Medical mall founders' satisfaction and integrated management requirements.

Medical malls help provide integrated medical services and the effective and efficient independent management of multiple clinics, pharmacies and other medical facilities. Primary care in an aging society is a key issue worldwide and the establishment of a new model for primary care in Japanese medical malls is needed. Understanding the requirements of integrated management that contribute to the improvement of medical mall founders' satisfaction levels will help provide better services. We conducted a questionnaire survey targeting 1840 medical facilities nationwide; 351 facilities responded (19.1%). We performed comparative analyses on founders' satisfaction levels according to years in business, department/area, founder's relationship, decision-making system and presence/absence of liaison role. A total of 70% of medical malls in Japan have adjacent relationships with no liaison role in most cases; however, 60% of founders are satisfied. Integrated management requirements involve establishing the mall with peers from the same medical office unit or hospital, and establishing a system in which all founders can participate in decision-making (council system) or one where each general practitioner (GP) independently runs a clinic without communicating with others. The council system can ensure the capability of general practitioners to treat many primary care patients in the future.

Introduction

The provision of primary care in an aging society is a key issue worldwide. Along with the growth of aged societies, in recent years, medical malls—clinics that are opened to provide medical services effectively and efficiently by gathering multiple independent clinics or dispensing pharmacies in the same building or area—have expanded across Japan as a novel system for the establishment of clinics. A medical mall is the medical version of a shopping mall with a superior access environment from a patient standpoint. The SL Medical Group in Nagoya was the first medical mall in Japan and has a 40‐year history (Kamei, 2005). According to Ito et al. (2009), there were 418 medical malls in 2009, particularly near stations in densely inhabited districts, office complexes or interchanges in suburban areas (Ito et al., 2009; Ito, 2010).

The health delivery system developed in Japan is strongly related to the increase in medical malls. First, physicians are allowed to use the free medical practitioner system and free advocacy system, and most general practitioners (GPs) typically open their own clinics after working as hospital specialists. While they are highly specialized, general medical function in their clinics is vulnerable (Ohmichi, 1998). Additionally, it is physically and mentally difficult to meet the diverse and complex medical needs in Japan's super‐aged society because most GPs are usually practicing alone (Terasaki, 2006).

Therefore, practitioners in Japan operate as specialists. Yet few differences exist between training in general medicine in Japan and training to be a physician in general practice in the UK. Given the solo nature of Japanese practitioners, this renders primary care provision weak.

As of 2014, the number of clinics (approximately 100 000) was 11.6 times greater than the number of hospitals (approximately 8600); due to the solo nature of these businesses, 50 clinics per year cease operating because of strong competition (Health Care Research Institute, Inc, 2006; Ministry of Health, Labour and Welfare, 2013b; Ministry of Health, Labour and Welfare, 2013a). Thus, efficient clinic management is required (Ito, 2015). This highlights the importance of containing competition and strengthening practitioner management skills via cooperation in the medical mall.

Patients can freely visit any medical institution across the country for a small self‐pay cost because of nationwide medical insurance and free access. However, medical information is not sufficiently provided at the various institutions (Shimazaki, 2011; Japan Medical Association Research Institute, 2012). Therefore, patients engage in excessive hospital or clinic hopping because they cannot properly evaluate each clinic's quality of information (Tsukahara et al., 2006). Issues such as fatigue or lack of hospital doctors then arise in public hospitals in local areas (Makino, 2009; Iseki, 2013). Both hospitals and clinics provide primary care. This demonstrates the ambiguity of the roles played by hospitals and clinics.

Moreover, the roles of primary care and the hospital must be defined so that many patients can be treated at primary care as 80% of health issues are treatable there (Fry, 1978; Green et al., 2001; Fukui et al., 2005). Medical malls are now regarded as a way of implementing this approach (Ito, 2013, 2014).

In Western countries, it is common to provide comprehensive health care, such as the implementation of a group practice by multiple physicians, and integrated medical facilities, and care facilities. However, such a system is uncommon in Japan (Brown, 1996; Hutten and Kerkstra, 1996; Zelman and Berenson, 1998; Wilensky, 2001; Mossialos et al., 2002; Matsuda, 2013). Building an allied cooperation system is extremely difficult because this type of medical mall consists of multiple managerially independent clinics and other facilities, such that business objectives, medical treatment policy or founders' backgrounds vary greatly (Sekita, 1995). For example, competition over patients may occur or patient referral systems may not fully work. If GPs are unsatisfied with the medical mall environment to which they belong, the medical mall will be at risk of disbanding as a result of the withdrawal of the GPs (Milgram and Roberts, 1992; Weekly Toyo Keizai, 2007). Additionally, transaction cost issues may occur in medical malls. Therefore, establishing an integrated management system that satisfies a number of founders is required to maintain favorable and stable relationships among medical mall founders (Japan Primary Care Association, 2012). Integrated management is a method used to accommodate and control transactions among functional units, which are facilities, such as clinics, constituting medical malls.

