International Journal of Management (IJM)

Volume 12, Issue 3, March 2021, pp.233-241, Article ID: IJM_12_03_021

Available online at http://iaeme.com/Home/issue/IJM?Volume=12&Issue=3
ISSN Print: 0976-6502 and ISSN Online: 0976-6510
DOI: 10.34218/IJM.12.3.2021.021

© IAEME Publication Scopus Indexed

FINDINGS ABOUT THE MAIN DRIVERS FOR

MEDICAL SERVICES AND PRIVATE HEALTH
INSURANCE CUSTOMER SATISFACTION IN
ROMANIA
Alexandru-Bogdan Ursoiu and Adina Rotileanu
The Bucharest University of Economic Studies, Romania

ABSTRACT
While the Romanian healthcare market continues to grow, it remains significantly
influenced by the Government’s not yet very successful endeavour to allocate an
increasing share from GDP to the health sector. The overall incidence of mid and long-
term disease above the European Union average requires a health system improvement
in Romania. In that regard, developing a better framework for integration of the public
and private healthcare organizations might prove an effective strategy, as demonstrated
by similar successful models used by other developed countries. Under that paradigm,
a basic health services package provided by the public system is adjusted by
complementary and supplementary packages provided by private system to cover
specific needs that the public health system has difficulties to provide a permanent
solution for. The purpose of this paper is to analyse the patients’ satisfaction drivers
and how much these are already covered by the public services, for the private system
to cover the gap with the private health insurance packages. The practical implications
of this paper are that the population who is willing to pay for these services and for
whom the public budget will be relieved of the corresponding expenditure, will support
decreasing the pressure on the public health system, encouraging more population
towards preventive healthcare that the COVID-19 pandemic accelerated already.
Key words: Patient behavior, Medical services, Private health insurance, Customer
satisfaction
Cite this Article: Alexandru-Bogdan Ursoiu and Adina Rotileanu, Findings About the
Main Drivers for Medical Services and Private Health Insurance Customer Satisfaction
in Romania, International Journal of Management (IJM), 12(3), 2021, pp. 233-241.
http://iaeme.com/Home/issue/IJM?Volume=12&Issue=3

1. INTRODUCTION
The concept of satisfaction is an idea that has showed up in various fields concerning the human
behavior, for example in sociology, economics, psychology, management and so on.
Notwithstanding, over the last decades, satisfaction has been essential for the field of marketing,

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 Findings About the Main Drivers for Medical Services and Private Health Insurance Customer
Satisfaction in Romania

