Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

Alliance of medical malls: Conditions for the establishment of
network practiceAtsushi Ito
Kyoto Prefectural University
Japan Academic Society of Hospitality Management
E-mail: iatsushi@kpu.ac.jp
Fumihiko Nakamura
Kitami Institute of Technology
E-mail: nfumihiko@mail.kitami-it.ac.jp
Abstract
Network practice is a method of efficiently sharing patient information and making patientreferrals, while utilizing information network technology among doctors. Although realizing
alliances in a medical mall is difficult, it may be possible if network practice is carried out withthe right partners. One of the reasons why alliances are difficult to establish in medical malls isthat they may not meet the conditions that make the network practice possible in the first place.
To investigate these conditions, we focused on the diagnostic sensitivity of doctors (hereafter,“sensitivity”) and conducted a model analysis to determine the optimal partners to form analliance. First, if the sensitivity of doctors is ensured at a high level, and there is acomplementary relationship, network practice may be established. Second, network practice
incurs transaction costs, which are influenced by sensitivity. Therefore, the higher the sensitivity,
the lower the transaction cost and the higher the incentive for network practice. Third, the lower
this sensitivity, the greater the mismatch between the patient and doctor’s areas of diagnosis,
and thus the greater the risk that patients will be interrupted in the course of their care.
Therefore, to realize alliances in medical malls, it is necessary to devise ways to reducetransaction costs and match the diagnosis areas of patients and doctors, while making full useof information network technology and fulfilling the conditions for network practice.
Keywords
Medical malls, Alliance; Conditions for the establishment of the network practice; Diagnostic
sensitivity; Transaction costs(1) Introduction

safety, and reliability, thus making it difficult for1. Identification of the Problem

competition to work, there is fierce competition

Although health care is known to be aamong health care organizations. This is due toregulated industry that requires publicity,

dramatic changes in the external environment,
1

Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

including financial problems, health careprimary care1. As long as a single doctor runs areform, and soaring awareness of patients’clinic, it is very difficult to ensure both therights (McSweeny-Feldand, Discenza, andquality of medical care and the soundness ofDefeis, 2010; Bernardo, Valls, and Casadesus,

management. Therefore, medical malls have2012).

recently been adopted as a strategic allianceIn

particular,

Japan’s

deflationary

economyandlong-term

rapidly

aging

that transcends the boundaries of medical

population have led to an expansion of theinstitutions. Their number has increased 6.7

health care cost-to-gross-domestic-product ratio,

times from about 375 in 2005 to 2,501 as of 2019

putting pressure on health insurance funding(Ito, 2020a).

(Hashimoto et al., 2011). Therefore, to control

To begin with, an alliance is defined as“voluntaryarrangements between firms
involving exchange, sharing, or codevelopment

the increasing rate of the country’s overall
health care costs and to make effective use offeesof products, technologies, or services” (Gulati, p.
293, 1998).

decreasingly, reducing the number of hospital

Although there is a long tradition and richbeds, increasing patients’ co-payments, andaccumulation of management research on

raising social insurance premiums and taxes onalliances, there are numerous definitions and no

citizens. At the same time, hospitals and clinics

common concept due to the diverse perspectives

are urged to rationalize and improve theand cross-cutting subject areas (Kinderis andefficiency of their management by promoting

Jucevičius, 2015). However, at the very least,

clear

there is no dispute that alliances represent ahealthcaregovernment

resources,isdivisiontherevisingofJapanese

medicalfunctionsandmutualcooperation, as well as information technology,

form

of

cooperation

among

multipleto provide low-cost, high-quality medical careorganizations to achieve a certain goal and that

(Ministry of Health, Labour and Welfare, 2015,

they are a strategic business form found in2016).

many markets regardless of industry. Its main

Owing to these circumstances, the number

effects are expected to be the following: anof hospitals peaked at 10,096 facilities in 1990

expansion of business scale, pursuit of profits,

and has significantly decreased to 8,442

sharing of management resources, reduction offacilities in 2016, while the number of clinics has

costs and risks, acquisition of learning effects

reached 101,529 facilities as of 2016, making

including knowledge and know-how, and eventhesurrounding

reduction of excessive competition. However,clinics even more difficult (World Healththere is no knowledge on medical malls

Organization, 2018). However, it has been

(Kinderis and Jucevičius, 2015).

competitiveenvironment

pointed out that clinics in Japan are usually run

Medical malls, as a form of establishment

by a single specialist who has worked in a

in which multiple clinics and pharmacies are

hospital, and thus have a small management

assembled in the same space, are mainly

scale and weak medical management andclustered

1 Primary care includes doctors, medical

patient comes into contact first. In Japan, it
generally refers to outpatient care in clinics.

institutions, and medical services with which a2

inconvenient

locationsforJournal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

transportation and living, and they have the

However, it should also be noted that

advantage of efficient access to appropriate

alliances are not a universal management

specialists and departments, while selecting

strategy or solution (Vattikoti and Razak, 2018).

them according to the convenience of patients

For example, it has been reported that half of(Epstein, 2016; Ito, 2020b). Additionally, there

the alliances fail and conversely, performanceare several advantages for even doctors. First, it

declines (Varadarajan and Cunningham, 1995).

allows for networked care. Network practice is a

Nevertheless, few solutions to problems related

new method of efficient patient information

to alliances have been identified (Albers,

sharing and referral coordination among

Wohlgezogen, and Zajac, 2013). In particular,

doctors using information network technology.

medical malls have long been pointed out as a

In medical malls, doctors are spatially close, so

future management issue because of thethe introduction of networked care can bedifficulty of cooperation among clinics (Ito, 2016).

