The relationships among quality, value, satisfaction and behavioral ...

Journal of Business Research 57 (2004) 913 – 921

The relationships among quality, value, satisfaction and behavioral intention in health care provider choice: A South Korean study Kui-Son Choia, Woo-Hyun Chob, Sunhee Leec, Hanjoon Leed, Chankon Kime,* a

National Cancer Research Institute, Ilsan, South Korea b Yonsei University, Seoul, South Korea c Ehwa Women’s University, Seoul, South Korea d Western Michigan University, MI, USA e Department of Marketing, Faculty of Commerce, Saint Mary’s University, Halifax, Nova Scotia, Canada B3H 3C3 Received 17 July 2001; received in revised form 11 March 2002; accepted 3 April 2002

Abstract This research proposes an integrative model of health care consumer satisfaction based on established relationships among service quality, value, patient satisfaction and behavioral intention, and tests it in the context of South Korean health care market. Results based on the data collected from 537 South Korean health care consumers corroborated the causal sequence among these constructs suggested by the multiattribute attitude model framework, i.e., cognition (service quality and value) ! affect (satisfaction) ! conation (behavioral intention). Between the two cognitive constructs, service quality emerged as a more important determinant of patient satisfaction than value. Results also showed that both service quality and value have a significant direct impact on behavioral intention while value assessment was influenced by perceived service quality. D 2002 Elsevier Inc. All rights reserved. Keywords: South Korean health care consumers; Service quality; Value; Patient satisfaction; Behavioral intention; Structural modeling

1. Introduction The health care industry in the United States has recently experienced unprecedented challenges and changes. Health care providers now face intensified competition due to the industry’s movement towards managed health care systems and maturation with overcapacity (Taylor, 1994). In order to create or sustain competitive advantage, health care providers are compelled to integrate the traditional medical approach, which stresses the effectiveness and efficacy of health service outcomes from the provider’s perspective, with a patient-centered principle, which takes into account patients’ concerns and interests (Ettinger, 1998). Consequently, consumerism now appears on the health care industry agenda (Williams and Calnan, 1991). In the consumerism paradigm, service quality and patient satisfaction remain critical issues for health care providers. * Corresponding author. Tel.: +1-902-420-5801; fax: +1-902-4205112. E-mail address: [email protected] (C. Kim). 0148-2963/$ – see front matter D 2002 Elsevier Inc. All rights reserved. doi:10.1016/S0148-2963(02)00293-X

The impact of perceived health care service quality on the provider’s success or failure has been well established (Donabedian, 1996; Gooding, 1995; Headley and Miller, 1993; Reidenbach and Sandifer-Smallwood, 1990). This significant relationship between service quality and profit is largely imputed to patient satisfaction, which functions as a mediating variable between the two constructs. Satisfaction is crucial when consumers and purchasers of health care services make decisions regarding new enrollment and reenrollment (Mummalaneni and Gopalakrishna, 1997; Woodside and Shinn, 1988; Woodside et al., 1989). Although there exists a large body of literature including models and theories of health care consumer behavior, most of the past studies were conducted within the US health care market. Consequently, the stability and applicability of past findings across different national/cultural settings remain largely untested. Compared to the different national health care service systems adopted by Canada, Sweden and England, health care in the United States is more closely tied to the market economy. Yet, patient choice of health care providers is more restricted than in other countries like

914

K.-S. Choi et al. / Journal of Business Research 57 (2004) 913–921

Japan and Korea where there is greater private sector domination (Han, 1997). Given the prevailing cross-national differences in health care delivery systems, the extent to which constructs and the relationships among them are system-bound calls for investigation. In this perspective, the purpose of this study is twofold: (1) to propose a model showing the functional relationships among patient satisfaction and related variables based on past research and (2) to test it in the context of another health care market, namely, South Korea. This nation has recently adopted a national health care insurance system, which has many different operational characteristics compared to that used in the United States. (More details will follow in a later section.) Hence, results of this study will allow an examination of the stability of well-established functional relationships among the key constructs in the field of patient satisfaction in a different market environment.

2. Conceptual framework and research hypotheses 2.1. Service quality Service quality has been perhaps the most explored topic in services marketing. Past research has linked service quality to a firm’s performance (Zeithaml et al., 1996; Boulding et al., 1993), customer satisfaction (Cronin and Taylor, 1992; Oliver, 1993; Taylor and Baker, 1994) and purchase intention (Zeithaml et al., 1996; Boulding et al., 1993). Patient perception of service quality is a key determinant of a health care organization’s success due to its primary role in achieving patient satisfaction (Williams and Calnan, 1991) and hospital profitability (Koska, 1990; Donabedian, 1996). The literature on service quality delineates two rather distinct facets of the construct: a technical dimension (the core service provided) and a functional dimension (how the service is provided) (Gro¨nroos, 1983). This closely parallels the outcome and process dimensions of service identified by Berry et al. (1985). In the traditional medical approach, the primary focus of health care centers on increasing the probability of desirable health care outcomes, given the state of knowledge and technology (Donabedian, 1988). Although outcomes of health care seem relatively concrete, cautions have been raised about using them to measure the quality of health care. Specifically, there is often a significant time lag between the provision of medical care and recognition of the outcome. Moreover, some issues regarding outcome assessment are difficult to resolve, such as whether to use survival or functional restoration, and who determines the quality of services. In addition, most patients lack sufficient expertise and skills to evaluate whether the delivered medical service was performed properly or was even necessary (Newcome, 1997; Williams, 1994). As a consequence, consumers rely greatly on nontechnical process-related dimensions such as the patient – practitioner