because this concept has been intensely utilized in writings associated with consumer
satisfaction (Aigbavboa and Thwala, 2013). Organizations’ efforts to augmenting consumer
loyalty don’t necessarily mirror their corporate selflessness, as the interest in consumer loyalty
is quite often egotistical because it provides substantial advantages (Allen, 2004). The intricacy
of medical services originates from its various business sectors all contending in a developing
key space, its complexity evolving at high speed. The key actors on healthcare environment
significantly exceed the patients and the medical staff and it has come to incorporate large
bodies of specialists in the insurance companies, financial backers, drug organizations, financial
backers, medical and non-medical suppliers, government, regulatory entities, humanitarian,
patient associations, lobbyists, influencers, philanthropists and so on. The proper assessment of
patient fulfilment requires on both a supplier cantered perspectives as well as a customer
cantered one. While supplier centered viewpoints allude to the arrangement of sound clinical
abilities, client focused angles are concentrating on the degree to which the patients feel their
requirements and assumptions are being met during the arrangement of medical care
administrations (Robinson et. al, 2008).
In the general economic framework, the medical services market has, like different business
sectors, demand carriers (patients) and those who offer the services (medics, specialists, nurses,
insurers and so forth). Yet, as pointed by Mankiw (2015), different highlights of this market are
making the examination of their interactions more complicated. In that regard, there is an
increase in the role of third parties like insurance companies, governing bodies and observers,
because they might have an own interest in medical care results. The patients on some occasions
do not have very clear idea what they need and thus cannot competently assess the treatment
they are getting. Also, given that there are many situations in which the medical services
suppliers are not paid by the patients but at least partially by private insurance companies or
government healthcare coverage, the allocation of assets might be decisively influenced by
those insurers. Under those conditions, achieving a higher patient fulfilment is a critical
component for improving the financial success of organizations operating on the healthcare
market, because it impacts to a great extent the choosing of the medical services providers
(Naidu, 2009), which, in turn, is a pre-requisite for the success of the business in a competing
environment.
The specific interactions between healthcare supply and demand are also complex in terms
of public or private services, and the choice is not dichotomic in many cases. A patient, for an
instance, may choose a public hospital for an intervention using the national insurance
coverage, while going to a private clinic for diagnosis and investigations, where the payment is
partially supported by the social insurance and the rest is paid out of the pocket. That interaction
can get even more complex, as the named patient can also decide to use his private health
insurance, for accessing some additional quality version of the services of the public hospital,
in terms of accommodations, like a paid premium ward. The public hospitals are allowed to
offer to some extent such premium accommodations that are sources of self-financing, on the
condition that those are not affecting the overall capability to provide quality healthcare services
for the regular patients. Under that premises, the public and private organizations are both
representing parts of a system that provides satisfaction to the patients. In the same time, the
medical services level of satisfaction, determines each private insurance beneficiary to behave
accordingly regarding its health insurance policy (He et al., 2020), upgrading, changing or
extending the medical services coverage.
Two different perspectives are covered in this paper by the literature review and the
explored surveys’ results: the medical services and the private health insurance providers,
following the modern, holistic, and multidimensional approach of nowadays research context.
Patients and private health insurance beneficiaries’ responses are the base of this paper findings

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 Alexandru-Bogdan Ursoiu and Adina Rotileanu

that reveal the most important health care product and service attributes with impact on
customer satisfaction. The health care provider, the patient who is also a private health
insurance owner and the private health insurance provider are all engaged in an ecosystem that
this paper is highlighting, bringing originality from empirical point of view and creating a
framework for better leverage on it.

2. REVIEW OF THE SCIENTIFIC LITERATURE

As the evaluation of patients’ satisfaction can provide a strong scientific support for improving
healthcare as a whole by meeting the expectations, as well as providing opportunities for better
strategies implementation, monitoring, benchmarking, and overall management of a medical
organization (Al-Abri and Al-Balushi, 2014; Bjertnaes et al., 2012), its research becomes of
great importance for the well-being of the population, as well as a valuable asset for business
excellence in the real economy. Patients' satisfaction can be reflected, in essence, as a reaction
they are having to various factors of influence. From that perspective, Bagozzi (1992) points
out that typically the consumers first assess the quality of services by performing a cognitive
evaluation and then experience a level of satisfaction, by emotionally reacting to that
assessment. As it is illustrated in Farzianpour et al. (2015), determining the factors that generate
an impact on satisfaction can be a sound option of supporting the achievement of the desired
patients’ satisfaction, even if that approach is basically an indirect one. In that regard, to
properly evaluate satisfaction, it is valuable to assess those determining factors and to
understand the expectations that patients have.

Figure 1 Simplified Private health Insurance ecosystem

Source: Author drawing
PHI – Private Health Insurance
Given the today’s highly competitive and dynamic market of healthcare services, the proper
meeting of the needs that patients have is essential for the medical unit’s competency as well
as for the effectiveness of the marketing strategy (Ham et al., 2015) and for that to be possible,
a thorough knowledge about the determinants of satisfaction is needed. The business
performance has a direct economic dimension concerning sales, market share, efficiency, profit
generation and so on, it also has an indirect dimension comprising aspects like innovation,
improvement, customer consequences and so on (Amangala and Wali, 2020). In that regard,
the medical services providers can take advantage substantially from the information that
satisfaction research can provide. For patients’ satisfaction research to produce useful data, as
LaVela and Gallan point out (2014), it is very important to be able to ensure that the defined
measures and the metrics involved are capturing the actual experience of the patients, in a