In Japan, the definition of a medical mall is not outlined in the Medical Service Act or government statistics. Moreover, because very few studies exist regarding medical malls, a method to establish a stable integrated management system has not been found (Ito et al., 2009; Ito, 2010). In this study, we aimed to ascertain the integrated management requirements that contribute to improving the satisfaction levels of medical mall founders.

Differences between medical practitioners in the UK and Japan

Table 1 shows the differences between practitioners in Japan and the UK. First, when we look at establishment regulation, clinic location has been severely restricted and inpatient care not provided in the UK. However, Japanese practitioners are able to open clinics freely, and, despite Japanese clinics having fewer than 20 beds, hospitalization can be provided.

Table 1

Differences and similarities between medical practitioners in the UK and Japan

		Japan's Practitioners	UK's GPs
Establishment regulation		×	○
Management style		Solo practice	Group practice
Department		Specialist	General practitioner
Payment for medical services		Fee‐for‐services + Self‐paying basis	Bundled payment + Income security
Consultation	Ambulatory practice	○	○
	Hospital treatment	○	×
	High‐level clinical inspection	○	×
Gatekeeper		×	○
		(Free access)	(General medical service)

Second, when we look at the management structure, in the UK, group practice is often undertaken; in Japan, solo practice is at the center. Therefore, there are no incentives for doctors to cooperate because a Japanese practitioner is self‐contained in their management; incentives to provide overall medical treatment do not exist. In this, there are risks and ethical concerns. Therefore, it is necessary to introduce a mechanism to review this in a better way.

Third, GPs in the UK acquire training in general medicine. In Japan, doctors become independent after practicing in hospital medicine; they are therefore highly specialized, but have little experience with synthesized medicine. Cooperation with other medical offices is needed to improve medical quality.

Fourth, medical rewards are common in the UK and Japan, and many elements are paid for by a national health insurance tax. For GPs in the UK, a global sum payment system has been introduced so that GPs have a certain amount of income that is guaranteed. Meanwhile, in Japan, a medical service fee is paid according to the treatment performed. In other words, when patients of a certain type do not come together, wider management is not formed because a payment‐per‐treatment system is adopted. In the worst‐case situation, a clinic goes bankrupt. Therefore, securing patients in stable way is needed.

Fifth, when the medical examination and treatment contents are compared, foreign medical examinations and GP treatments are mainly outpatient care in the UK. Meanwhile, a clinic in Japan offers foreign medical examination and treatment, hospitalized medical treatment and high laboratory tests in diagnostic imaging; in other words, their function is similar to that of a hospital. There are also many medical offices that are equipped with helical CT and MRI, as well as operating rooms. Therefore, in Japan, there are many clinics and medium‐scale hospitals and competition is high. It is necessary to strengthen the management body in order to compete properly.

Sixth, the UK has a gatekeeper, but Japan does not. In terms of the patient, free access to services is guaranteed; in other words, the patient has the right to choose their medical facilities. Patients do not visit a bad doctor of a medical office with a poor‐quality reputation. Furthermore, in Japan, the budget deficit is now at one quadrillion yen and patient costs grow significantly with a reduction in medical resources required. Patient evaluations can be very severe. Therefore, it is necessary for clinics to improve their medical quality. A contribution to qualitative medical improvement is needed by introducing a competition principle in the medical system; yet, this can also produce problems, such as regarding the intentions of large hospitals or the combining of two patient consultations.

Because sustainability is not secured, Japanese clinics must build organizational cooperation with other clinics to help this situation. However, because of differences between the UK and Japan in terms of history, culture, taxation system, finances and social security, the GP system cannot be introduced easily. Therefore, the medical mall functions as a primary care model that corresponds to Japan's specific environment.

The features of medical malls in Japan

Japanese primary care is supported by clinics and hospitals. Competition is high, so both need to clarify their allocated roles and strengthen the clinic's function substantially. In Japan, because of its medical system, culture, and so forth, it is desirable for two or more clinics to combine and to build a medical mall from such a situation. Therefore, in this study, medical malls are evaluated. As a comparison, three medical system types in Japan—the clinic, hospital and medical mall—are outlined in Table 2. In Japan, they all offer primary care.