advantageous. It has long been common inSo, how can alliances be realized in medical

primary care in Western countries for multiple

malls? This is the research question of this

doctors to collaborate to provide group practice,

paper.

but the difference is that this is not necessarily

Then, can the network model of online

based on the use of information network

shopping malls not be used as a reference? We

technology (Josi and Pietro, 2019). However,may be able to refer to online shopping malls,

since networking is an essential element inwhich have already built models of matchingrealizing alliances, this paper discusses thestores and consumers and providing convenientpremise of adopting a networked practiceservices. In addition, several studies of online(Bernardo et al., 2012).

shopping malls have reported the results ofAnother advantage is that high-cost
medicalequipment

such

as

research that modeled the relationship between

computedstores and consumers (Ahna, Ryu, and Han,

tomography and magnetic resonant imaging

2004; Macmillan, 2009). Indeed, the two arecan be shared in a medical mall to guarantee

similar in that they both provide convenient andutilization rate and reduce the risk ofcomplex services through the concentration of

overinvestment. Furthermore, the sharing ofmultiple stores. Moreover, online shopping isconsultation tickets issued to patients canhighly appreciated because consumers value

reduce the waste of consultation procedures. As

the quality of service that enables contactlessa result, doctors can be freed from theseshopping experience. This implication is also

administrative tasks and concentrate on

applicable to network practices. However, thismedical care.

approach should be applied with caution

As previously described, medical malls that

because the assumptions of transactions arehave introduced networked medical care havefundamentally different in the medical andan incentive to form alliances among doctors

general commercial sectors. For example, pricebecause they can strengthen managementcompetition is not allowed in the medical field,

functionsofand advertising is strictly regulated; therefore,

management resources and provision of high-one cannot advertise freely. Moreover, one

quality medical care among clinics.

cannot open a business without a doctor’s

throughefficientsharing3

Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

license, and the barriers to entry are high.

quality, is not allowed. In other words, theFurthermore, word of mouth and rankings do

quality of the partner doctor is considered to be

not always reflect the quality of medical care.

a major incentive for the establishment of a

Therefore, it is necessary to propose an original

network practice. Therefore, an alliance ofmodel that takes these circumstances into

medical malls may be feasible if the network

account.

practice can be carried out with appropriate
partners. However, there are few studies on this

2. Study Objectives and Methods

topic because it is a sensitive issue that deals

This study examines the managementwith the qualifications of doctors and has been

issues for the realization of alliances in medical

avoided until now.

malls. It has been pointed out that the

The purpose of this study was thus tobackground to the difficulty of alliances inclarify the conditions for the establishment of

medical malls is related to the large transaction

networked medical care in medical malls,

costs between clinics (Ito, 2016). The following

focusing on diagnostic sensitivity (hereafter,

two issues are considered to be the main causes“sensitivity”) as a quality of doctors.

of this increased transaction cost.

First, in Section 2, we propose a method to

The first is that the majority of clinics stillevaluate the quality of doctors using sensitivity,

rely on paper medical records and fax machines,

and we conduct a model analysis of theand have not yet adopted information network

difference in sensitivity between solo andtechnology,

inefficient

network practice. In addition, we will classify

collaboration among clinics. However, thisalliances among doctors into three cases andproblem should be solved by introducing the

elucidate the cases in which network practiceinformation technology mentioned earlier (Hajli

can be established. Furthermore, we will

et al., 2014). Second, the choice of partners isanalyze the problem of transaction costs, whichvery important for the success of an alliance, but

is considered to be the main disincentive forthere has not been sufficient discussion on what

network practice, in relation to the sensitivity ofkind of relationship is appropriate to establish

doctors. In Section 3, we discuss the conditions(Hitt et al., 2000). In particular, to realize

for the establishment of network medical carealliances in medical malls, incentives tobased on the results of these studies, as well as

establish network practice are necessary, but it

the limitations and future challenges of thisis suspected that these may not be functioning

research. Finally, in Section 4, we conclude witheffectively in practice. Medical care is inherently

recommendations on the conditions for thevery different from other service industries inestablishment of networked medical care andthat it affects the prognosis of the patient’s life,

issues for the realization of alliances.

resulting

in

very

and it is a profession that requires safety andreliability with the highest priority. Therefore,(2) Model Analysis of a Network Practicedoctors are strongly required to possess

1. Solo Practice Model

autonomy and ethics as professionals. For thisThe sensitivity discussed here refers to thereason, network practice, which pursues only

probability that a doctor can correctly diagnose

commercial purposes and leads to a decline ina patient’s disease. Although it is difficult to4

Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

measure the sensitivity of individual doctors
strictly,itispossibletomeasureof all the doctors are determined asitfollows:

experimentally by identifying diseases and∑=using image findings. For example, a reading
test can be conducted by mixing symptomatic=and Diagnostic images to determine thesensitivity in this area (Ito, 2017). Alternatively,
positive rate can be considered.

∑=introduced to discuss the sensitivity of doctors:

+

+ ⋯+

=

+
+

+⋯+
+ ⋯+

As suggested by these equations, the sensitivity)- : Number of the diagnosis area ( = 1, ⋯ , )

and

+ ⋯+
+ ⋯+

follows:

In this paper, the following symbols will be(In general,

=

+
+

When
= , the network practice sensitivity
for the entire doctor population is defined asa method to determine sensitivity from the false- : Doctor’s number ( = 1, ⋯ ,∑=used in this study depends on the number of

can be different.)

patients per diagnosis area. Hereafter,= .