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 Findings About the Main Drivers for Medical Services and Private Health Insurance Customer
Satisfaction in Romania

sufficient manner. At the same time, by rigorously identifying the relevant attributes for medical
services and the associated importance conferred by the patients, it is possible to prioritize the
efforts to generate a higher satisfaction and to achieve a greater effectiveness for the system
(Giovanis and Pierrakos, 2015).
The Private Health Insurance providers/ suppliers are part of this ecosystem as their clients,
individuals, need to renew their policy and may choose to change the included medical services
or even the insurance provider (Puri and Sun, 2021), based on the previous policy experience.
This complex system is depicted in a simplified frame in Figure no. 1. that displays all variables
for creating the ecosystem where medical services, patients and private health insurance
providers are operating.

3. METHODOLOGY
Two extensive quantitative studies were conducted aiming to exploring both public and private
health insurance beneficiaries’ satisfaction drivers for the healthcare related services provided
by different medical units and health insurance providers. Given the scope of the present paper
and considering the complexity and the broader content of the mentioned studies’ objectives,
the focus is on the results concerning the patients’ satisfaction drivers with a focus on those
which eventually are or may be better covered by the private system when the public system
would have difficulties to fulfil the needs and desires of patients.
The studies were aimed at the national population, with the inclusion criteria of minimum
age of 18 years and voluntarily using the healthcare services provided by a medical unit and
through a private health insurance provider at least once during the last 12 months. Since both
categories of medical services users included in the studies, public patients and private health
insurance beneficiaries, have been addressed questions regarding their usage, motivation to use
and satisfaction, this paper addresses the question related to what are the satisfaction elements
that public system is not offering and could be offered by private system and aims to identifying
the gaps between what patients need and what they get in terms of medical related services.
Under the generic terms of research, the surveys mentioned in this paper aimed at a maximum
standard error within a margin of ±5.73% at a 95% level of confidence calculated starting from
total target population and total sample. The data interpretation approach is empirical with
samples consisting of 385 respondents for medical services usage and 293 for private health
insurance related services, where 95 individuals are also one or more private health insurance
policies owners.

4. RESULTS AND DISCUSSION

The participants in the study about the satisfaction for medical services were presented with 39
relevant attributes for satisfaction, grouped in 10 categories of drivers. The performance of the
medical staff addressed the professional ability of medics and nurses, while the performance of
the auxiliary staff targeted the ability of the reception staff and the support personnel. The
waiting encompassed a range of factors that included the work schedule of the medical unit, the
ease of setting an appointment, the possibility to obtain an appointment in the near future, the
waiting times at the reception, at the doctor’s office and respectively for other investigations.
Price was addressed under the aspect of its absolute level as reimbursement for medical services
and, secondly, regarding payment options’ attractiveness. In terms of providing complete
information regarding the benefits and the risks of each treatment option, two types of
explanations were investigated, the first concerning the benefits and risks of each treatment
option and the second about the treatment perspectives. In the group on information about the
medical procedures itself, the degree of completeness reflected the possibilities to easily obtain

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 Alexandru-Bogdan Ursoiu and Adina Rotileanu

information from the medical unit, the provision of accessible explanations regarding the
medical act as well as the advices on health caring, receiving answers to all questions and the
correlation of the conclusions of the consultation with previous health information. The respect
with which the patients are treated, the attention paid to them and the kind amiability shown by
the staff were each defalcated on the medics, nurses, reception and support staff. The logistics
base grouped the various aspects covering the address where the medical unit is located, the
ease of movement in the buildings, the comfort provided by the condition of the buildings, the
comfort provided of other amenities and facilities, the food catering services, the cleanliness
and hygiene of spaces, location’s accessibility and the effectiveness of the setting of the parking.