Table 2

Differences and similarities between clinics, hospitals and medical malls in Japan

	Clinic	Hospital	Medical Mall
Management style	Solo practice	Group practice	?
Department/area	Specialist	Specialist group	Specialist group
Employment status (doctor)	A medical practitioner	Hospital doctors	A medical practitioner
Ability to attract customers	Low	High	High
Stability of management	Low	High	High
Founders' relationships	Adjacent	Affiliative	?
Decision‐making system	Independent type	Sole system	?

First, the clinic is a solo practice with a specialist. This doctor has management rights and free decision‐making. However, because the medical care range as a specialist is limited, it is difficult to manage and does not assure a certain number of patients.

Second, more than one medical specialist can assemble in a hospital, and various testing equipment can be established. Regarding founders' relationships, a doctor undertakes medical duties, but has no management rights. If poor wages are paid for work, the practitioner will leave and this generates a social problem. However, group practice between medical specialists and medical treatment provides comprehensive, high‐quality care. The patients' burden at the clinic and hospital hardly changes, so many patients gather in a hospital. Therefore, an environment more akin to a hospital rather than a clinic means a more stable management environment.

Third, the medical mall provides a special medical service synthetically, like a hospital, because two or more medical specialists come together. Because the scale is large compared with a solo practice, patients also gather easily and the management of the clinics in a medical mall is stable. As such, the objective of this research is to look at the founders' relationships and decision‐making systems in place in a medical mall.

Methods

Research data

The investigation group of the Japanese Primary Care Union Society collected address data regarding domestic medical malls between April 2008 and March 2009. These data were obtained via an Internet search, a medical magazine and an academic journal. A total of 1840 clinics and pharmacies across Japan, constituting 398 medical malls, were found.

Using these data, the questionnaire was mailed to doctors who started a business in a medical mall, pharmacists and store managers. Informed consent was obtained from respondents. The surveillance period was approximately one month (from the end of April to the end of May 2011). Targeted medical facilities included clinics, dispensing pharmacies or nursing service offices. We categorized these into two groups—‘clinic’ and ‘other business offices’—because their medical goals, medical service fee requests and functional characteristics are different.

Surveyed items

Previous studies indicated ‘years in business,’ ‘department/area,’ ‘relationships among founders of clinics or other business offices’ (hereafter referred to as ‘founders' relationships’), ‘decision‐making system’ and ‘deployment of liaison role’ as the requirements of integrated management for medical malls (Ito et al., 2009; Ito, 2010; Japan Primary Care Association, 2012). Thus, we focused on these five variables in this study.

Years in business

It is assumed that the longer the ‘years in business,’ the more stable the relationships of the founders and the higher the satisfaction. As few businesses were operating for under 5 years, and analysis is challenging with a small sample size, we categorized clinics into ‘under 5 years,’ ‘5 to 10 years,’ and ‘over 10 years.’

Department/area

Departments were divided into ‘internal medicine,’ ‘surgery,’ ‘internal medicine and surgery’ and ‘dental clinics.’

Founders' relationships

Table 3 shows the nature of the relationships between medical practitioners that exist in Japanese medical malls: ‘Adjacent’ (no cooperation or communication exists, although multiple clinics exist in the same building, such as with a multiple‐medical tenant building), ‘Trading’ (no close cooperation exists, although job relationships exist among clinics or between clinics and other business offices in a medical mall), ‘Peer’ (physicians are gathered from the same medical office unit or same hospital to run a mall), and ‘Affiliative’ (clinics or other facilities are operated as a branch of a medical corporation group or hospital chain).

Table 3

Founders' relationships

	Adjacent	Trading	Peer	Affiliative
Cooperation and Communication	×	×	○	○
Workplace relationships	×	○	○	○
Sharing of a medical‐examination plan or a sense of values	×	×	○	○
A branch of a medical corporation or hospital chain	×	×	×	○

As mentioned earlier, these can be classified into four types according to previous research (Ito, 2010; Japan Medical Association Research Institute, 2012). While these relationships tend be seen in the clinics and medical malls in Japan, they are not necessarily seen in other countries' clinics.

Decision‐making system

Table 4 indicates the decision‐making mechanisms. Four types have been outlined: ‘Independent type’ (individual facility is managerially independent, such as a multiple‐medical tenant building without any involvement in each other's business or medical treatment), ‘Council system (elected)’ (some elected founders manage the entire medical mall as representatives, based on a council system operated by those representatives), ‘Council system (all)’ (a medical mall is managed by a council system operated by all founders), and ‘Sole system’ (an authorized single person manages the entire medical mall as a representative of a corporation and a top‐down management philosophy is used).

