The “Chinese model” of health care reform has achieved remarkable effect in the past decade. The accessibility of medical services and the health indicators of residents have been greatly improved. The experience and practice of reform deserve to be used for reference by many developing countries . Whether such reform is effective requires not only the evaluation of objective indicators, but also the subjective evaluation of patient satisfaction.
Hospitals in China are divided into three levels according to their functions and tasks. The first-level hospital is a primary medical institution that provides basic medical care, prevention, rehabilitation, and health care services to a community. The second-level hospital is responsible for providing diagnosis and treatment of common diseases and frequently occurring diseases to a number of communities, receiving referral patients from primary medical institutions and the tertiary hospitals and undertakes some teaching, training and scientific research tasks. The tertiary hospital is a regional medical institution that provides specialized medical services to a number of regions. This hospital provides prevention, health care and rehabilitation service and undertakes clinical teaching, training and scientific research tasks. The hospital is also a provincial and national high-level medical institution and technology center. In addition, there are many community health service centers in China; their main functions are the initial diagnosis of common diseases, health guidance for chronic diseases, disease screening, monitoring and management of high-risk groups, prevention of infectious diseases and control and health education. These hospitals are primary medical institutions, as well .
However, due to the low level of per capita medical resources in China, the total amount of high-quality medical resources is insufficient and unevenly distributed, mainly concentrated in “big cities” and “high-level hospitals”. In addition, with the lacks of Chinese medical insurance system constraints and other factors, disorderly medical services are common, which leads to the phenomenon of “inadequate and overly expensive medical services”. According to the statistical bulletin of China’s health development in 2009, the total number of outpatients and emergency visits reached 5.49 billion, including 1.92 billion (35.0%) in hospitals and 380 million (6.9%) in primary medical institutions. From an international perspective, because some developing countries such as India do not have a compulsory primary consultation, patients can seek the medical treatment with the high-level hospitals in the region or in their own country freely, which may also lead to the phenomenon of disorderly medical treatment, resulting in the low efficiency of the health service system and a higher national health accounts, even reducing the patients’ satisfaction.
The Chinese government proposed a hierarchical diagnosis and treatment system in the new health care reform of 2009 for the first time in hopes that patients can be guided to seek medical treatment by nonmandatory means. Patients whose disease cannot be diagnosed and treated by the primary medical institutions will be referred to a higher-level hospital for treatment. Patients with a severe disease will be referred to the primary care institutions for long-term treatment or rehabilitation after entering the recovery and rehabilitation periods. The importance of the policy has been evaluated as “the day of the hierarchical-diagnosis-and-treatment-system success is the day of the Chinese-medical-reform success” by the minister of the National Health Commission of the People’s Republic of China .
The essence of the hierarchical diagnosis and treatment system is to promote the vertical flow and integration of medical resources. Countries around the world are also taking various measures to promote the integration of medical resources to meet the requirements of patients’ medical services. Patients’ disease treatment will be delayed if there is no integration and effective communication between these doctors . An accountable care organization (ACO) in the United States is a medical alliance composed of primary care doctors, specialists and rehabilitation doctors. A series of measures is required to improve the quality and control of medical costs . In Germany, the cost of medical care is expensive because there is a serious break between the specialists and the primary care physicians, resulting in the patients’ information not being shared and repeated examinations. Most patients go without further rehabilitation therapy after discharge because they do not know which doctor to contact. In 2004, Germany implemented medical resource integration with the “Medical Care Centers” program, also known as “Multidisciplinary Clinic,” composed of specialists and general practitioners. In Canada, the health care system established in the 1970s has encountered such problems as increased costs, poor coordination of medical institutions, and difficulty in obtaining doctors’ resources. Therefore, Canada has integrated medical resources. For example, Ontario established a network of multidisciplinary physicians with a primary care physician as the core. This network is conducive to improving quality and reducing medical costs, especially for patients with chronic diseases.
In China, it was proposed for the first time in 2012 to encourage the establishment of “medical alliances” (In this study, the medical alliance refers to the loose medical alliance.) among hospitals. A medical alliance, as a push power for the implementation of hierarchical diagnosis and treatment systems, strengthens the vertical integration of medical resources of different levels. Medical alliances are dominated by the government. The medical institutions with the highest medical technologies in the region are regarded as core hospitals (generally tertiary hospitals), and a certain number of other medical institutions in the region are cooperative hospitals (including second-level general hospitals, first-level general hospitals and community health service centers), that is, joint organizations of unincorporated individuals. The core hospitals within a medical alliance are responsible for such efforts as the diagnosis and treatment of difficult diseases, doctors’ training, teaching, and research. The cooperative hospitals are responsible for, for instance, multiple diseases, common disease diagnosis and treatment, rehabilitation of referral patients and public health tasks. In a medical alliance, a series of measures are implemented, such as total prepaid medical insurance and other payment methods. Doctors do not need to apply for a change of practice location, and the filing procedure of the practicing organization in the practice of other hospitals in the medical alliance. The continuous recording of electronic health records and electronic medical records, information sharing and mutual recognition of inspection results are promoted among hospitals. Beijing began to explore the establishment of medical alliances in 2012. By March 2018, 58 medical alliances had been built with regional boundaries, including 55 core hospitals and 528 cooperative hospitals, covering all 16 districts in Beijing.
Medical alliances have been established in Beijing for over 7 years. The service capacity of cooperative hospitals has improved through the integration of medical resources and a variety of measures, but the situation of disorderly medical treatment has not been greatly improved. The data showed that the number of outpatients and emergency visits in tertiary hospitals of Beijing in 2012 was 80.723 million and reached 99.774 million at the end of 2017 with a 23.60% increase. While the number in primary medical institutions in 2012 was 36.268 million and was 37.01 million in 2017, only increasing 3.12%. The policy has intensified, to a certain extent, efforts of tertiary general hospitals to attract patients, while the crucial reason for patients to prefer high-level hospitals for medical treatment should be discussed.
Through the previous research on medical alliances in Beijing, the patients’ choice of medical treatment and the willingness to first visit primary care institutions were affected by the patients’ satisfaction, and the higher the satisfaction is, the higher the willingness is to first visit primary medical institutions. In other studies, similar conclusions have been found. In addition to the patients’ satisfaction, the influence of external factors such as medical insurance and hospital geographic location are guiding effects on medical treatment choices. According to customer satisfaction theory, the higher the customer satisfaction the higher customer loyalty and the possibility of repeated purchases and recommendations to others. This theory means that the more satisfied patients are in the health care system, the more likely it is that they are willing to choose this hospital . According to the above data (the number of outpatients and emergency visits in tertiary hospitals and primary medical institutions of Beijing), patients in Beijing prefer to visit core hospitals with higher hospital levels. Does this mean that compared with cooperative hospitals, core hospitals are more reassuring and satisfying to Chinese patients? An existing study found that the overall satisfaction of respondents increased with the rise of the level of medical institutions in Ningxia and Shenzhen in China; however, in another study of patients’ satisfaction in the Zhejiang province, the satisfaction of the patients in primary medical institutions was significantly higher than that of the high-level hospitals. With the two completely different results, under the background of the integration of medical resources in Beijing, which has the preferable patient satisfaction, core hospitals or cooperative hospitals? In this study, a cross-sectional survey was conducted in 16 districts of Beijing to compare the differences in patients’ satisfaction between the core hospitals and the cooperative hospitals within a medical alliance.