Figure 2 The patients’ satisfaction aspects structure

Source: Author drawing
As revealed by the study, the patients manifest the greatest interest, thus conferring the
highest importance, about receiving a high level of attention from the medical unit (8.35 score
out of 10) and benefiting from the services of a medical staff that delivers a high performance
(8.30 score). The respondents also display a high regard for the perceived level of respect (8.14
score) and desire to be well informed concerning the benefits and the risks of each treatment
option (7.67 score). In terms of logistics base and waiting time, the interest is relatively average
(with 7.54 and 7.26 score respectively). The staff’s amiability also receives a decent importance
(6.78 score), surpassing that of the complete information regarding the medical procedures
(6.43 score). The lowest relative importance is associated with price (6.21 score) and the
performance of the auxiliary staff (6.04 score). Notably, all the proposed criteria scored with
above absolute average importance from the patients on the scale from 1 to 10 points, showing
a relevant choice of elements included in the study.

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 Findings About the Main Drivers for Medical Services and Private Health Insurance Customer
Satisfaction in Romania

Figure 3 The hierarchy of importance for some relevant aspects for patients’ satisfaction
Source: Author statistical survey
Gender plays a significant role regarding the importance given to the logistic base (p=0.045
resulted from ANOVA analysis, unifactorial, α=0.05), and age, as it was revealed, influences
the importance given by the participants to the attention for the patient (p=0.014), medical
staff’s performance (p=0.013), the respect for the patient (p=0.043), providing complete
information regarding the benefits and the risks of each treatment option (p=0.029), logistics
base (p=0.002), waiting time (p=0.045) and staff’s amiability (p=0.013). Household income
level is relevant when considering the amount of importance conferred by the patients to the
logistics base (p=0.020) and to the complete information regarding the benefits and the risks of
each treatment option (p=0.018). Visiting a state-owned medical facility or a private-owned one
has an influence on the way the patients associate importance to the attention they receive from
the medical unit (p=0.027) while the education level, on the other hand, does not seem to
generate any distinct impact on the importance given to the attributes of the medical services.
However, the higher education, the higher adoption of private health insurance.
Regarding the health insurance, from the total sample that is representative for Romanian
urban population, almost all respondents who declared that are using paid medical services are
in above average income category. Nevertheless, there is a significant 9.5 percentage who are
not using family doctor, mainly in 25-44 years old age category (the same category that is using
mostly PHI or Healthcare subscription).
For medical services related consumer attitudes and more specific, for private health
insurance services, the consumer beliefs are both informative and eval uative (Cătoiu and
Teodorescu, 2004), associated with the five identified product attributes, such as the access to
medical products or services in a private clinic or private hospital, when the policy holder needs
it and the hospitalization or access to certain products or medical services in case of illness,
offered up to the amount of the health insurance. In the PHI research, the public patients’ group
is much larger than the private one, of a private health insurance beneficiaries, 67.7% of the
respondents having an attitude that needs to be considered by the insurance companies’
marketers to increase the probability to acquire a PHI in the future, either stand alone or as a
supplementary/ complementary package on top to the basic public covered services.
Another essential element for the satisfaction is the expectation level set by the patients
regarding the quality of the medical services before effectively benefiting from them. The
results of the study show that the relationship between expectations and satisfaction is an
inversely proportional one, with medium strength (as indicated by the value -0.464 determined

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 Alexandru-Bogdan Ursoiu and Adina Rotileanu

for the parametric correlation coefficient Pearson r). Overall, on the matter of household
income influence on the quality expectation level, the study reveals that the patients that have
a below average income exhibit a quite symmetrical distribution of cases, with very low and
low levels of expectation being roughly equal to high and very high levels (both around 36%).
The average income group however tends to favour high and very high expectations (46%) in
contrast to low and very low expectations (28%). The participants coming from households
with high income, on the other hand, exhibit an even stronger tendency for high and very high
expectations (61%), as opposed to only 24% of the cases representing low and very low
expectations. The analysis concluded that household income does influence the level of
expectations with a very high relevance.
On the other hand, the PHI study provides the similarities and differences of the public and
private insurance beneficiaries in terms of private health insurance perceived characteristics,
reason to purchase it as well as satisfaction drivers as shown in the Figure no. 4.

