This study surveyed 1032 physicians in China, examined the implementation influencing factors of MAs, and explored physicians' views toward MAs. We found that only a fraction of physicians were satisfied(30.62%). Although physicians believed that MAs had effect on promoting the integration of medical resources, they have undertaken more work without additional compensation in MAs, and there were differences at the regional level.
The regression results show that whether physicians’ benefit from MA will affect their evaluation. Specifically, the improvement of physicians' medical technology, the better income and benefits, and the higher degree of satisfaction are, the better the evaluation of MAs. The results of single factor analysis showed the same results and district D was better than that of district F. Because district D also invited third-party institutions to conduct comprehensive evaluations of the five MAs in the region each year and issued bonuses based on the evaluation results, directly stimulating the enthusiasm of hospitals and physicians. In addition, due to the rich medical resources in District D, help from core hospitals can greatly improve the medical service capacity of cooperative hospitals. The fact that highly competent physicians carry out visits and rounds in the cooperative hospitals of MAs will attract more patients and increase their trust. Moreover, the core hospitals often hold case discussions and academic conferences, greatly improving physicians’ technical level and the number of patient visits at cooperative hospitals. Even core hospitals can help cooperative hospitals through disciplinary co-construction, joint participation in scientific research projects, and the establishment of two-way referral green channels.24 Clearly, district F, which lacks well-known core hospitals, cannot achieve these outcomes. Therefore, physicians in F district were lower in the evaluation of improvement in professional competence, income and benefits than those in D area.
Although the main goal of MAs is centered on patients and to provide better medical services, another important purpose of MAs is often overlooked: improving the medical skills of physicians, especially in CHCs and second-level hospitals.25 The improvement of physicians' medical technology will increase the number of services provided in these institutions and indirectly improve the income and benefits of physicians. The medical capacity of physicians has been improved in MAs, which is also conducive to promoting the formation of the first diagnosis and two-way referral of patients at the CHC and finally forming a virtuous cycle to improve the performance of the health system. Therefore, more attention should be paid to the opinion of physicians in MAs and focus on the personal development of physicians so that the effect of MAs can be better.26
Then the results show that cognition degree of MA policies is the influencing factor of the implementation effect of MAs. Some Chinese studies have revealed that the cognition degree of MA policies by physicians will affect the implementation of policies. A study in Jiangsu, China, found that physicians’ cognition degree of the policy was 61%, and the higher the policy cognition degree was, the higher the satisfaction with the MAs was.27 Another study in Guangdong, China, found that physicians’ cognition degree of the policy was 75.98%, and the higher the policy cognition degree was, the higher the support for MAs.28 These results are consistent with this study. However, this result is rarely mentioned in the international literature.29,30 As physicians are important stakeholders of the MA policy and the agent of patients, physicians' cognition will be indirectly passed on to patients and even affect patients' medical behavior (such as whether they are willing to receive the first diagnosis at CHC and be referred to the primary medical institution after recovery).31 Therefore, if physicians do not have a high understanding of policy, the supporting of MAs will be greatly reduced. Therefore, the healthcare departments should use various measurements to improve policy cognition degree.
Finally, region is the most important factor affecting MAs. Through an international literature review, regional characteristics have always been one of the important factors affecting the development of healthcare systems, and regional factors are more likely to be attributed to economic level and medical resource level.32–35 Due to the relatively developed economy of district D, investment in the health care system is relatively large, and there is better financial support for MAs. The informatization level of MAs in area D is obviously better than that in area F, which makes the cooperation between hospitals in District D more convenient. In summary, the operating conditions of MAs varies in different regions, and the government's financial investment is necessary, especially when the MA incentive mechanism is incomplete at present. For a district where medical resources are scarce, it is important to establish a unified management organization in MAs, to coordinate all resources within MAs.36 In addition, the experience of District D reveals that the government should conduct an annual performance assessment of MAs and establish a reward and punishment system.
Strengths and Limitations
There are some strengths and limitations in this study. This study is based on the perspective of physicians, who are important stakeholders in the development of MAs. Through the overall evaluation of MAs by physicians, we find that medical service providers reflect the problems and provide scientific suggestions on the construction of MAs. However, MAs should be evaluated using a mature theoretical framework and included more comprehensive objective data. In this study, MAs were evaluated only from the perspective of physicians, but the evaluation should be multi-dimensional. Although this study contains some missing data, it still provides Chinese experience for the practice of international medical resource integration. Finally, the regional factors that affect MAs deserve further exploration, and many subregional factors need to be identified.