Table 4

Decision‐making system

Decision‐making system	Independent type	Council system (all)	Council system (elected)	Solo system
Entry to the decision‐making	One person	All the members	Somewhat	Representative of a corporation
Independency and Autonomy	Very high	High	Low	Very low
Structure	Individual facility is managerially independent, such as a multiple‐medical tenant building without any involvement in each other's business or medical treatment.	A medical mall is managed by a council system operated by all founders.	Some elected founders manage the entire medical mall as representatives based on a council system operated by those representatives.	One authorized person manages the entire medical mall. There is a top‐down method of decision‐making.

Deployment of liaison role

We confirmed whether the medical malls had a liaison role, which is necessary for smooth management of medical malls.

Satisfaction level

In Japan, practitioners are free to open and operate at any time as clinics can be freely established. If a practitioner is not satisfied with the location of a clinic or the management environment, it is possible to move elsewhere. In a medical mall, the founders must interact, so moving to a different medical mall has consequences, which disadvantage the local community and patients. Here, it is not possible to provide stable primary care. Understanding and implementing a good management environment by ascertaining the satisfaction levels of the founders is needed for the continuation of primary care in the local community. Hence, the focus in this study is on founder satisfaction. A five‐point scale measured founders' satisfaction level as follows: ‘Unsatisfied’ (1–2 points), ‘Neutral’ (3 points) and ‘Satisfied’ (4–5 points).

Analysis method

First, key statistics for the five variables were calculated to define respondents' backgrounds. Second, cross analysis and chi‐square tests were performed between each of those five variables and ‘satisfaction level’ to define the requirements of integrated management satisfying a number of medical mall founders. The results showed that ‘satisfaction level’ was statistically associated with ‘founders' relations’ and ‘decision‐making system’ among clinics. Third, we performed a cross analysis and chi‐square test on the association between ‘proportion of clinics’ and ‘satisfaction level.’ Here, we extracted some types of clinics, and among those, identified the types in which more than 50% answered ‘satisfied.’ Fourth, we elucidated the requirements of integrated management contributing to improving the satisfaction level of medical mall founders, with some discussions on those results. Fifth, we discussed future prospects regarding medical malls and integrated management, and our further research.

Results

Results of collected answers

Among the 358 facilities (19.5%) that responded, responses from 351 (19.1%) were valid. The analysis included 338 facilities, excluding those that did not provide answers to the earlier mentioned survey items. The sample consisted of mostly clinics (over 80%), followed by dispensing pharmacies, service facilities and others. There were 48 facilities other than clinics (other business offices: 14%).

Respondents' backgrounds

Table 5 outlines the respondents' attributes, based on the parameters mentioned below.

Table 5

Respondents' backgrounds

		Total	Clinic	Other business offices	p‐value a)
		n (%)	n (%)	n (%)
Years in business	Less than 5 years	28 (8.3)	22 (7.6)	6 (12.5)	0.427
	5 to 10 years	134 (39.6)	111 (38.3)	23 (47.9)
	More than 10 years	176 (52.1)	157 (54.1)	19 (39.6)
	Total	338 (100)	290 (100)	48 (100)
Department/area	Internal medicine	102 (35.4)	102 (35.4)	―	―
	Surgery	104 (36.1)	104 (36.1)	―
	Internal medicine + surgery	33 (11.5)	33 (11.5)	―
	Dental	49 (17)	49 (17)	―
	Total	288 (100)	288 (100)	―
Founders' relationships	Adjacent relationships	240 (71.1)	215 (74.1)	25 (52.1)	<0.01*
	Trading relationships	18 (5.3)	6 (2.1)	12 (25)
	Peer relationships	66 (19.5)	60 (20.7)	6 (12.5)
	Affiliative relationships	14 (4.1)	9 (3.1)	5 (10.4)
	Total	338 (100)	290 (100)	48 (100)
Decision‐making system	Independent type	247 (76.7)	214 (77.5)	33 (71.7)	0.935
	Council system (all)	63 (19.6)	51 (18.5)	12 (21.6)
	Council system (elected)	2 (0.6)	2 (0.7)	0 (0)
	Sole system	10 (3.1)	9 (3.3)	1 (2.2)
	Total	322 (100)	276 (100)	46 (100)
Liaison role	Yes	97 (29.1)	78 (27.3)	19 (40.4)	<0.10†
	No	236 (70.9)	208 (72.7)	28 (59.6)
	Total	333 (100)	286 (85.9)	47 (14.1)

Figures indicate actual number, and figures in () indicate percentage.

χ2 test.

p < 0.05

p < 0.01

p < 0.10

Most answered ‘over 10 years’ (52.1%), followed by ‘5 to 10 years (39.6%),’ and ‘under 5 years’ (8.3%). No statistically significant difference in ‘years in business’ was observed between ‘clinic’ and ‘other business offices.’