relationship and/or the surroundings of the service encounter in evaluating service quality (Bowers et al., 1994; Ettinger, 1998; Donabedian, 1988). In this regard, the service marketing approach that interprets service quality from the care recipient’s perspective offers health care providers an attractive strategic framework. SERVQUAL (Parasuranam et al., 1985) has been the most extensively used service quality measurement scale. It is based on the expectancy disconfirmation model, which states that evaluation of service quality results from comparing the perception of service received to prior expectations of what the service should provide. However, when it comes to health care service, this popular ‘‘gap’’ approach may be inappropriate because many patients do not have prior expectations or are not sure about what to expect (Fitzpatrick and Hopkins, 1983). Aside from this, Cronin and Taylor (1992), after comparing four differing models of service quality that included the SERVQUAL model and the SERVPREF model (the performance-only model), reported that the SERVPREF model was superior to competing models in accounting for the variation in a global measure of service quality. Subsequent studies which have examined this issue concurred with Cronin and Taylor’s (1992) conclusion, thereby further discrediting the expectancy disconfirmation model, which underlies the SERVQUAL scale (see Babakus and Boller, 1992; Boulding et al., 1993; Cronin and Taylor, 1994; Oliver, 1993). 2.2. Satisfaction Consumer satisfaction is fundamental to the practice of consumer sovereignty. For health care providers, consumer satisfaction leads to favorable results, such as higher rates of patient retention, positive word of mouth and higher profits (Peyrot et al., 1993; Zeithaml, 2000). Patient satisfaction also influences the rate of patient compliance with physician advice and requests (Calnan, 1988; Pascoe, 1983). Thus, satisfaction actually affects the outcome of medical practices. For these reasons, patient satisfaction assessment has become an integral part of health care organizations’ strategic processes (Reidenbach and McClung, 1999). There seems to be consensus in the literature that satisfaction and service quality are unique constructs. However, distinctions in their definitions, be they conceptual or operational, are not always made clear in the services marketing literature (Tomiuk, 2000). The construct of satisfaction, as in the case of service quality, has largely been interpreted within the expectancy disconfirmation paradigm (e.g., Oliver, 1993; Johnston, 1995). In an attempt to provide conceptual and operational distinctions between these two constructs, Boulding et al. (1993) propose that the ideal expectation (or should) be used as the referent in the expectancy disconfirmation involving service quality and the desirable expectation (or will) as the referent in the case of satisfaction. However, confounding of these two


constructs is evidenced in other recent writings. For instance, Iacobucci et al. (1994) argue that both service quality and satisfaction are attitudinal constructs. Others go further by suggesting that service quality and satisfaction are almost interchangeable evaluations (e.g., Kleinsorge and Koenig, 1991). The lack of clarity in the definitions of service quality and satisfaction is linked to the ongoing controversy surrounding the causal order of service quality and satisfaction. A dominant view on this issue is that service quality represents a cognitive judgment, whereas satisfaction is a more affect-laden evaluation (Oliver, 1993, 1997; Gooding, 1995). The cognitive status of service quality is strongly implied in the SERVQUAL scale, which is based on the assumption that consumers apply a mental calculus to reach an evaluation. The majority of past studies of satisfaction formation view it as an affective response to an expectancy disconfirmation that involves a cognitive process (Oliver, 1997; Taylor, 1994; Tse and Wilton, 1988; Pascoe, 1983). For instance, Tse and Wilton (1988) defines satisfaction as ‘‘the consumer’s response to the evaluation of discrepancy between prior expectations and the actual performance of the product as perceived after its consumption’’ (p. 204). Distinguishing between service quality as a cognitive construct and satisfaction as an affective construct suggests a causal order (consistent with the traditional multiattribute attitude model framework (Wilkie, 1986), that positions service quality as an antecedent to satisfaction. There is empirical evidence supporting this causal linkage between health care service quality and patient satisfaction (Bowers et al., 1994; Reidenbach and Sandifer-Smallwood, 1990; Woodside et al., 1989). The first hypothesis of this study pertains to the causal link between service quality and patient satisfaction. Based on the predominant view in the literature, it is hypothesized that: Hypothesis 1: Perceived service quality will influence patient satisfaction. Zeithaml et al. (1996) have advocated that the servicequality agenda be reconfigured to set the highest priority on gaining a better understanding of the impact of service quality on profit and other financial outcomes of the organization. Accordingly, several studies have modeled service quality as an antecedent to behavioral intentions and found a significant link (Bitner, 1990; Boulding et al., 1993; Zeithaml et al., 1996). Much evidence has also been gathered in the field of health care marketing for the direct impact of quality perception on patient behavioral intentions (Gooding, 1995; Headley and Miller, 1993; Reidenbach and Sandifer-Smallwood, 1990). Therefore, it is hypothesized that: Hypothesis 2: Perceived service quality will affect patient behavioral intentions.