-Sensitivity of doctor : ( = 1, ⋯ , )-Sensitivity of diagnosis area of doctor :numerical values of Pij and Nij, we can consider-Total number of patients:

diagnosis area by the doctor and the diagnosis( = 1, ⋯ ,As previously described, by controlling thevarious degrees of matching between the= 1, ⋯ , ),-Number of patients who visit doctor :=2. A Network Practice Model from the-Number of patients in diagnosis area
see doctor :=,area required by the patient.

who

Perspective of Three Alliances
2.1 Cases of Complementary Relationships
between Doctors= 1, ⋯ ,First, we consider the case where eachdoctor is a specialist and excels in diagnosing-Number of patients in diagnostic area ：=,one of the medical areas.
In particular, doctor= 1, ⋯ , ,is a case with great

sensitivity in clinical area i:
( ≠ )
≥

=

Consider the case where the above equation

In this section, we assume that Ni = 1 or higher.

holds.

This is because a doctor with Ni = 0 (ForThis means that doctors complement eachexample, such case happens when the number

other, and do not compete in their area ofof doctors is larger than patients, or when apractice.

particular doctor has a monopoly on patients) is

Case 1: The sensitivity of each doctor’s specialty

assumed to have low sensitivity, and network

is equalpractice with such a doctor is unrealistic to

The first simple caseimprove sensitivity. The sensitivity of doctor,=, and the mean sensitivity of all doctors,

is equal. In this case,5=⋯=

Journal of Japanese Management Vol.5, No.2, May 2021

This

=

∑

means

that

=

the

∑

ISSN 2189-9592

holds. In other words, this is a situation where=

the order of magnitude of the sensitivity of the

networkpracticedoctor’s areas of expertise exactly matches thesensitivity is equal to the sensitivity of eachorder of the number of patients in each of those

doctor’s specialty area. In addition,
∑
∑
=
≤
=

areas.
This shows that doctors are complementary=

to each other and have an incentive to adopt

From the above equation, we can see that the

network practice whenever there is a patient in

network practice sensitivity is larger for any
doctor. Also, in this case,≤ .

each domain corresponding to the magnitude ofthe doctor’s sensitivity. The numerical example

From this, we can say that there is an

for this case is Case (b) in Table 1. However,incentive to adopt network practice when thesince this is a sufficient condition, there may be

doctors are complementary, and each doctor has

situations where the network clinic sensitivity

equal sensitivity in his or her area of expertise.

is greater even when there is no such

The numerical example in this case corresponds

correspondence. For example, consider Case (b)to Case (a) in Tables 1 and 2.

in Table 2.
In general, it can also be calculated as

Case 2: There is variation in sensitivity.

follows:

The difference between the network−

practice sensitivity and the average sensitivityof all doctors can be calculated as follows.
First, from
−

≤

≥

∑

=

,

=

∑
−

∑

−

∑

1

=

The above equation can be derived, but in orderThat is,

∑

≥

1

≥

∑

−
∑

−

1

∑
−
≥0

network practice. Even if this becomes a

1

≥⋯≥

∑

we can say that there is an incentive to adopt a
negative number for some , , the sum for all,

This is known as Chebyshev’s sum inequality:≥∑−sides, the following equation is obtained:
1−

Therefore, for each ,, and dividing by n on both

=∑

∑

1
=

for it to be positive≥=

should be positive. Further in text, weconsider a situation where this inequality holds.

,

First, for≥⋯≥

When such a relationship exists, the inequality
6= , the inequality is as follows.

≥Journal of Japanese Management Vol.5, No.2, May 2021

Table 1 Comparison of mean sensitivity

ISSN 2189-9592

and network practice sensitivity

for Doctor 1 andDoctor 2
Case(P 11 , P 12 )(P 21 , P 22 )(N 11 , N 12 )(N 21 , N 22 )

N^1

N^2

(a)

(0.9, 0.6)

(0.5, 0.9)(500, 500)

(500, 500)

1000

1000

P1
0.75

P2
0.70

P mean
0.73

Pg
0.90

(b)

(0.9, 0.4)

(0.5, 0.7)(800, 200)

(400, 600)

1200

800

0.80

0.62

0.71

0.82

(c)

(0.9, 0.4)

(0.5, 0.7)(200, 600)

(1000, 200)

1200

800

0.53

0.53

0.53

0.82

(d)

(0.9, 0.3)

(0.2, 0.5)(300, 100)

(100, 1500)

400

1600

0.75

0.48

0.62

0.58

(e)

(0.9, 0.7)

(0.9, 0.6)(600, 400)

(600, 400)

1200

800

0.82

0.78

0.80

0.78

(f)

(0.9, 0.7)

(0.9, 0.6)(900, 500)

(100, 500)

1000

1000

0.83

0.65

0.74

0.75

(g)

(0.9, 0.7)

(0.3, 0.4)(800, 800)

(200, 200)

1000

1000

0.80

0.35

0.58

0.65

(h)

(0.9, 0.7)

(0.3, 0.4)

(200, 100)

(200, 1500)

400

1600

0.83

0.39

0.61

0.50

Source: Created by the author.