Regarding service provision, most facilities answered according to department/area as follows: surgery (36.1%), internal medicine (35.4%), internal medicine and surgery (11.5%) and dental (17%). Generally, 60% of clinics in Japan claimed to offer internal medicine; however, the results showed that only slightly more than 30% of clinics offered internal medicine (Ito, 2013).

‘Adjacent relationships’ was the most frequent answer (70%), followed by ‘Peer relationships,’ ‘Trading relationships’ and ‘Affiliative relationships.’ The chi‐square test results used to compare the ‘clinics’ and ‘other business offices’ showed a significant difference (p < 0.01). While more than 70% of clinics answered that they were in adjacent relationships, only slightly over 50% of the ‘other business offices’ answered this. While 3.1% clinics answered that affiliative relationships were their ‘Founders' relationships,’ 10.4% of ‘other business offices’ gave this answer. ‘Other business offices’ answered that they were in affiliative relationships almost three times more. There were 60 clinics in ‘Peer relationships’ and six ‘other business offices’ in ‘Peer relationships.’ Although the number of clinics in ‘Trading relationships’ was very low, the proportion of ‘other business offices’ in ‘Trading relationships’ was more than 10‐fold higher. Therefore, although approximately 70% of medical malls are in ‘Adjacent relationships,’ relationships among founders vary between ‘clinics’ and ‘other business offices.’ In the relationships among clinics, very little mutual cooperation is found.

The most frequent answer was ‘Independent type,’ followed by ‘Council system (all),’ ‘Sole system,’ and ‘Council system (elected).’ Although no statistically significant difference was observed between ‘clinics’ and ‘other business offices,’ the rate of clinics in ‘Adjacent relationships’ and clinics adopting the ‘Independent type’ are almost the same. Moreover, the rate of clinics in ‘Peer relationships’ and the combined rate of clinics adopting ‘Council system (all)’ and ‘Council system (elected)’ were almost the same. Thus, while medical malls in ‘Adjacent relationships’ used an ‘Independent type’ decision‐making system, medical malls with ‘Peer relationships’ were managed based on the ‘Council system.’

Liaison role

A total of 70.9% of facilities answered ‘No,’ while 29.1% answered ‘Yes.’ Comparative analysis results showed a difference between ‘clinics’ and ‘other business offices’ at a significant level of 10%.

Associations between the five variables and founders' satisfaction levels

Table 6 outlines the associations between the five variables and founders' satisfaction levels. A five‐point scale measured founders' satisfaction level: ‘Unsatisfied’ (1–2 points), ‘Neutral’ (3 points) and ‘Satisfied’ (4–5 points).

