Background This study aims to explore the effect of public hospital managers' risk and gain perception on their attitude towards physician dual practice (PDP). Methods A cross-sectional study enrolling 1513 managers from East, Middle and West of China in public hospitals was conducted. Generalized linear mixed models (GLMM) were used to find the determinants of managers' support for PDP. Results The rate of managers support for allowing PDP or implementing PDP with restriction was 94.3% (95%CI: 0.93, 0.95). The mean score of managers' risk perception was 67.7±14.46 and the mean score of managers' gain perception was 24.0±5.56. After controlling for individual and institutional characteristics, GLMM presented the score of risk perception increased 1 point, the rate of managers' support for PDP decreased 5% (OR=0.95, 95%CI: 0.93, 0.97); the score of gain perception increased 1 points, the rate of managers' support increased 18% (OR=1.18, 95%CI: 1.12, 1.24). Conclusions The majority of Chinese public hospital managers are in favor of allowing or implementing PDP with restrictions. While managers in public hospitals have stronger risk consciousness. Although gain perception is comparatively weaker than risk perception, but they are much influential in determining public hospital managers’ support for PDP.