915

Evidence for the significant impact of satisfaction on behavioral intention comes from a wide variety of service industries including health care (Anderson and Sullivan, 1993; Bitner, 1990; Reichheld, 1996; Woodside and Shinn, 1988; Woodside et al., 1989). Therefore, it is expected that: Hypothesis 3: Patient satisfaction with health care services will have an impact on behavioral intentions. 2.3. Value Marketers are constantly challenged to increase the value of their product/service by improving the product/service benefits, reducing costs through productivity or both (Sheth et al., 1999). Superior value of a product/service represents a significant competitive advantage for the firm in building profits and customer satisfaction (Naumann, 1995). However, thus far in the health care industry, value has been a largely neglected concept in the health care provider’s strategic considerations. Given the potential significance of value in health care management, there is a need to better ascertain the nature of its relationships with patient satisfaction and behavioral intention. Perceived value is conceptualized as the consumer’s evaluation of the utility of perceived benefits and perceived sacrifices (Zeithaml, 1988). That is, consumers may cognitively integrate their perceptions of what they get (i.e., benefits) and what they have to give up (i.e., sacrifices) in order to receive services. In health care, benefits are largely the results of good quality service in both outcome and process domains. Although superiority of service performance is the major component of perceived benefits, customers may consider other factors such as prestige or reputation as benefits (Holbrook and Corfman, 1985). Sacrifices from the patient’s perspective can be divided into two types: the price that patients have to pay, and the nonmonetary costs such as time spent and the mental and physical stress experienced in receiving the care. Like service quality, value is also a cognitive construct. However, unlike quality assessment, perceived value requires a trade-off between benefits and sacrifices. As an extension of the above conceptualizations of value (as consisting of benefits and sacrifices) and service quality (as benefits), it is postulated that value perceptions of medical services will be directly influenced by perceived service quality. Past research, though scant in volume, has corroborated the service quality ! value link for health care service (Cronin et al., 1997; Gooding, 1995) and for other services (Fornell et al., 1996; Wakefield and Barnes, 1996). Hypothesis 4: Perceived health care service quality will impact the perception of service value. Surprisingly, there is a scarcity of findings on the functional relationship between perceived value and satisfaction (as exceptions, see Fornell et al., 1996; Patterson

916


Fig. 1. Model of health care consumer satisfaction.1

and Spreng, 1997). Service quality has typically been modeled as the sole antecedent to consumer satisfaction, and the notion of benefit-sacrifice trade-off in service evaluation has not received due attention. Perceived value is the consequence of a mental weighing of perceived benefits versus sacrifices, whereas satisfaction is an affective response to service evaluation. Therefore, based on the multiattribute attitude model framework, it is postulated that: Hypothesis 5: Perceived value will have an influence on patient satisfaction. (Fornell et al., 1996; Gooding, 1995). This causal link between value and intention is also expected to hold in health care purchase situations. Therefore, it is hypothesized that: Hypothesis 6: Perceived value will influence patient behavioral intentions. The conceptual model which integrates the hypothesized relationships (Hypotheses 1, 2, 3, 4, 5 and 6) appears in Fig. 1. The relationships among the four constructs depicted in this model were empirically tested based on health care consumer data collected in South Korea.

second tier consists of two types of hospitals: a small hospital (31 –100 beds) and a general hospital (101 – 700 beds). The third tier includes university hospitals and general hospitals with over 700 beds. Korean patients are allowed to visit any first tier or second tier facility without a medical referral, based on their own personal preferences. Patients are free to choose a general practitioner or specialist who works at any first or second tier facility. However, a referral is required when patients need medical services from a third tier hospital. All the medical facilities charge for services according to the fee schedule determined by the NHI. The NHI pays 70% of medical fees including the doctor’s fees and the lab fees if a patient uses a first tier medical facility and 60% for a patient who visits a small hospital in the second tier. However, the NHI pays 45% of the medical expenses for a visit to a second tier general hospital or to any third tier hospital (Ministry of Health and Welfare of Korea, 1999). A major difference in the health care delivery system between the United States and South Korea relates to the latitude patients have in choosing a specialist. The health care delivery system in the United States requires a referral for a visit to a specialist and managed health care systems further constrain the choice of specialty services. In contrast, the NHI system of Korea allows patients more freedom in service provider selection.