Then, the left-hand side is the percentage ofThis is a situation that should be met in many

patients seen by doctor

cases when network practice is used, but inafter the network

practice, and the right-hand side is thesome very special cases,

percentage of patients in practice area(d) in Tables 1 and 2).

seen

by doctor before the network practice. In otherwords, the proportion of patients seen by doctor
who specializes in area≥(see Case

2.2 Cases of Competing Doctors

must increase with

Second, we will consider the case where thethe implementation of network practice. This issensitivities of the doctors are in a competitivea requirement that must be met whenrelationship. In other words, the sensitivity of a

introducing network medical care.

certain Doctor 1 and Doctor 2 isThen for ≠ , the inequality is

this case,≥⋅≥ 1 , and/. In

must besmall enough to satisfy the inequality*). This… ∗)and this equation is rewritten as *),/≤means that the percentage of patients inDiagnosis Area 1 that Doctor 2 sees is small.

where the left-hand side represents theThis case is unlikely to occur because Doctor 2

percentage of patients that doctor

sees after

specializes in Diagnosis Area 1. In other words,

the network treatment, the first part of thethere is no incentive to provide network care inright-hand side represents the ratio of thecases where there is a competitive relationshipsensitivity of doctor

to diagnosis(see Tables 1 and 2 Cases (e) and (f)). However,, and the back part represents thesince the sensitivity of the two doctors is thearea

and doctor

percentage of patients in clinical area
doctorfor

same, and the quality of their medical care is

before the network treatment. Since

guaranteed, there may be an incentive to form

, we know that network

an alliance if the clinic is closed for some reason

practice should result in the proportion ofor if the number of patients increases and other

patients seen by a specialist being greater thandoctors are needed to support the clinic. In otherthe proportion of patients seen by a non-words, this can be interpreted as a conditional

specialist multiplied by the sensitivity ratio.

establishment of a network practice when/

≤ 1 if≥7

Journal of Japanese Management Vol.5, No.2, May 2021

Table 2 Comparison of mean sensitivity

ISSN 2189-9592

and network practice sensitivity

for Doctor 1, Doctor 2,

and Doctor 3
Case
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)

(P 11 , P 12 , P 13 )(P 21 , P 22 , P 23 )(P 31 , P 32 , P 33 )(N 11 , N 12 , N 13 )(N 21 , N 22 , N 23 )(N 31 , N 32 , N 33 )(0.9, 0.6, 0.3)

(0.5, 0.9, 0.4)

(0.3, 0.5, 0.9)(500, 500, 500)

(500, 500, 500)

(500, 500, 500)

(0.9, 0.6, 0.3)

(0.5, 0.8, 0.4)

(0.3, 0.5, 0.7)(800, 300, 200)

(500, 700, 400)

(300, 400, 900)

(0.9, 0.6, 0.3)

(0.5, 0.8, 0.4)

(0.3, 0.5, 0.7)(300, 400, 800)

(600, 300, 600)

(800, 400, 300)

(0.9, 0.7, 0.6)

(0.6, 0.7, 0.6)

(0.4, 0.4, 0.5)

(100, 400, 1000)(100, 400, 1000)(100, 300, 1200)(0.9, 0.6, 0.3)

(0.8, 0.5, 0.4)

(0.7, 0.5, 0.2)(800, 500, 300)

(800, 500, 300)

(800, 300, 200)

(0.9, 0.6, 0.3)

(0.8, 0.5, 0.4)

(0.3, 0.5, 0.9)(800, 500, 300)

(500, 800, 300)

(200, 300, 800)

(0.9, 0.8, 0.7)

(0.4, 0.5, 0.3)

(0.1, 0.2, 0.3)(1000, 900, 800)

(400, 500, 300)

(100, 200, 300)

(0.9, 0.8, 0.7)

(0.4, 0.5, 0.3)

(0.1, 0.2, 0.3)(300, 200, 100)

(200, 500, 400)

(200, 800, 1800)

N^1

N^2

N^3

P1

P2

P3

P meanPg

1500 1500

1500 0.60

0.60

0.57

0.59

0.90

1600 1400

1500 0.74

0.61

0.58

0.64

0.80

1700 1100

1700 0.50

0.52

0.43

0.48

0.80

300 1100

3200 0.65

0.63

0.48

0.58

0.57

2400 1300

800 0.69

0.63

0.58

0.63

0.66

1500 1600

1400 0.69

0.58

0.72

0.66

0.76

1500 1600

1400 0.81

0.42

0.23

0.49

0.57

700 1500

2300 0.83

0.41

0.26

0.50

0.46

=

,

Source: Created by the author.

doctors are competing with each other in theirminareas of practice.

=

, max

and so on. In other words, Doctor 2 has Area 2
as the highest sensitivity, but it is lower than the

2.3 Case of a Superior–Inferior Relationshipsensitivity of any other doctor's specialty.

between Doctors

In this case,

Third, consider a case in which one doctor=

has high sensitivity and the other doctor has
extremely low sensitivity, i.e., a “superior–inferior” relationship. In other words, if thesensitivity of Doctor 1 and Doctor 2 is assumed

andto be satisfied.

=

≥

∑

∑

≥

∑
≤

∑

always holds.

==

This implies that there is an incentive formin

Doctor 2 to have a network practice. This has≥ max

implications for the possibility of supporting

This is the case where the sensitivity of all

low-sensitivity doctors as a whole (see Tables 1

regions of Doctor 2 is lower than the leastand 2 Case (g), (h)). This finding is also

sensitive region of Doctor 1. In this case, as in
the case of (1),≥, and there is anconsistent with the view that there is anendorsement

incentive to adopt network practice. However,considering the very rare case,≥mayeffectwhen

lowqualityorganizations join alliances (Stuart, 2000).

also be true (see Table 1 case(e)(h)). In addition,
8

Journal of Japanese Management Vol.5, No.2, May 2021

2.4 Sensitivity Analysis

ISSN 2189-9592

transcribing medical records and test data, andIn this section, we attempted a sensitivity

coordinating retest requests and hospital

analysis for the three cases mentioned above,

admissions and discharges. The magnitude ofwith several numerical examples thrown in.

these costs is thought to depend on the quality

Table 1 shows the results for= 2, and Table 2of the doctor. For example, if a doctor is highly

shows the results for= 3. However, we fixedsensitive, he or she will be able to provide