Table 6

Associations between the five variables and founders' satisfaction levels

	Total					Clinic					Other business office
	Total	Unsatisfied	Neutral	Satisfied	p‐value a)	Total	Unsatisfied	Neutral	Satisfied	p‐value a)	Total	Unsatisfied	Neutral	Satisfied	p‐value a)
Years in business
Less than 5 years	28 (100)	2 (7.1)	8 (28.6)	18 (64.3)	0.9940	22 (100)	1 (4.5)	6 (27.3)	15 (68.2)	0.9795	6 (100)	1(16.7)	2 (33.3)	3 (50)	0.9607
5 to 10 years	134 (100)	14 (10.4)	36 (26.9)	84 (62.7)		111 (100)	12 (10.8)	31 (27.9)	68 (61.3)		23 (100)	2(8.7)	5 (21.7)	16 (69.6)
More than 10 years	176 (100)	14 (8)	50 (28.4)	112 (63.6)		157 (100)	13 (8.3)	44 (28)	100 (67.3)		19 (100)	1(5.3)	6 (31.6)	12 (63.2)
Total	338 (100)	30 (8.9)	94 (27.8)	214 (63.3)		290 (100)	26 (8.9)	81 (28)	183 (63.1)		48 (100)	4(8.3)	13 (27.1)	31 (64.6)
Department/area
Internal medicine	102 (100)	11 (10.8)	25 (24.5)	66 (64.7)	0.5742	102 (100)	11 (10.8)	25 (24.5)	66 (64.7)	0.5742
Surgery	104 (100)	9 (8.7)	33 (31.7)	62 (59.6)		104 (100)	9 (8.7)	33 (31.7)	62 (59.6)
Internal medicine + surgery	33 (100)	4 (12.1)	6 (18.2)	23 (69.7)		33 (100)	4 (12.1)	6 (18.2)	23 (69.7)
Dental	49 (100)	2 (4.1)	15 (30.6)	32 (65.3)		49 (100)	2 (4.1)	15 (30.6)	32 (65.3)
Total	288 (100)	26 (9)	79 (27.4)	183 (63.5)		288 (100)	26 (9)	79 (27.4)	183 (63.5)
Founders' relationships
Adjacent relationships	240 (100)	23 (9.6)	75 (31.3)	142 (59.2)	<0.001**	215 (100)	23 (10.7)	67 (31.2)	125 (58.1)	<0.001**	25 (100)	0 (0)	8 (32)	17 (68)	<0.07†
Trading relationships	18 (100)	4 (3)	4 (10.6)	10 (86.4)		6 (100)	1 (16.7)	1 (16.7)	4 (66.6)		12 (100)	3 (8.3)	3 (27.1)	6 (64.6)
Peer relationships	66 (100)	2 (3)	7 (10.6)	57 (86.4)		60 (100)	2 (3.3)	7 (11.7)	51 (85)		6 (100)	0 (0)	0 (0)	6 (100)
Affiliative relationships	14 (100)	1 (7.1)	8 (57.1)	5 (35.7)		9 (100)	0 (0)	6 (66.7)	3 (33.3)		5 (100)	1 (25)	2 (25)	2 (50)
Total	338 (100)	30 (8.9)	94 (27.8)	214 (63.3)		290 (100)	26 (9)	81 (27.9)	183 (63.1)		48 (100)	4 (10)	13 (40)	31 (40)
Decision‐making system b)
Independent type	10 (100)	2 (20)	3 (30)	5 (50)	<0.001**	9 (100)	2 (22.2)	3 (33.3)	4 (44.4)	<0.001**	1 (100)	0 (0)	0 (0)	1 (100)	0.949
Council system (all)	2 (100)	0 (0)	0 (0)	2 (100)		2 (100)	0 (0)	0 (0)	2 (100)		0 (0)	0 (0)	0 (0)	0 (0)
Council system (elected)	63 (100)	5 (7.9)	5 (7.9)	53 (84.1)		51 (100)	4 (7.8)	2 (3.9)	45 (88.2)		12 (100)	1 (8.3)	3 (25)	8 (66.7)
Sole system	247 (100)	22 (8.9)	81 (32.8)	144 (58.3)		214 (100)	20 (9.3)	71 (33.2)	123 (57.5)		33 (100)	2 (6.1)	10 (30.3)	21 (63.6)
Total	322 (100)	29 (9)	89 (27.6)	204 (63.4)		276 (100)	26 (9.4)	76 (27.5)	174 (63)		46 (100)	3 (6.5)	13 (28.3)	30 (65.2)
Liaison role
Yes	97 (100)	7 (7.2)	22 (22.7)	68 (70.1)	0.262	78 (100)	5 (6.4)	17 (21.8)	56 (71.8)	0.187	19 (100)	2 (10.5)	5 (26.3)	12 (63.2)	0.916
No	236 (100)	22 (9.3)	71 (30.1)	143 (60.6)		208 (100)	20 (9.6)	63 (30.3)	125 (60.1)		28 (100)	2 (7.1)	8 (28.6)	18 (64.3)
Total	333 (100)	29 (8.7)	93 (27.9)	211 (63.4)		286 (100)	25 (8.7)	80 (28)	181 (63.3)		47 (100)	4 (8.5)	13 (27.7)	30 (63.8)

Figures indicate actual number, and figures in () indicate percentage.

χ 2 test.

As there is no system in other business offices that corresponds to council system (elected), χ 2 test was performed excluding this item.

p < 0.05

p < 0.01

p < 0.10

Association between ‘years in business’ and ‘satisfaction level

’ No significant difference was observed (p = 0.9440). However, most facilities answered ‘Satisfied,’ followed by ‘Neutral’ and ‘Unsatisfied.’

Association between ‘department/area’ and ‘satisfaction level

’ There was no statistically significant difference (p = 0.5742).

Association between ‘Founders' relationships’ and ‘satisfaction level

’ Significant differences for entire facilities and clinics, and for other business offices were found (p = 0.001; p = 0.07, respectively). Among the facilities that selected ‘satisfied,’ the most frequent answer was ‘Peer relationships,’ followed by ‘Adjacent relationships,’ ‘Trading relationships’ and ‘Affiliative relationships’; collecting multiple facilities in the same building enhanced satisfaction for about 60% of founders, although establishing a medical mall with ‘Peers’ was likely to improve founders' satisfaction further. For clinics that selected ‘Satisfied,’ the most frequent relationship was ‘Peer,’ followed by ‘Trading,’ and ‘Adjacent.’ However, the rate of clinics in ‘affiliative relationships’ was extremely low (three facilities). Therefore, establishing a medical mall among clinics in affiliative relationships may degrade GP satisfaction.