2.4. The health care delivery system of South Korea 3. Methodology Under the new National Health Insurance (NHI) system, which was implemented on October 1, 1998, medical services facilities are classified into three tiers based on the number of beds and degree of specialization (Choi et al., 1988). The first tier consists of clinics (0– 30 beds). The 1

Structural coefficients are standardized.

3.1. Subjects The study was conducted at a general hospital with 430 beds located in Sungnam, a satellite city of Seoul, which is the capital of South Korea. This hospital is one of 16,610 medical facilities within the 40-mile radius of Sungnam


(National Statistical Office, 2000). South Korea is the third most densely populated country in the world. Over a 10-day period, data collection took place in the area where outpatients waited for medication after being examined by physicians. A total of 800 outpatients were personally asked to participate in the survey, which used a self-administered questionnaire. The questionnaire took about ten minutes to complete. In all, 557 patients answered the self-administered questionnaire containing questions regarding the four constructs and demographic information. The final sample included adults whose age ranged from 18 to 65. Patients receiving psychological services were excluded from the sample. A total of 537 usable questionnaires were used for the data analysis. Patients in the final sample pool were largely female (68.9%) with an average age of 33. 3.2. Measures Given the cultural and medical service delivery system differences between South Korea and the United States, extra effort was put into the development of measurement items for this study. Especially for the service quality items, the process took cognizance of the past studies’ recommendations that the scale be unique to the specific service situation under consideration (see Babakus and Boller, 1992). The development of the service quality scale was based on focus group interviews conducted with three different groups of adult patients to generate insights into how Korean health care users viewed the health care services they were receiving and the aspects of health care service they felt important and/or wanting according to their own experiences. Scripts from the interviews revealed that patients were primarily concerned with four dimensions when evaluating the quality of medical services: (1) convenience of the care process, (2) health care providers’ (other than physicians) concern, (3) physician’s concern and (4) tangibles. Overall, the interviewees’ main concern was with the process-related factors of service. Thirty items were developed based on the results of the interviews. Some of these were modifications of the SERVQUAL scale items that reflected the interviewees’ comments. All items used seven-point Likert scales (1 = strongly disagree, 7 = strongly agree). Perceived value was assessed with two items based on the perceived utility/worth resulting from the trade-off of ‘‘get’’ versus ‘‘give-up’’ (Zeithaml, 1988). They were: (1) ‘‘the amount of money I paid for the care was appropriate’’ and (2) ‘‘the quality of the medical service I received was worth more than what I paid.’’ The same seven-point Likert scales were used for these two items. Patient satisfaction was operationalized using two items: (1) ‘‘How satisfied were you with the treatment you received in the hospital?’’ and (2) ‘‘How satisfied were you with your decision to use the hospital?’’ Both items used a seven-point scale that ranged from very dissatisfied to very satisfied. Three items were used to operationalize behavioral intention. The behaviors referred to in these items included:

917

willingness to recommend, intention to repurchase and positive word of mouth. The corresponding items, all using a seven-point Likert scale (1 = strongly disagree, 7 = strongly agree), were as follows: (1) ‘‘I will recommend that other people use this hospital,’’ (2) ‘‘If I needed medical services in the future, I would consider this hospital as my first choice’’ and (3) ‘‘I will tell other people good things about this hospital.’’

4. Analysis and results 4.1. Measurement analysis 4.1.1. Measurement model of service quality The initial scale for service quality consisted of newly generated and modified SERVQUAL items designed to capture four dimensions—convenience of the care process (nonphysician) health care providers’ concern, physician’s concern and tangibles. The assessment of measurement properties (reliability and validity) for the proposed scale and its purification were the key tasks in the measurement analysis. This assessment-purification process was carried out in an iterative procedure described as follows: 1. Conduct an exploratory factor analysis and see whether the hypothesized four-factor structure emerges. 2. Delete items that are poorly related to their hypothesized factors or that are associated with more than a single factor. 3. Using the Cronbach’s a estimates and item-to-total correlations, check the reliabilities of items measuring each hypothesized factor and delete items that are unreliable. 4. Repeat Steps 1– 3, until a clean factor structure emerges. Item deletion was done one at a time and Steps 1 –3 were repeated several times until a clean four-factor structure emerged. In the end, the process resulted in 19 reliable items that conformed to their hypothesized dimensions (see Appendix A). The estimated Cronbach’s a values for the four purified service quality dimensions ranged from .80 to .94. In the subsequent stage, the four-factor structure encompassing the 19 service quality items was subjected to a confirmatory factor analysis (CFA) using LISREL VIII (Jo¨reskog and So¨rbom, 1993). The overall model fit as indicated by the c2 statistic (c2 = 534.2, df = 146, P < .00) was unsatisfactory. However, given the c2 test’s sensitivity to sample size and our relatively large sample (n = 537), attention was focused on the incremental fit measures, namely, the adjusted goodness of fit index (AGFI), the comparative fit index (CFI) and the normed fit index (NFI). These index measures explain the practical significance of the variance explained by the model and is less sensitive to sample size effects (Bentler, 1990). For the service quality measurement model, the AGFI, CFI and NFI