In both cases, Cases (a), (b), (c), and (d) show

collaborate seamlessly with other doctors.

complementary relationships, Cases (e) and (f)Conversely, if the doctor’s sensitivity is low, theshow competitive relationships, and Cases (g)medical treatment will be inappropriate, andandwhen collaborating, many tasks will need to be= 2,000 for(h)= 2 andshow= 4,500 for= 3.

appropriate

dominance–subordination

relationships.

medicalcareefficiently

andreconfirmed, and questionable referrals will

In Case (a), the sensitivity of the specialty

occur, which is inefficient and may increase

was equal, as well as the number of patients; intransaction

Case (b), there was a small difference in the

introduction of diagnostic support systems andsensitivity of the specialty, but the number ofelectronic health records (EHR) has recently

patients was correspondingly large; and in Case

been recommended to reduce such transaction(c), the sensitivity of network practice was highcosts, but it has not necessarily spread to thewhen many patients visited doctors fromnational level (Tanaka, 2007). However, as long

different diagnosis areas. Conversely, in Caseas the existence of transaction costs is left(d), the network practice sensitivity was small

unaddressed, it is difficult to develop networked

when there were few patients who should visit

medical care, so it is necessary to understanda doctor with high sensitivity and manytransaction costs to improve the problem.

patients who should be seen by a doctor with

Here, we define it as follows:- 1 − : cost incurred by doctor

low sensitivity. In addition, (e), which iscompetitive, was reversed. The same was true

costs.

For

this

reason,theto see one

patient in area jfor (f), which was competitive but had a higher-: a uniform burden rate for providing

network practice sensitivity. Even in the

network medical services.

dominant–subordinate relationship, there wereIn other words, the higher the sensitivity, thecases where (g) network sensitivity was high,lower the cost. In this case, the total cost before

and cases where (h) network sensitivity was low.

network clinic is the following equation:=

3. A Network Practice Model That Reflects
Transaction Costs
Whenproviding

networked

medical1−

The total cost of a network practice can beservices, a variety of labor and coordination

calculated as follows:burdens are incurred. For example, there aremany transaction costs, such as obtaining
patient consent, preparing referral letters,
Furthermore, if

sending and receiving clinical information,
9

=
⋅

(1 −
≤

)

, the total

Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

Table 3 Total cost comparison before and after the

Table 4 Comparison of interruptions in outpatient

network practice (corresponding to the cases incare (corresponding to the cases in Tables 1 and 2

Tables 1 and 2 (left) n=2, (right) n=3)

(left) n=2, (right) n=3)

Case Before After

1/k

Case Before After

1/k

Case

L1

L2

Lg

Case

L1

L2

L3

Lg

(a)

550

200 0.36

(a)

1850

450 0.24

(a)

0.25

0.30

0.10

(a)

0.40

0.40

0.43

0.10

(b)

580

360 0.62

(b)

1650

890 0.54

(b)

0.20

0.38

0.18

(b)

0.26

0.39

0.43

0.20

(c)

940

360 0.38

(c)

2320

900 0.39

(c)

0.48

0.47

0.18

(c)

0.50

0.48

0.57

0.20

(d)

930

840 0.90(d)1930 1960 1.02

(d)

0.25

0.52

0.42

(d)

0.35

0.37

0.53

0.43

(e)

400

440 1.10(e)1630 1530 0.94

(e)

0.18

0.22

0.22

(e)

0.31

0.37

0.42

0.34

(f)

450

500 1.11(f)1540 1090 0.71

(f)

0.17

0.35

0.25

(f)

0.31

0.43

0.28

0.24

1680 1930 1.15

(g)

0.20

0.65

0.35

(g)

0.19

0.58

0.77

0.43

2830 2430 0.86

(h)

0.17

0.61

0.50

(h)

0.17

0.59

0.74

0.54

(g)
(h)

580

700 1.21(g)1090 1000 0.92(h)Source: Created by the author.

Source: Created by the author.

cost of adopting network practice will be small

Health Insurance Societies (2000), it wasand there is an incentive. Moreover, if
1/ =/reported that 32.2% of patients visited morethan one medical institution at the same time

we can estimate how much we can bear when

for the same injury or illness, so this may be

adopting network practice. Table 3 summarizes
the values of,, and 1/ for thehappening because of a mismatch between=0.36) means that there is an incentive even ifpatients interrupting the course of their care ispatients’ and doctors’ practice areas (National

cases in Tables 1 and 2. For example, Case (a)Federation of Health Insurance Societies, 2017).

with the smallest 1/

in the left table ( 1/Therefore, the risk of these mismatched

the transaction cost corresponding to 100% -Interruption level:

36% = 64% is incurred as a result of network, ( 0 ≤ ≤ 1)
As shown above, it can be calculated by simply=1−

treatment. On the other hand, (g), has thehighest 1/ , that is, 1.21. However, there is no
incentive

becausethe

network

subtracting the sensitivity of the target doctor

practicefrom the maximum sensitivity value. Thus, we

generates transaction costs equivalent to 121%,

can use the following numerical examples forwhich, conversely, is an increased burden

each parametercompared to the solo practice. Hence, (a) can be= 0.8,

interpreted as more desirable than (g).

