Over the past decade, relationship marketing (RM) has also had a major impact on marketing activities in the not-for-profit sector (MacMillan, Money, Money, & Downing, 2005). Morgan and Hunt (1994) defined RM as "all marketing activities directed toward establishing, developing, and maintaining successful relational exchanges." In health service sectors, the performance level of those hospitals engaged in RM was found to be better than the average level of hospitals overall (Naidu, Parvatiyar, Sheth, & Westgate, 1999). With the growing demand for high-quality services and increased market competition, many hospitals are seeking opportunities to engage in long-term relationships with customers. RM activities can benefit the relationship between the outpatient and the physician, which can in turn have a significant influence on patient loyalty (Weng, Huang, & Huang, 2006). Thus, an increasing number of health service sectors have begun to implement RM to try to benefit customers.
Customer relational benefit has been an important subject for RM and is defined as "those benefits customers receive from long-term relationships above and beyond the core service performance (Gwinner, Gremler, & Bitner, 1998)," which also relates to customer loyalty behavior (Berry, 1995). If customers perceive this as a part of a long-term relationship, then this would subsequently facilitate trust and engagement with the organization. Such attitudes will be further reflected in a positive influence on customer loyalty behavior (Patterson & Smith, 2001). A relationship between health service sectors and customers should be established initially to achieve the corresponding long-term benefits for the health service sectors. However, what kind of benefits can be obtained for customers through creating a long-term relationship with health service sectors? In terms of the health service sector, what kind of customer relational benefit might be able to attract customers to form a long-term interaction with the health service sectors, and how might attitudes toward the relationship benefit impact customers? Unfortunately, few studies have examined these problems in the health service industry. This is a question that leads to the necessity of assessing and analyzing the concept of customer relational benefits in greater detail.
Berry, Jeffrey, and Parasuraman (1991) proposed that a good relationship must be founded on a common commitment in the field of service marketing. Relationship commitment can be helpful for reducing customers' propensity to leave the relationship, increasing customer's switching difficulties, and maintaining long-term relationships and is thus seen as an important factor affecting relationship continuity and customer loyalty. However, in the highly competitive and trust-based health care industry, patient commitment not only impacts on patient loyalty but is also positively related to extra-role performance (Ouschan, Sweeney, & Johnson, 2006; Williams, Rondeau, & Francescutti, 2007). Therefore, it is necessary for researchers to explore the influence of antecedents on relationship commitment (Cater & Zabkar, 2009; Morgan & Hunt, 1994). Commitment depends on a kind of psychological motivation (Barnes, 2001). In this respect, many studies found that trust, social bonds, communication effectiveness, and satisfaction are the important antecedents of relationship commitment (Cater & Zabkar, 2009; Hess & Story, 2005; Morgan & Hunt, 1994; Sharma & Patterson, 1999). In the health service sectors, patients' control over the illness condition, participation during medical consultations, and perception of physicians positively influence on the level of their commitment (Ouschan et al., 2006).
In addition to the abovementioned literature, many studies on RM also pointed out that customers perceive relationship benefit with organizations and then decide whether to form a separate relationship commitment with each organization (Cote & Latham, 2006; Friman, Gärling, Millett, Mattsson, & Johnston, 2002; Hennig-Thurau, Gwinner, & Gremler, 2002; Morgan & Hunt, 1994). Although past research has shown that there are relational benefits associated with relationship commitment, most of these surveys were based on business to business rather than business to consumer and did not focus on health service sectors. We have therefore proposed in this study to discuss whether relationship commitment, with regard to health service sectors, might be influenced by the relationship benefit existing between the customers and health service sectors within Taiwan's health industry.
Commitment refers to a relationship where one party responds with a particular behavior that subsequently gives rise to a tendency that favors an ongoing reciprocal interaction between the parties concerned, which derives from a form of psychological motivation that is also found in organizational behavior (Storbacka, Strandvik, & Grönroos, 1994). Moreover, there seems to be a need to maintain this relationship over the long term, which usually involves an investment in certain activities on a continuous basis (Brown, Barry, Dacin, & Gunst, 2005). Commitment is an important concept in RM, which refers to an absolute or definite assurance that a continuing relationship will be sustained with a transaction partner, and represents the ultimate interdependent relationship operating between the buyer and the seller (Wilson, 1995). Commitment also refers to behavior that maintains the existence of a relationship between the organizations and the customers, irrespective of whether the emphasis flows from the organization to the customer or vice versa. However, when customers experience high relationship commitment, they seem less inclined to seek out other organizations (Grossman, 1998). With regard to the importance of relationship commitment, we explored the impact of customer relational benefit on relationship commitment in health service sectors.