918


values were .86, .94 and .92, respectively. The model’s fit as indicated by these estimates was deemed satisfactory. An examination of factor loadings reveals that their magnitudes ranged from .64 to .94, and all of them were significant ( P < .05). The average trait variances (lij2) accounted for by each group of items were: 49% for ‘‘tangibles,’’ 77% for ‘‘physician’s concern,’’ 63% for ‘‘convenience of the care processes’’ and 62% for ‘‘health care providers’ concern.’’ The percentage of variance in the items explained by traits/constructs indicates the extent of convergence among the items measuring the same construct (Bagozzi and Yi, 1991). According to Bagozzi and Yi (1991), a trait variance greater than 50% provides strong evidence of convergent validity. Based on this rule of thumb, the above trait variance figures establish a quite satisfactory level of convergent validity for our service quality scale. Discriminant validity among the four dimensions of health care service quality was examined by conducting chi-square difference tests between a model in which a factor correlation was fixed at 1.0 and the unconstrained model. In all cases, the constrained model showed a significantly poorer fit compared to the unconstrained model. This suggests that the four service quality dimensions are discriminant of one another. Furthermore, none of the 95% confidence intervals computed for the six-factor correlations (range: .54– .74, mean: .64) contained unity. It should be noted that these factor correlations have been corrected for measurement error and therefore been disattenuated, i.e., they are larger than correlations among measurement items. Past health care research using the SERVQUAL scale or its modified versions report considerably higher interdimensional correlations (see Dabholkar et al., 1996; Lee et al., 2000). Therefore, our scale is more capable of discriminating the service quality dimensions among which the conceptual and empirical separability has often been a question. In sum, results of the measurement analysis show evidence of convergent validity for the four dimensional service quality scale. Furthermore, the four dimensions, although substantially correlated, are sufficiently distinct. These results enabled us to construct additive, equally weighted indices for each of four service dimensions. These dimensional indices were later incorporated into structural modeling (as indicators for perceived service quality), which was conducted to test the hypothesized model. However, prior to estimating the structural model, another measurement analysis was conducted; this time involving the measures for all four constructs (service quality, value, satisfaction and behavioral intention) in the model. 4.2. Total measurement model A CFA of the four-factor measurement model for the 11 indicators produced an excellent overall fit as indicated by the AGFI, CFI and NFI values equaling .91, .98 and .97, respectively, even though the chi-square statistic was sig-

nificant (c2 = 152.29, df = 38, P=.00). All of the estimated factor loadings were in the .80’s and .90’s except for one with the .65 value. The average variances in the indicators accounted for by each of the four constructs were all quite high: .60 for the four-item measure of service quality, .88 for the two-item measure of value, .82 for the two-item measure of atisfaction and .82 for the three-item measure of behavior intention. These figures apparently suggest high levels of convergence among the items measuring their respective construct. An examination of discriminant validity was made in the same manner as before. A series of chi-square difference tests were run to see if constraining factor correlations equal to unity, one at a time, would entail a significantly poorer fit vis-a-vis that of the unconstrained model. The disattenuated correlations among the factors ranged this time between .67 and .83 with a mean correlation of .74. Results showed that in all cases the constraint significantly worsened the fit (at P=.01). As before, this provided evidence that the four constructs are discriminant of one another. None of the 95% confidence intervals computed for the six-factor correlations contained unity. 4.3. Structural model After confirming the measurement model, the structural model shown in Fig. 1 was estimated using LISREL VIII (Jo¨reskog and So¨ rbom, 1993). The LISREL analysis showed an excellent overall fit of the model as indicated by the CFI, NFI and AGFI values of .98, .97 and .91, respectively. However, the chi-square statistic was significant (c2 = 152.29, df = 38, P=.00). Given the satisfactory fit of the model, the estimated structural coefficients were then examined to evaluate the hypotheses. As predicted in Hypothesis 1, perceived service quality had a significant positive influence on patient satisfaction (g21=.82, P < .01). The results also showed that behavioral intention was directly influenced by perceived service quality (g31=.18, P < .01) and by patient satisfaction (b32=.56, P < .01), thereby confirming Hypotheses 2 and 3, respectively. Also as expected, perceived service quality had a significant impact on value assessment (Hypothesis 4) (g11=.67, P < .01), which in turn affected patient satisfaction (Hypothesis 5) (b21=.25, P < .01). The proposed model also conjectured that perceived value would directly influence patient behavioral intention (Hypothesis 6). The results provided support for this link as well (b31=.17, P < .01). In sum, all the hypotheses were strongly supported by the data. It should be further noted that the proposed model demonstrated a strong explanatory power. The estimated R2 values for the three structural equations in the model were quite high: .72 for behavioral intentions, .71 for patient satisfaction and .45 for value. Past health care research conducted in the United States found comparable or lower R2 values for similar structural/regression models involving the same constructs. For example, Bowers et al. (1994)