== 0.6,=== 0.6,

= 500

= 0.8

then the degree of interruption of outpatient
4. The Problem of Interruption of a Visit to an

care for each doctor in the case of solo care is

Outpatient Clinic=1−

4.1 Outpatient Clinic Interruption Model=1−= 1 − 0.7 = 0.3= 1 − 0.7 = 0.3

Furthermore, to increase the effectiveness

Therefore, we can say that both Doctor 1of network practice, it is important to match theand Doctor 2 cause a mismatch of 30% of allareas of practice of patients and doctors as muchpatients diagnosed. On the other hand,as possible. In a study by National Federation ofduring network practice is10

Journal of Japanese Management Vol.5, No.2, May 2021

=1−

= 1 − 0.8 = 0.2

ISSN 2189-9592

to the doctor’s area of practice is interrupted

and mismatch occurs in 20% of patients,(reduced) with each visit. For convenience ofindicating that the possibility of interruption ofanalysis, we did not include the number of new

hospital visits is reduced by one-third comparedpatients. With the above parameters, weto solo care.

estimated how much the number of patients

Table 4 summarizes the values of andfor each of the cases in Tables 1 and 2.

would decrease each time a patient visited thedoctor in question. The results are shown in
Figure 1.

4.2 Simulation of the number of patients by the

As a result, at= 1 , the number of

number of visits using the interruption level ofpatients was steady regardless of the number of

outpatient carevisits, because the patients and doctors were

Next, we attempted to simulate theperfectly matched in their fields of practice.

number of patients by the number of visits

However, at= 0.9 , the number of patientsusing the “Outpatient Care Disruption Model”

was halved at the seventh visit, at

to clarify the relationship between doctor

the fourth visit, and at

sensitivity and patient interruptions. In thisthird visit. Therefore, it can be interpreted thatstudy, we tentatively set the upper and lower

the larger these mismatches are, the greater thelimits of the doctor’s sensitivity level to fiverisk that patients will interrupt their visits.

= 0.8 at

= 0.7 and 0.6 at thelevels in increments of 0.1, from the maximum
value of 1 to 0.6. We assumed that the average

5 Possibility of matching clinical areas in

number of outpatients per month in a typicalpatients and doctors by introducing automaticclinic is 1,000, and that the number of patientssorting function

who require regular visits and are mismatched

Finally, what about the case where patients

Number of outpatients1000

L＝0(P=1)

900
800
700
600
500
400

L＝0.1(P=0.9)

300
200
100
0
1

2

3

4

5

6

Source: Created by the author.

Figure 1 Estimated number of outpatients by expected loss
11

7

8

9

10

L=0.2(P=0.8)
L＝0.3(P=0.7)
L＝0.4(P=0.6)

Number of consultations

Journal of Japanese Management Vol.5, No.2, May 2021

Before introduction: Indiscriminate situation
Nx

ISSN 2189-9592

After introduction: Automatic sorting function model
Nx
Ny

Ny

ASF

No
Yes

No

No
Yes

Yes

Paa

Pab

Pba

Doctor A

Pbb

Paa

Doctor B

Pba

Pab

Pbb
Doctor B

Doctor A

Note：Nx = Ny = (Na + Nb)，Na：Nb = 1：1
Source: Created by the author.

Figure 2 Automatic sorting function model

canselectdepartments

appropriate
beforespecialists

visiting

a

and

:

medical= 1: 1and assume that the patients are evenly

institution? It is empirically known that, in

distributed in the Treatment Areas A and B.

general, the purpose and function of specialty

On the other hand, the sensitivities of

hospitals are more clearly defined than those ofDoctors A and B are

general hospitals, which makes it easier for-Sensitivity of Doctor A’s area of Practice A:

patients to identify specialists and departments-Sensitivity of Doctor A’s area of Practice B:

and to match patients and doctors in their fields-Sensitivity of Doctor B’s area of Practice A:of practice. This situation is naturally expected-Sensitivity of Doctor B’s area of Practice B:

to be a signaling to patients in medical malls

Let us assume that here, we havethat are composed mainly of specialists. In-

particular, to increase the effectiveness of-

networked medical care, if artificial intelligence-(AI)-equipped questionnaires are introduced at-

the general counter of medical malls andthen Doctor A is dominant in Practice Area A,

reflected in patients’ medical choices, efficientand Doctor B is dominant in Practice Area B,

matching by patients and doctors can bemeaning that they are complementary.

achieved (Petkus and Hoogewerf et al., 2020).

At this time, it is optimal for

≥

≥

≥

≥

to seeLet us look at Figure 3 now. The left-hand side

Doctor A andto see Doctor B. However, as

shows a situation where the automatic selection

long assee doctors indiscriminately

function has not yet been introduced, that is., inwithout taking into account the expertise of the

an indiscriminate manner, Doctor A is treating

two doctors, that is, the superiority of theirpatient grouppatient groupareas of practice, half of the patients will

and Doctor B is treatingsolo. Hereandtheoretically experience a mismatch.

Patient group in Clinical Area A:

However, the right side of Fig. 2 shows a

Patient group in Clinical Area B:==+

situation in which a medical questionnaire with
AI can be used to automatically select a Doctor
12

Journal of Japanese Management Vol.5, No.2, May 2021

A or Doctor B that matches the medical fields ofand. For example, by having

ISSN 2189-9592

of excessive medical care known as doctor

andshopping. However, the premise of this debate is

answer this questionnaire in advance at theundesirable

becauseit

may

dividethegeneral counter, one of the two doctors with highrelationship between patients and medicalsensitivity can be appropriately selected. This

professionals.

will reduce the mismatch between the patient

overmedication should not be left unaddressed,

and the doctor in the area of medical care to thebut it is an oversimplification to interpret thismaximum value of the doctor’s sensitivity, andas unreasonable demands or lack of healthalso reduce the risk of patient interruption.

literacy on the part of patients.