Association between ‘decision‐making system’ and ‘satisfaction level

’ Statistically significant differences were found for entire facilities and clinics (p = 0.001), while no significant difference was observed for other business offices (p = 0.949). Then, we looked at entire facilities; the most frequent answer was ‘Council　system (elected),’ followed by ‘Council system (all),’ ‘Independent type,’ and ‘sole system.’ Then, we looked at clinics; two facilities adopted the ‘Council system (elected)’ and 53 facilities adopted the ‘Council system (all).’ Adopting the ‘Council system’ for decision‐making may have enhanced the satisfaction of founders; conversely, adopting the ‘Sole system’ satisfied only half of the former group's founders.

Association between ‘deployment of liaison role’ and ‘satisfaction level

’ No statistically significant difference was observed in entire facilities, clinics or other business offices.

Integration management requires contribution to founders' satisfaction

Because the earlier results demonstrated that ‘Founders' relationships’ and ‘Decision‐making system’ were associated with ‘Satisfaction level’ in clinics, we performed cross analyses on the associations. Table 7 shows the number of respondents (medical practitioners) according to type. Out of the 12 types that exist, the most frequent type was ‘Adjacent relationships + Independent type’ (184), followed by ‘Peer relationships + Council system (all)’ (30) and ‘Peer relationships + Independent type’ (24), ‘Adjacent relationships + Independent type’ (184). There are few ‘Adjacent relationships + Council systems’ (1) and ‘Affiliative relationship + Council systems’ (1).

Table 7

Clinics' and founders' satisfaction levels regarding founder relationships and decision‐making systems

			Decision‐making system
		Total	Sole system	Council system (all)	Council system (elected)	Independent type
Founders' relationships
Adjacent relationships	Satisfied	121 (58.2)	2 (40)	16 (88.9)	1 (100)	102 (55.4)
	Subtotal	208 (100)	5 (100)	18 (100)	1 (100)	184 (100)
Trading relationships	Satisfied	5 (83.3)	―	1 (50)	―	4 (100)
	Subtotal	6 (100)	―	2 (100)	―	4 (100)
Peer relationships	Satisfied	46 (83.6)	―	28 (93.3)	0 (0)	18 (75)
	Subtotal	55(100)	―	30 (100)	1 (100)	24 (100)
Affiliative relationships	Satisfied	2 (28.6)	2 (50)	0 (0)	―	0 (0)
	Subtotal	7 (100)	4 (100)	1 (100)	―	2 (100)
Total	Satisfied	174 (63)	4 (44.4)	45 (88.2)	1 (50)	124 (57.9)
	Subtotal	276 (100)	9 (100)	51 (100)	2 (100)	214 (100)

Figures indicate actual number, and figures in () indicate percentage.

Gray indicates where the majority answered ‘satisfied.’

Table 7 shows the ratio of practitioner responses for ‘Satisfied’ in terms of the ‘Founders' Satisfaction Level.’ These types are considered the main integrated management systems adopted in medical malls. Cross analysis was performed to define the associations between those 12 types and the rate at which most clinics were selected. In terms of satisfaction among the six types, ‘Peer relationships + Council system (elected)’ (100%) had the highest ‘Satisfied’ rating, followed by ‘Peer relationships + Council system (all)’ (93.3%), ‘Peer relationships + Council system (all)’ (88.9%), ‘Peer relationships + Independent’ (75%), ‘Adjacent relationships + Independent type’ (55.4%), and ‘Affiliative relationships + Solo system’ (50%). ‘Peer relationships + Council system (elected)’ and ‘Affiliative relationships + Solo system’ could not be appropriately compared due to their low numbers and were thus excluded.

Discussion

In this study, over half of all facilities in medical malls had been operating for over 10 years, and almost three‐quarters comprised surgery and internal medicine departments. Recently, Japan experienced a significant population decline mainly in rural areas and suburbs, with migration to the city center, leading to a shortage of doctors in suburban and metropolitan areas. This is exacerbated by the fiscal and budget constraints experienced by the government and/or local self‐governing bodies, which means that government hospitals cannot be erected and doctors cannot be transferred to these areas. For this reason, instead of government hospitals, the operation of a medical mall by the private sector is regarded as a possible solution. The medical mall can enable provision of various specialties, such as internal medicine and surgery, hospital facilities and advanced medical service. The medical needs related to these specialties cannot be satisfied in one clinic. Moreover, dentistry services comprise approximately 20% of services provided in a medical mall. To date, approximately 70 000 dentistry clinics exist in Japan; these institutions have reached saturation. Because competition in the provision of such services is quite intense, compared with that in general practice, strict management is required. For this reason, a medical mall has many incentives.