reported that service quality dimensions explained 54% of total variation of outpatients’ satisfaction, while 42% of patient satisfaction was explained by perceived health care quality in Woodside and Shinn’s (1988) study. With respect to behavioral intention, Woodside and Shinn (1988) reported that 72% of the total variation of behavioral intention was accounted by inpatients’ satisfaction. In another study, Woodside et al. (1989) reported that only 31% of behavioral intention was explained by patient satisfaction. In order to determine the relative impact of each of the two cognitive constructs (i.e., value and service quality) on behavioral intentions and satisfaction, their direct and indirect effects on the latter two constructs were examined (based on unstandardized structural coefficients). The total effect of service quality on patient satisfaction was .96, whereas value showed the total effect (which consists only of the direct effect) of .25 on patient satisfaction. The direct effects of service quality and value were .77 and .25, respectively. These results clearly point to service quality as a more important antecedent to patient satisfaction than value. The total effects of service quality and value on behavioral intentions were .88 and .32, respectively. The direct effect of service quality on behavioral intentions was .21, whereas the direct effect of value on behavioral intentions was .18. Again, service quality emerged as a more important determinant of behavioral intention than value.

5. Discussion The main thrust of this paper was to propose an integrative model of health care consumer satisfaction based on established relationships among four key constructs (service quality, value, patient satisfaction and behavioral intention), and to test it in the context of Korean health care environment. As such, this study was intended to make contributions to the current understanding of health care consumer behavior in two ways. First, most of past studies of health care consumer satisfaction have focused on the links among service quality, patient satisfaction and behavioral intention. Perceived value, despite its importance to satisfaction formation, has largely been neglected in past patient satisfaction research. Therefore, the four-construct conceptual model of this study provides a more integrative framework for the relevant constructs and their presumed relationships in the area of patient satisfaction. Second, the vast majority of the past studies on health care service issues have been geographically concentrated in the United States. Although the importance of examining the applicability of theories and models across cultures and health care systems has been addressed by many researchers (Calnan, 1988; Peterson and Jolibert, 1995), very few studies have been conducted to date for this purpose. In this regard, this study, which examined an established conceptual framework of patient satisfaction in the context of another unique health care

919

delivery system, contributes to the cross-border or crosssystem extension of existing knowledge. The proposed model was strongly supported by the data collected in South Korea, where the health care system offers a greater choice in provider selection for health care consumers but a more competitive environment for health care providers. Notably, results of this study present evidence that the causal sequence suggested by the multiattribute attitude model framework, i.e., cognition (service quality and value) ! affect (satisfaction) ! conation (behavioral intention), is robust across national boundaries. Between the two antecedents of satisfaction, service quality and value, service quality emerged as a more important determinant of patient satisfaction and behavioral intentions. However, this finding should not be viewed as denigrating the significance of perceived value in health care marketing. Results of this study clearly demonstrate the ability of value to influence patient satisfaction and behavioral intention, albeit to a lesser extent than service quality. Also, all the structural path coefficients connected to the value construct were found to be statistically significant. Hence, health care providers are encouraged to seek ways in which they can reduce perceived monetary and nonmonetary service costs and increase perceived benefits. A discussion of some limitations of this study is in order. The measurement scope of service quality in this study was limited to the process aspect of services. The reason for this was presented earlier. All of the service quality dimensions used in this study were inferred from focus group interviews, and technical outcome did not surface as an important health care service quality criterion. This observation that focus group interviewees were primarily concerned with the process dimensions of health care service, in a way, attests to the belief that patients lack medical knowledge to judge the technical quality of the medical service (Newcome, 1997; Williams, 1994). The relative importance of process dimensions of health care service was further demonstrated by the strong effects of service quality on satisfaction and on behavioral intention. Nonetheless, some may argue that the ultimate goal for patients is to restore and/or maintain their health. It may thus be desirable to develop and incorporate in future studies a health care service quality scale that includes not only the processrelated dimensions but also the outcome dimensions which lay people can properly evaluate. It should be also noted that the service quality scale used in this study, though developed in reference to the extant scales in the literature (particularly the SERVQUAL scale), might be culturally biased. Because its dimensional and item contents are not equivalent to the scales used in past studies, a caution is clearly called for in making conclusions regarding the extent of similarity in the relationships among the key constructs found in this study and in previous studies. A rigorous test of equivalence in measures and/or in structural relationships is only possible when the study involves multinational samples of health care consumers.

920


Appendix A. Measurement items for service quality2 Convenience of the care process (Cronbach’s a=.80): 1. 2. 3. 4.