Customer Relationship Benefit
From the perspective of the customer, when organizations initiate activities with regard to RM, the customer may also gain profit from such a relationship (Reynolds & Beatty, 1999). Gwinner et al. (1998) conducted an empirical investigation and classified the concept of customer relational benefit into three distinct dimensions: confidence benefits, social benefits, and special treatment benefits, and many scholars carried out empirical research in accordance with the aforementioned three dimensions (Hennig-Thurau et al., 2002; Patterson & Smith, 2001). For example, Patterson and Smith (2001) examined Thai people as the target group to assess whether there might be any difference in the customer relational benefit across different cultures. Because the three-dimensional approach of Gwinner et al. with regard to customer relational benefits has been widely used by many scholars, this study will also follow this example by using the same dimensions.
Customer confidence benefit is based on trust, but this leads to the question as to why customers come to gain such confidence in the first instance. The answer can be found in the fact that such a sense of trust is initially derived from service providers. In this regard, the definition of confidence benefit adopted in this article is mainly the one based on trust. Trust is the confidence between members involved in a relationship and therefore suggested that members would be disinclined to take action against one another but would be willing to take risks where possible actions involve trust between the parties concerned (Moorman, Zaltman, & Deshpandé, 1992). For the development of a relationship between service providers and customers, there should be a feeling of comfort and security, leading to a reduction in anxiety or uncertainty. Thus, customers would gain a sense of confidence toward providers who supply future products and services (Gwinner et al., 1998).
One of the most striking characteristics of health service is information asymmetry. Customers as consumers of health care services have much uncertainty about health care. The extent of the level of trust provided by health care services has become a key factor for the customers to decide whether to sustain a relationship. In this respect, Trust can reduce uncertainty as a function of the accumulation of previous positive service experiences. If customers were satisfied with past performance, they would also tend to be more confident about the future and may have higher intention to stay in the relationship with the organization (Garbarino & Johnson, 1999; Morgan & Hunt, 1994). Therefore, it can be stated that when customers experience confidence benefit with health care service providers because of a long-term relationship, the commitment behaviors of customers will endure in a way that actively maintains the relationship. Hennig-Thurau et al. (2002) also demonstrated that confidence benefit is a positive and significant influence on customer relational commitment gained through customer satisfaction.
Hypothesis 1: Confidence benefit provided by health service sectors will have a positive influence on customer relationship commitment toward those sectors.
Social benefits describe those relationships that have an emotional dimension, which emphasize on how customers' attitudes can be shaped by the personal awareness of the staff and the way friendship develops between employees. Providers and customers may develop a commercial friendship in certain service contexts (Price, Wise, & Frackowiak, 1996). Darden and Dorsch (1990) as well as Gwinner et al. (1998) indicated that, apart from core service benefits, customers and employees also fraternize and identify personally and exclusively with service providers. Similarly, Zeithaml, Bitner, and Gremler (2006) pointed out that social benefits may also be derived from the interaction and the friendship existing between customers and not just those between customers and service providers.
Hennig-Thurau et al. (2002) demonstrated that social benefit indeed has a positive and significant influence on the relationship commitment to a service provider. Thus, when customers set up a long-term relationship with a health care service provider, they will experience a sense of familiarity with that service provider, which could be considered as a type of social relation with the health service industry. When customers interact with service providers, service providers can easily identify those customers who feel comfortable in socializing with others. By establishing good social interactions with customers, service providers can both improve and provide more effective relationship commitment with customers.
Hypothesis 2: Social benefits provided by health service sectors will have a positive influence on customer relationship commitment toward those sectors.
Special Treatment Benefit
Customers may be willing to maintain a long-term relationship with an organization when they expect to receive a special reward. This was labeled as a special treatment benefit that includes both economic and customized benefits. Economic benefits refer to customer expectations concerning special price discounts or concessions, whereas customized benefits refer to a priority service, special care, personal awareness, and what other customers would not receive, which can be further divided into three dimensions: namely, preferential treatment, additional services or consideration, and development history. When compared with other customers, long-term customers would receive better and faster service from service providers (Wulf, Odekerken-Schröder, & Lacobucci, 2001). Hennig-Thurau et al. (2002) found that customers expect to obtain some discounts, faster service, or individualized extra services, which are a part of the core services or would be extended by service providers in the long-term relationship. In addition, if customers maintain an enduring relationship with an organization, they may gain special discounts or financial savings (Peterson, 1995).
