In China, the advantages of PDP for improving health care service access to those under-served areas have been well-noticed by managers in the public hospitals , and above all, they also recognized PDP as an effective way to readjust the price of health care service provided by Chinese’s public hospitals which has long been underestimated. However, in common with most countries, completely allowing PDP would inevitably result in a serious of negative outcomes, especially brain drains from public sector to private sectors, not to mention hidden damages to medical quality and patient safety. Moreover, responsibility on medical accidents or adverse events among dual practitioner, full time employer, and part time employer still remains vague in regulation, which greatly reduce the feasibility of completely allowing PDP in China. Therefore, most managers in Chinese’s public hospitals choose implementing PDP with restrictions, rather than completely prohibiting or allowing PDP.
General hospitals showed less preference for IR than the other types of public hospitals. One reason might be administrative cost of general hospitals on PDP. Regulations impose costs that have to be coupled with rewards and punishments in order to be enforceable. General hospitals were more diversified in terms of disciplines, services, positions, organization structure and human resource, so their administrative cost would be a comparatively more expensive solution. The other reason could partly be explained by over-load responsibilities for general hospitals. In China, general hospital physicians could barely afford time to PDP. According to the Chinese general hospital’s operations ranking 2020, the annual operation volume varied from 76 to 350 thousand (see Table S2 in Additional file 1) . Based on the Chinese general hospital’s emergency and outpatients ranking 2020, the annual emergency and outpatients visiting volume varied from 3.25 million to 7.76 million, with total volume came up to 1542.42 million (see Table S3 in Additional file 1) , equal to 41.1% the total volume of 34,354 hospitals in China . Facilities in public general hospitals are always fully occupied, and most physicians are “too busy to engage PDP” regardless of their willingness . Hence, IR would be of little practicability for general hospitals.
Public hospitals in the West of China were found preferable to IR compared to hospitals in the East and the Middle of China. Judging from performance evaluation report by the national health committee in 2020, public tertiary hospitals in the East of China were of much better comprehensive competence, with Shanghai (Eastern), Beijing (Eastern), Zhejiang (Eastern) as the TOP 3 among all the 32 provincial administrative areas in mainland China. Moreover, Shanghai (Eastern), Beijing (Eastern), Jiangsu (Eastern), Guangdong (Eastern) and Zhejiang (Eastern) were recognized as the TOP 5 provinces for immigrant patients, accounting for 52.7% of the nation’s total volume . In other words, public hospitals in the West of China are less attractive to both physicians and patients. As a consequence, physicians’ salary levels in the West China are much lower. Given such a situation, PR would probably give rise to negative responses. For example, putting earning limits on physicians may lead to problems such as low productivity, frequent absence, tardiness, inefficiency , brain drain, or under-the-table payments . It is worth noticing that financial restrictions, intrinsically require well-established health financing systems to monitor physicians’ activities between public and private sectors . A combination of tax-based public financing, mandatory health insurance and private insurance might be necessary, as well as transparent bureaucracies. Therefore, it is less feasible to maintain PR neither in the West nor in the Middle of China.
We found managers with academic background of clinical medicine held lower PR intention. PR require good competence in skills of communication, organization and coordination, however, most Chinese public hospital presidents lack systemic professional training in management , especially those major in clinical medicine. Compared to hospital presidents with non-clinical medicine academic background, most of whom majored in management or administration, it would be more challenging for managers with academic background of clinical medicine to adopt PR.
According to the contingency theory of leadership (CTL), managers’ decisions and strategies are influenced by their personality . We found female managers in public hospitals favored PR, and the reason might lie in better interpersonal skills of women.
Managers from public hospitals in non-provincial capital cities were distinguished for preferring PR. In China, tertiary hospitals are geographically distributed in capital cities. In contrast, most public hospitals in non-provincial capital cities are of lower levels and charged less . According to the Chinese general hospital’s operations ranking, 2020, 88% operations were performed by general hospitals in provincial capital cities . Based on the Chinese general hospital’s emergency and outpatients ranking, 2020, 86% emergency and outpatients volume were from general hospitals in provincial capital cities . Therefore, salaries of public hospitals in non-provincial capital cities are much less competitive, and financial incentive for physicians to engage in PDP would be stronger. Therefore, in non-provincial capital cities, it is necessary to monitor physicians’ public-private time allocation, and PR would be much more effective than IR.