The procedure to get the lab test was convenient. The lab test was done in a prompt way. The payment procedure was quick and simple. The process for setting up the appointment was simple and easy. 5. I did not have to wait long for the medical examination from the physician. Health care providers’ concern (Cronbach’s a=.88): 1. 2. 3. 4. 5.

The nurses were friendly. The nurses explained the medication process well. Care providers tried to help me as much as they could. Care providers truly cared for me. There was a good coordination among the care providers.

Physician’s concern (Cronbach’s a=.94): 1. The physician was polite. 2. The physician adequately explained my condition, examination results and the treatment process. 3. The physician allowed me to ask many questions, enough to clarify everything. 4. The physician paid enough consideration to my concerns in deciding on a medical procedure. 5. The physician made me feel comfortable. Tangibles (Cronbach’s a=.86): 1. The waiting areas for doctors and medication were pleasant. 2. It was easy to use amenities (e.g., public telephone, cafeteria, etc.). 3. The hospital seems to be equipped with the latest equipment. 4. It was easy to find care facilities (e.g., lab, doctor’s office, etc.).

References Anderson EW, Sullivan M. The antecedents and consequences of consumer satisfaction for firms. Mark Sci 1993;12:125 – 43 (Spring). Babakus E, Boller GW. An empirical assessment of the SERVQUAL scale. J Bus Res 1992;24:253 – 68. Bagozzi RP, Yi Y. Mutitrait – multimethod matrices in consumer research. J Consum Res 1991;17:426 – 39. Bentler PM. Comparative fit indices in structural models. Psychol Bull 1990;107(2):238 – 46. 2 All of the items used a seven-point Likert scale (1 = disagree strongly and 7 = agree strongly).

Berry LL, Zeithaml VA, Parasuraman A. Quality counts in services too. Bus Horiz 1985;28:44 – 52 (May/June). Bitner MJ. Evaluating service encounters’ effects of physical surroundings and employee responses. J Mark 1990;54:69 – 82 (April). Boulding W, Karla A, Staelin R, Zeithaml VA. A dynamic process model of service quality: from expectations to behavioral intentions. J Mark Res 1993;30:7 – 27 (February). Bowers MR, Swan JE, Koehler W. What attributes determine quality and satisfaction with health care delivery. Health Care Manage Rev 1994; 19(4):49 – 55. Calnan M. Towards a conceptual framework of lay evaluation of health care. Soc Sci Med 1988;27(9):927 – 33. Choi E, Kim J, Lee W. Health care systems in Korea. Seoul, Korea: Korea Institute for Health and Social Affairs, 1988. Cronin JJ, Taylor SA. Measuring service quality: a re-examination and extension. J Mark 1992;56:55 – 68 (July). Cronin JJ, Taylor SA. SERVPERF versus SERVQUAL: reconciling performance-based and perceptions-minus-expectations measurement of service quality. J Mark 1994;58(1):125 – 31. Cronin JJ, Brady MK, Brand RR, Hightower R, Shemwell DJ. A crosssectional test of the effect of conceptualization of service value. J Serv Mark 1997;11(6):375 – 91. Dabholkar PA, Thrope DI, Rentz JO. A measure of service quality for retail stores: scale development and validation. J Acad Mark Sci 1996; 24(1): 3 – 16. Donabedian A. Quality assessment and assurance: unity of purpose, diversity of means. Inquiry 1988;25:175 – 92 (Spring). Donabedian A. The effectiveness of quality assurance. Int J Qual Health Care 1996;8(4):401 – 7. Ettinger WH. Consumer-perceived value: the key to a successful business strategy in the healthcare marketplace. J Am Geriatr Soc 1998; 46(1): 111 – 3. Fitzpatrick R, Hopkins A. A problem in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illness 1983;5(3):297 – 311. Fornell C, Johnson MD, Anderson EW, Cha J, Bryant BE. The American customer satisfaction index: nature, purpose, and findings. J Mark 1996;60:7 – 18 (October). Gooding SKS. Quality, sacrifice, and value in hospital choice. J Health Care Mark 1995;15(4):24 – 31. Gro¨nroos C. Strategic management and marketing in the service sector. Boston: Marketing Science Institute, 1983. Han MC. New horizon in quality care: Asian perspective. World Hosp Health Serv 1997;33(2):8 – 13. Headly DE, Miller SJ. Measuring service quality and its relationship to future consumer behavior. J Health Care Mark 1993;13(4):32 – 41. Holbrook MB, Corfman KP. Quality and value in the consumption experience: Phaedrus rides again. In: Jacoby J, Olson J, editors. Perceived quality: how consumers view stores and merchandise. Lexington, MA: Lexington Books, 1985. p. 31 – 57. Iacobucci D, Grayson KA, Ostrom AL. The calculus of service quality and customer satisfaction: theoretical and empirical differentiation. Adv Serv Mark Manage 1994;3:1 – 67. Johnston R. The zone of tolerance: exploring the relationship between service transactions and satisfaction with the overall service. Int J Serv Ind Manage 1995;6(2):46 – 61. Jo¨reskog KG, So¨rbom D. LISREL8 user’s reference guide. Chicago, IL: Scientific Software, 1993. Kleinsorge IK, Koenig HF. The silent customers: measuring customer satisfaction in nursing homes. J Health Care Mark 1991; 11(4):2 – 13. Koska MT. High quality care and hospital profits: is there a link? Hospitals 1990;5:62 – 3 (March). Lee H, Delene LM, Bunda MA, Kim C. Methods of measuring health-care service quality. J Bus Res 2000;48:233 – 46. Ministry of Health and Welfare. National Standards for National Health Insurance and Fee Schedules. Seoul, Korea, 1999. Mummalaneni V, Gopalakrishna P. Access, resource, and cost impacts on