Regarding founders' relationships, nearly three‐quarters were adjacent relationships and, regarding decision‐making, nearly three‐quarters had an independent system. Only 30% of all facilities used a liaison role; therefore, in 70% of the medical malls, more than one medical facility exists. This is similar to a shopping mall in which people take up tenancy. In such a situation, it is possible for some form of cooperation with the remaining 30%, as a group practice can be operated; however, more in‐depth investigation is required. In Japan, it is very rare for each clinic to have expensive medical devices and for the use of devices to be shared among clinics; hence, group practice in Japan differs greatly from Western group practice, such as at the Mayo Clinic in the USA (Japan Primary Care Association, 2012).

However, the concept of medical malls has attracted a number of specialized clinics in one space. From the patient's perspective, it is advantageous to have an advanced one‐stop service. Access of this magnitude cannot be facilitated in a private practice clinic. Therefore, the establishment of clinics in a medical mall can draw relatively more patients. As a result, stabilization of management adjacency is necessary. An analysis of the requirements of integrated management that increase founders' satisfaction levels demonstrated that ‘Satisfaction level’ was strongly associated with ‘Founders' relations’ and ‘Decision‐making system.’ In particular, being in ‘Adjacent relationships’ appeared to satisfy about 60% of founders, although establishing a medical mall with ‘Peers’ is likely to improve founders' satisfaction. Medical malls, in general, are likely to exist around stations in densely inhabited districts or as part of commercial areas with good access. Accumulation effects, exerted through collecting multiple clinics or others in the same building, which has a greater effect than an internal‐cooperation effect, may have been an incentive to establish adjacent relationships. In addition, the transaction cost issue existed among medical facilities, as well as among general companies (McPake et al., 2004). In Japan, the current healthcare system hinders internal cooperation in medical malls (Ito, 2010, 2014). For example, it places restrictions on sharing patient information, medical devices, equipment and the reception/information window among clinics. If internal cooperation in medical malls is forcibly promoted under such circumstances, transaction costs will increase, resulting in a greater burden on each practitioner. For this reason, facilities in medical malls in Japan may intentionally select adjacent relationships in which no communication with other facilities is necessary. Therefore, the medical practitioner does not necessarily regard cooperation between clinics in a medical mall as particularly important. However, peer review mechanisms for doctors are necessary to enable improvement to the quality of primary care, and this cost could be included in patients' medical fees.

Analysis of the associations between the proportion of clinics and satisfaction level from the perspective of ‘Founders' relationships’ and ‘Decision‐making system’ presented the following four types as integrated management requirements: ‘Peer relationships + Council system (all),’ ‘Adjacent relationships + Council system (all),’ ‘Peer relationships + Independent type,’ and ‘Adjacent relationships + Independent type.’ Therefore, the integrated management type satisfying many founders may be either (i) a system in which a medical mall is established by peers from the same medical office unit or same hospital and in which all founders can participate in decision‐making, or (ii) a system in which a medical mall is operated by managerially independent practitioners, without interference or communicating with each other.

Conclusion

There were three important findings. First, the integrated management system is insufficient because most Japanese medical malls are in adjacent relationships and very few liaison roles are used; however, most founders are largely satisfied with being in a medical mall. In other words, it is important that more than one clinic is established in the same building for business to commence. Second, opening a medical mall with peers and establishing a decision‐making system based on the council system is guaranteed to improve many practitioners' satisfaction levels. Although previous studies have suggested that the liaison role was important, it does not directly contribute to improving founders' satisfaction levels according to these results. Moreover, most clinic founders with adjacent relationships were satisfied; thus, concentrating multiple founders in a medical mall can be a strong incentive. Third, the desirable requirement of founders for integrated management in medical malls is to introduce one of the following types: ‘Peer relationships + Council system (all),’ ‘Adjacent relationships + Council system (all),’ ‘Peer relationships + Independent type,’ and ‘Adjacent relationships + Independent type.’ However, those requirements were derived based on the premise of improving founders' satisfaction level; thus, this does not necessarily ensure improvements in clinic revenue, practitioner capability or patient benefit. In particular, ensuring practitioner capability is required for treating many patients at primary care. Therefore, relationships in which practitioners can recognize each other by creating opportunities to interact with others, rather than just maintaining adjacent relationships, are desirable (Gunji, 2001; Ito, 2015).

This investigation outlined the requirements for effective integrated management of the medical mall, as seen from the establisher's perspective regarding satisfaction levels. However, the study is limited in that it has not evaluated these aspects in terms of medical practitioners' profits and patient satisfaction. In addition, as the number of medical malls continues to increase nationwide, the development of a new database is also necessary. Further investigative research and validation is required in the future to ascertain the requirements of integrated management that contribute to improving practitioner capabilities.

Conflict of Interest

The author declares no conflict of interest.