Certainly,

theproblemof

In this paper, to explore the relationship(3) Discussion

between the mismatch of medical fields andIn this study, we examined the conditions

patients’ interruption of outpatient care, we

for the establishment of a network practice,tried a simulation and found that the higher thefocusing on the sensitivity of doctors to realize

sensitivity of the doctor, the lower the risk ofan alliance in a medical mall. As a result, it wasinterruption (Figure 2). In light of this fact, it

found that in addition to “ensuring a high level

may rather be due to the mismatch between

of

doctors,”

patients and doctors in their areas of practice.

“complementary relationships” would have the

To prevent fragmentation and unnecessary

effect of increasing the sensitivity of the entire

confusionpractice. Therefore, if the above two conditions

professionals,

are met, networked medical care can be

relationship between both parties, we should

established, and benefits that cannot beseek to solve the problem through technicaldemonstrated by individual doctors can beassistance, while allowing free access wheneverprovided to both doctors and patients. In otherpossible. Nevertheless, these efforts are fragile

words, this conclusion means that a medicalin the medical field. This paper is novel because

mall alliance will not be realized by blindly

it proposes the conditions for the establishment

gathering doctors without taking these twoof network practice as one of the solutions toconditions into consideration.

these problems.

sensitivity

of

the

partner

betweenandpatients
toandmaintain

medicalagood

Furthermore, to increase the feasibility ofIn this study, we proposed the automaticalliances, we must make full use of informationsorting function model as a mechanism to

network technology. This is because the effective

match patients and doctors at the initial stage

use of such technology will make it easier toof their visit to a medical mall. When a patient

reduce transaction costs between doctors andvisits the general information desk of a medical

eliminate mismatches between patients andmall for the first time, a medical questionnaire

doctors without placing an undue burden on thewith AI can be used to efficiently select an

medical field. However, in recent policy debates,

appropriate specialist and department (Figure

the argument for limiting free access has been

3). This is a problem that can be realized using

accelerated because many people perceive thatmodern ICT, and it is not a difficult method.

allowing free access has led to patients’However, conventional discussions have lacked

preference for large hospitals and the problem

the perspective of problem solving using the13

Journal of Japanese Management Vol.5, No.2, May 2021

ISSN 2189-9592

latest technology. Therefore, a model that would

are required to verify the effectiveness of thismatch doctors and patients by applying

model

information network technology is novel in thisFurthermore, this analysis did not take into

study. The question is, however, why is it that

account the relationship between network

these models are not widely used in the medical

practice and doctor capacity. In this study, thefield? The issue of concern here is that the initial

discussion was based on the assumption that Ni

cost of EHRs is unusually high, regardless of the= 1 or higher, but when considering the doctor

country, and this is hindering the spread of thecapacity issue, it may be possible even fortechnology (The Commonwealth Fund, 2020;

doctors with low sensitivity to participate in

Nakamura, 2006). The Japanese government

network practice. Therefore, it is expected thathas been injecting huge subsidies to medical

these research issues will be further discussed

institutions to compensate for the high initialin the future. However, I would like tocosts in an effort to improve this situation, butemphasize that the contribution of this study is

the introduction of this technology on thethat it focused on the issue of alliances, which

premise of subsidies in the absence ofhas been a concern in medical malls for someappropriate prices in the field has caused

time and led to a method to increase theproblems that have in turn induced costfeasibility of alliances by satisfying theincreases. Hence, if these technologies do notconditions for the establishment of a network

spread due to the adverse effects of such pricepractice. This method has value that can behikes, it may be difficult to realize alliances andapplied to the management of medical malls.

when

appliedtomedicalmalls.

increase the effectiveness of networked medicalcare, and further discussion is needed in the(4) Conclusion

future. However, since the aforementioned

To realize an alliance in a medical mall, theconditions of establishment have been met inchoice of partners is extremely important, and a

medical malls, which have in fact establishednetwork practice must be established under thethe network practice with their own financial

appropriate partners. Therefore, the following

resources, it is believed that there is potential

two conditions must be met to establish a

for application (Ito, 2017).

network practice:

Finally, there are several limitations to this

1. The sensitivity of the doctors must be at astudy. First, since the sensitivity analysis ofhigh level.

doctors employed in this study is only a model

2. Doctors must have a complementary

analysis

relationship with each other.

withcertainconstraints,amethodological study on specific measurement

The importance of alliances has long beenand evaluation is needed. In conjunction withtouted among medical professionals, but tothis, verification of the relationship between

make them a reality, it is essential that thedoctor sensitivity and interruptions in patient

doctors themselves are qualified and have aoutpatient care is required. Additionally, thespecialty in which they excel, in other words,

issue of transaction costs occurring in medicalthat they have an advantage over other doctors.

malls needs to be investigated and verified in

In addition, since alliances always involve

more detail. For example, computer simulationstransaction costs, these costs should be covered
14

Journal of Japanese Management Vol.5, No.2, May 2021

by actively utilizing information network

ISSN 2189-9592(accessed on November 27, 2020).

technology. Furthermore, by making full use of

Epstein, J. (2016). Going to the medical mall: A

information network technology, transaction

patient retention strategy not to becosts can be reduced, and matching of patientsconfused with storefront clinics, Becker's

and doctors in their areas of practice can beachieved. Therefore, to realize alliances in

Hospital Review, https://www.beckershospi
talreview.com/hr/going-to-the-medical-

medical malls, further efforts are expected to bemall-a-patient-retention-strategy-not-to-

made to lower prices to the electronic medical

be-confused-with-storefront-clinics.html

record industry side, while promoting active(accessed on November 27, 2020).

investment in information technology by the

Gulati, R. (1998). Alliances and networks,

clinics’ own funds, rather than assuming

Strategic Management Journal, 19(4), pp.
293-317.

subsidies.