Figure 4 The most (left chart) and least (right chart) important decision attributes for public and
private insurance beneficiaries
Source: Author drawing
The PHI attributes perception is similar for the pair public and private insurance
beneficiaries in the sense that what private insurance beneficiaries perceived as top important
attributes was the same with public health insurance beneficiaries. From the analyses
performed, both categories provided low scores for hospitalization related attributes, the lowest
for PHI beneficiaries being ‘proximity to the hospital/clinic’ which demonstrates that previous
hospitalization is not the reason for purchasing a PHI but rather the preventive consultations
and investigations. The public-private health insurance dichotomy is used to identify the factors
responsible for buying decisions of the two categories and to estimate the near future private
health insurance development trends in terms of more adoption from public health insurance
beneficiaries.
The study reveals that patients can discern between different elements that have impact on
their satisfaction with the medical services and they bestow the importance on those aspects
accordingly. The healthcare providers as well as the health insurance providers must tailor their
offers and must generally adapt their business philosophy, planning and operations to make
sure that the criteria most relevant to the consumer receives the proper resources to run
smoothly. Patients desire mainly to receive great attention, to interact with a very competent
medical staff, to sense they are paid the proper respect and for every treatment option they are
fully informed to be aware of the benefits and the risks. Healthcare providers’ logistics base
and the waiting time they can offer also receives a significant level of importance from the
patients. Therefore, despite the rather inevitable increase in the investments and operating cost,
there seems to be rewarding for the medical units to develop their facilities and keep them up
to date, from the state of the basic “brick and mortar” buildings to the technical facilities,

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 Findings About the Main Drivers for Medical Services and Private Health Insurance Customer
Satisfaction in Romania

pleasant ambiance, enough parking space, good catering services etc. Efforts must also be done
to keep the waiting time decently short. That fact usually means a higher cost per patient
because, for an instance, there must be an increase in personnel or a decrease in patient servicing
capacity, but fortunately there are ways to compensate. The public-private-partnership can be
here of a real help to cover these specific patients’ needs that do not have a sustainable, long
term solution offered solely by the public system. The other determinant for satisfaction,
namely staff’s amiability, the complete information regarding the medical procedures, price,
and the performance of the auxiliary staff, although they receive relatively lower importance, it
must be considered that are still in absolute terms placed at over 6 out of 10 points. The main
implication is that healthcare providers must use their resources primarily for strengthening the
most important for the patients’ areas and to rationalise, but not to neglect, the less important
elements and to keep them at a decent level, to prevent they become problems in the real sense.
The quickness of the investigations and test results were considered very important attributes
for individuals’ decision in buying a private health insurance, also for the ones who have only
the public health insurance which means that for the correct price for the value received, people
would opt and adopt a private health insurance to cover this specific need.

5. CONCLUSION
This paper is the result of two quantitative studies that aimed to analyse the patients’ satisfaction
drivers and the needs that can be covered by private health insurance considering a future
public-private-partnership health reform. This represents an element of novelty in the field,
providing an increase in the capability for the research to provide valuable information about
the health services related determinants of satisfaction that would eventually encourage
population to access the medical services more for preventive care. Because the findings from
this study can contribute to the better understanding of consumer satisfaction in the field of
healthcare, its applied dimension is also consistent, and the scientific content can be transposed
in both the governmental and practical, business decisions about directing the marketing efforts
towards educating population in health care services usage, to maximize the consumer
satisfaction.

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