Bitner (1995) pointed out that if service personnel provided appropriate special treatment benefits to a customer over the long term, this would effectively enhance customers' commitment. In addition, appropriate economic and resource contents would effectively improve customers' commitment during the process of forming a relationship. The special treatment of customers constitutes a way of switching cost by improving different types of special treatment or customized services and therefore may further improve customers' commitment to service providers (Morgan, 2000). Hennig-Thurau et al. (2002) confirmed that special treatment benefits have a positive and significant influence on relationship commitment.
Hypothesis 3: Special treatment benefits provided by health service sectors will have a positive influence on customer relationship commitment toward those sectors.
The subjects of this research consisted of outpatients from one central and two southern regional hospitals in Taiwan (who underwent treatment several times). Hospital ownership can be categorized into public hospitals and nonpublic hospitals (including nonprofit proprietary hospitals and private hospitals) in Taiwan. About 84.47% (435/515) of the Taiwanese hospitals are nonpublic hospitals, and 15.53% are public. Since the introduction of the National Health Insurance (NHI) in Taiwan in 1995, the coverage rate has increased from 60% to 99% by 2009. Payments from the National Health Insurance Bureau for the treatment of patients have become the most important revenue source for hospitals. As of 2008, 91.87% of all health care facilities in Taiwan were contracted by the NHI system. The three hospitals and all survey patients in this study were all contracted by or enrolled in the NHI program. Recently, the Global Budget Payment System was implemented, which further limited the amount of payment by the National Health Insurance Bureau and also heavily affected profits from medical services. Currently, all types of hospitals are forced to aggressively seek for the ways to improve customer relationship and to develop a variety of innovative medical service alternatives to establish stronger customers' commitment to the relationship with hospitals. The context of the Taiwanese health care system is much different from that of the North America system. For example, NHI has not been initiated in the United States. Therefore, patients always have to pay high out-of-pocket expenses, and the burden of medical expenditures on low-income family is relatively high. In addition, the provision of ambulatory health services is the core business of hospitals in Taiwan; however, outpatient services are not the main source of hospital revenue in North America.
Before launching our survey, we had asked the chief of the Department of Management of each hospital two questions. The first question was "Have your hospital develop or implement any marketing activities directed toward establishing, developing, and maintaining the relationship with customers?" All the respondents of the three hospitals answered "yes." Therefore, we asked the second question: "What kinds of RM activities do you develop or implement?" All the answers of respondents from the three hospitals were highly related to customer RM. For example, they all had used their patient databases to understand patient characteristics and further developed some alternatives to reinforce the physician-patient relationship or the hospital-patient relationship. The older subjects asked a family member to help them provide the information that was requested. The data were collected by using a public self-administered questionnaire that was supplemented with instructions. The survey covered the period from September 12, 2007, to January 31, 2008. From a total of 500 questionnaires administered, 403 valid questionnaires were collected for the actual study (the recovery rate of the valid questionnaires was 80.6%). After this procedure, an empirical analysis with AMOS 6.0 (IBM, Chicago, IL) and SPSS 12.0 (IBM, Chicago, IL) was conducted.
We defined the confidence benefits for customers with respect to the health service industry as the patients' trust in the hospital staff that depends on honesty, integrity, and reliability, whereby the best possible service is provided through regular interaction. Social benefits are defined as cases where patients and hospital staff develop friendships during the interactive process. Special treatment benefits are defined as those that patients are able to obtain from the hospital because of a long-term relationship. To more specifically assess the "important" and "perceptive" factors with regard to outpatients in relation to customer relational benefit and the influence on relationship commitment in Taiwan's hospitals, this research used the concepts of the customer relational benefit of confidence as well as the social and special treatment benefits to carry out the "perception appraisal" and "importance appraisal" of the responses to the questionnaire. On the basis of the scales by Gwinner et al. (1998), Hennig-Thurau et al. (2002), and Patterson and Smith (2001) (the range of Cronbach's α value of each customer relational benefit dimension in these three studies was .82-.93), the measurement items were totally 14 questions. The measurement method that we used in this study was the 5-point Likert scale, where 1 = do not agree very much or very unimportant and 5 = strongly agree or very important.
Customer relationship commitment was defined as customers being eager to retain a continuing, specific, and valuable relation with the health service industry. The design of the question items was based on the study by Morgan and Hunt (1994; Cronbach's α = .895) and Hennig-Thurau et al. (2002; Cronbach's α = .921) and were totally four items. The measurement method used in this study was a 5-point Likert scale, where 1 = do not agree very much and 5 = strongly agree.