K.-S. Choi et al. / Journal of Business Research 57 (2004) 913–921 consumer satisfaction with health care: a satisfaction across alternative health care modes and time. J Bus Res 1997;39:173 – 86. National Statistical Office. Statistical handbook of Korea 2000. Seoul, Korea: National Statistical Office, 2000. Naumann E. Creating customer value. Cincinnati, OH: Thompson Executive Press, 1995. Newcome LN. Measuring of trust in health care. Health Affair 1997; 16:50 – 1 (January/February). Oliver RL. A conceptual model of service quality and service satisfaction. In: Swartz TA, Bowen DE, Brown SW, editors. Advances in services marketing and management. Research and practice, vol. 2. Greenwich, CT: JAI Press, 1993. p. 65 – 8. Oliver RL. Satisfaction: a behavioral perspective on the consumer. Boston, MA: Irwin-McGraw-Hill, 1997. Parasuraman A, Zeithaml VA, Berry LL. A conceptual model of service quality and its implications for future research. J Mark 1985;49:41 – 50. Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plann 1983;6:185 – 97. Patterson PG, Spreng RA. Modeling the relationship between perceived value, satisfaction, and repurchase intentions in a business-to-business, services context: an empirical examination. Int J Serv Ind Manage 1997;8(5):414 – 34. Peterson RA, Jolibert AJ. A meta-analysis of country of origin effects. J Int Bus Stud 1995;26:883 – 900. Peyrot M, Cooper PD, Schnapf D. A consumer satisfaction and perceived quality of outpatient health services. J Health Care Mark 1993;13:24 – 33 (Winter). Reichheld F. The loyalty effects: the hidden force behind growth, profit, and lasting value. Boston: Harvard Business School Press, 1996. Reidenbach RE, McClung GW. Managing stakeholder loyalty: when satisfaction is just not enough. Mark Health Serv 1999;21:21 – 9 (Spring). Reidenbach RE, Sandifer-Smallwood B. Exploring perceptions of hospital operations by a modified SERVQUAL approach. J Health Care Mark 1990;10(4):47 – 55.

921

Sheth JN, Mittal B, Newman BI. Customer behavior: consumer behavior and beyond. Orlando, FL: Dryden Press, 1999. Taylor SA. Distinguishing service quality from patient satisfaction in developing health care marketing strategies. Hosp Health Serv Adm 1994; 39(2):221 – 36. Taylor SA, Baker TL. An assessment of the relationship between service quality and customer satisfaction in the formation of consumers’ purchase intentions. J Retailing 1994;70(2):163 – 78. Tomiuk MA. The impact of service providers’ emotional displays on service evaluation: evidence of emotional contagion. Unpublished Doctoral Dissertation, Concordia University, Canada, 2000. Tse DK, Wilton PC. Models of consumer satisfaction formation: an extension. J Mark Res 1988;25(2):204 – 12. Wakefield KL, Barnes JH. Retailing hedonic consumption: a model of sales promotion of a leisure service. J Retailing 1996;72(4):409 – 27. Wilkie WL. Consumer behavior. New York: Wiley, 1986. Williams SJ. Patient satisfaction: a valid concept? Soc Sci Med 1994; 38(4):509 – 16. Williams SJ, Calnan M. Convergence and divergence: assessing criteria of consumer satisfaction across general practice, dental and hospital care setting. Soc Sci Med 1991;33(6):707 – 16. Woodside AG, Shinn R. Consumer awareness and preference toward competing hospital services. J Health Care Mark 1988;8(1):39 – 47. Woodside AG, Frey LL, Daly RT. Linking service quality, customer satisfaction, and behavioral intention. J Health Care Mark 1989; 9(4):5 – 17. Zeithaml VA. Consumer perceptions of price, quality, and value: a means-end model and synthesis of evidence. J Mark 1988;52:2 – 22 (July). Zeithaml VA. Service quality, profitability, and the economic worth of customers: what we know and what we need to learn. J Acad Mark Sci 2000;28(1):67 – 85. Zeithaml VA, Berry LL, Parasuranam A. The behavioral consequences of service quality. J Mark 1996;60:31 – 46 (April).