hypothesise the following relationship (Fig. 1B):
Hospital costs will moderate relationship between interactive care and satisfaction.
White et al.  stress that the differences between low – and high – costs hospitals are their size and market share. Much researcher works associate hospital costs with care and reputation, and hospital cost with reputation and patient satisfaction patient [21; 24; 63; 64]. This suggest that costs may moderates the relationships between care and reputation as well as between reputation and satisfaction (See Fig. 1C):
Hospital costs will moderate relationship between interactive care and reputation.
Hospital costs will moderate relationship between reputation and patient satisfaction.
We may also suggest the following hypothesis (Fig. 1C):
In presence of reputation, the hospital costs will stay moderating the relationship between interactive care and reputation.
the validity of hypotheses 4 to 6 depends on the strength and effect of reputation relative to costs. For instance, in case that reputation strongly influences the relationship between integrative care and satisfaction much more than the effect of costs, the correlation between integrative care and satisfaction will stay insignificant in presence of both reputation and costs. In such situation, hypothesis 6 will not be satisfied.