Hajli, M.N., Shanmugam, M., Hajli, A., et al.
Acknowledgements(2014).

Healthcaredevelopment:This work was supported by the Japan

Integrating transaction cost theory withSociety for the Promotion of Science KAKENHI

social support theory. Informatics for

Health and Social Care, 40(4), pp. 334-344.
Hashimoto, H., Ikegami, N., Shibuya, K., et al.
（2011). Cost containment and quality ofgrant number 18K12831.
References
Ahna, T., Ryu, S., and Han, I. (2004). The impact

care in Japan: Is there a trade-off? Theof the online and offline features on theLancet，378，pp. 1174-1182.
Hitt, A.M，Dacin, M.T., Levitas, E., et al.（2000）．

user acceptance of Internet shopping
malls, Electronic Commerce Research andPartner

Applications, 3(4), pp. 405-420.

developed market contexts: Resource-based

selectioninemerging

andAlbers, S., Wohlgezogen, F., and Zajac, J.E.

and organizational learning perspectives，(2013). Strategic alliance structures: An

Academy of Management Journal, 43(3), pp.

organization design perspective, Journal of449-467.

Management, 42(3)，pp. 582-614.

Ito,

A.

(2016).

Medicalmall

founders’

Bernardo, M., Valls, J., and Casadesus, M.

satisfaction and integrated management(2012). Strategic alliances: An analysis ofrequirement ， International Journal of

Catalan hospitals [Alianzas estratégicas:

Health Planning and Management，32(4),un análisis de los hospitales catalanes], Pan

pp. 449-466.

American Journal of Public Health, 31(1),pp. 40-47.

Ito, A. (2017). Verification of the efficacy of the

The Commonwealth Fund. (2020). Cost is biggest

Sustainable Primary Care Provision
System in Japan, Nippon Hyoron Sha, pp.

barriertoelectronic

implementation,

medicalstudy

functional

records
finds,

unit

integration

system,165-261.

https://www.commonwealthfund.org/publica

Ito, A. (2020a). Strategy and management

tions/newsletter-article/cost-biggest-barrier-behavior of medical malls: Focusing onelectronic-medical-records-implementationcompetition over location and clinical15

Journal of Japanese Management Vol.5, No.2, May 2021

Journal ofManagement, 5(1), pp. 1-17．
departments,

Japanese

ISSN 2189-9592

Systems,https://www.kenporen.com/includ
e/press/2017/20170925_8.pdf (accessed on

Ito, A. (2020 b). Identifying motivational factors

November 27, 2020).

to visit a medical mall by conjoint analysis,

Petkus, H., Hoogewerf, J., and Wyatt, C.J.

International Journal of Japan Academic
Society of Hospitality Management, 6(1)，（2020). What do senior physicians think

pp.1-10．

systems:Josi, R. and Pietro, C. (2019). Skill mix in Swiss
primary

care

group

about AI and clinical decision support
Quantitative

andqualitative

analysis of data from specialty societies,

Clinical Medicine Journal, 20(3), pp. 324-328.
Stuart, E.T. (2000). Interorganizational

practices—anationwide online survey ， BMC Family

Practice, 20(39), pp. 1-11.
Kinderis, R. and Jucevičius, G.（2015）．
Strategic

alliances and the performance of firms: A
study of growth and innovation rates in a

Strategic
Management Journal, 21, pp. 791-811．

Alliances Their Definition and Formation,

high-technology

Latgale National Economy Research, pp.
106-128.

industry.

Tanaka, H. (2007). Current status of electronic

Macmillan, P. (2009). Growing shopping malls

health record dissemination in Japan. JMA

and behaviour of urban shoppers, Journal

Journal, 50(5), pp. 399-404.
Vattikoti, K. and Razak, A. (2018). An empiricalof Retail & Leisure Property, 8(2), pp. 99–
118.

study on strategic alliances of multi-

McSweeney-Feld, M.H., Discenza, S., andnational companies in the Modern Global

Defeis, L.G. (2010). Strategic alliances &Era-A Select Case Study, Academy ofcustomer

Strategic Management Journal, 17(4), pp.

impact:

A

case

study

of

community hospitals, Journal of Business

1-13.

& Economics Research, 8(9), pp. 13-21.

Varadarajan, P.R. and Cunningham H.M.

Ministry of Health, Labour and Welfare. (2015).

（1995）．Strategic alliances: A synthesis of2015 Edition Annual Health, Labour andconceptual foundations, Journal of the

Welfare Report, https://www.mhlw.go.jp/
english/wp/wphw9/dl/summary.pdf（accessed on December 23, 2020）．

Academy of Marketing Science, 23(4), pp.
282-296.
World Health Organization. (2018). Japan

Ministry of Health, Labour and Welfare. (2016).

health system review, Health Systems in2016 Edition Annual Health, Labour andWelfare Report, https://www.mhlw.go.jp/

Transition, 8(1), https://apps.who.int/iris/
bitstream/handle/10665/259941/978929022

english/wp/wp-hw10/dl/summary.pdf

6260eng.pdf;jsessionid=0ED2FEF3351BE(accessed on December 23, 2020）．

5134E3DF8CA78445C83?sequence=1(accessed on December 23, 2020）．

Nakamura, M. (2006). Current status of electronic
medical recording in Japan and issues
involved，JMA Journal, 49(2), pp. 70-80.
National Federation of Health InsuranceSocieties. (2017). Public Attitude Survey(Received: January 15, 2021)

Report on Medical and Health Care

(Accepted: March 10, 2021)
16