Many past studies have pointed out that gender, age, marital status, education level, occupation, monthly household income, discount of treatment charge, chronic disease, treatment department, subjective severity of illness, number of hospital Outpatient Department (OPD) visits, and transportation time will affect the results pertaining to how a relationship develops (Hennig-Thurau et al., 2002; Weng et al., 2006). Such variables were subject to control during the follow-up phase of hierarchical regression analysis.
The empirical analysis was divided into two parts. The first part was concerned with the confirmation of the reliability and validity of the scale through a confirmatory factor analysis (CFA) to verify the construct validity with respect to research constructs. In addition, Cronbach's α method was used to measure the internal uniformity of the constructs. However, the second part used a hierarchical regression analysis to assess the impact of perception and importance of customer relational benefits on relationship commitment.
Validity and Reliability Analysis
When we designed the questionnaire items of customer relational benefit and relationship commitment, we used all the items of these five studies (excluding items having the same or similar meanings) to conduct the initial questionnaire and then evaluated, modified, and selected the suitable items according to the characteristics of the health care environment to accomplish the second-stage questionnaire. All the items of the second-stage questionnaire were modified and validated by six experts in the fields of health care marketing and hospital practitioners (two scholars and four top hospital managers). We finally developed the items of final-version questionnaire according to the experts' opinions.
To avoid errors in relation to many items analyzed in the CFA, we exploited the "half reliability" approach with respect to the average for each factor by comparing odd numbers and even numbers. For instance, this study divided the five items that were designed to measure the perception of confidence benefit (PCB) into two composite indicators; the average value for the odd-numbered items was designated as PCB 1, and the average value for the even-numbered items was designated as PCB 2. The CFA analysis resulted in a goodness of fit for the overall model (χ 2 = 135.86, χ 2/df = 2.56) and other indicators. As the goodness-of-fit index (GFI) = .95, adjusted goodness-of-fit index (AGFI) = .91, normal fit index (NFI) = .96, comparative fit index (CFI) = .97, and incremental fit index (IFI) = .97 were all greater than .90 and root mean square error of approximation (RMSEA) = .06 and root mean square residual (RMR) = .03 were less than .08, we assumed that the goodness of fit was of an appropriate standard. The factor loading of the measurement was greater than .5 (p < .01), and the average variance extracted for each construct was higher than .5. These results show that each construct has good convergent validity and that the average variance extracted is higher than the square of the correlation coefficient between this construct and the others. Furthermore, it also has good discriminant validity (Table 1). In addition, in this study, the range of each factor of Cronbach's α value demonstrated a reliability of .63-.83; hence, these factors can be considered to show dependable reliability.
This study used various methods to minimize the effects of common method variance. Anonymous information and item language organization method were used before using the questionnaire, whereas scale-item trimming and Harman's one-factor test were used after using the questionnaire (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). The results of Harman's one-factor test indicated that the first factor could explain 23.05% of the variation, and 10 of the main components were with larger-than-one eigenvalue. In total, 30 main components were needed for explaining 96.33% of the variation.
Results and Discussion
The demographic analysis of the respondents who completed the 403 validated questionnaires is shown in Table 2. The perception of the customer relational benefit ranked first, and the highest average was 3.91 for "I trust that this hospital will protect my right to treatment." In the case of social benefit, the highest average was 3.76 for "The hospital staff are warm and friendly toward me." Regarding the special treatment benefit, "The hospital will provide me with good service and high-quality facilities" represented the highest average at 3.58. "The hospital will provide me with more discounts or price concessions than is the case for most of the other patients" constituted the lowest average at 2.87, which was ranked 14th. The results of importance analysis showed that the first rank and the highest average were for "I trust that this hospital will protect my right to treatment." With regard to social benefit, the highest average was for "The hospital staff will be very nice and friendly to me." The lowest average, ranked 14th, was 3.15 for "The hospital staff know my first or last name." In the case of the special treatment benefit, "This hospital will provide me with better service and facilities" had the highest average at 3.89 (Table 3).
According to the study's findings, confidence benefit ranked first or highest, and special treatment benefit ranked last or the lowest, which are in line with the findings of Gwinner et al. (1998) and Hennig-Thurau et al. (2002) in relation to the perception of the customer relational benefit. People, in general, were observed to consider confidence benefits as the most important, and the social benefits were considered as the least important, among the different kinds of customer relational benefit, and thus both the perception and the importance of people's confidence benefits were high. When seeking medical treatment, a customer's main concern is to obtain a cure for an illness and to receive appropriate treatment. In this respect, customers are not concerned about creating good social interactions with and receiving special treatment from health service organizations. Moreover, as already pointed out, there tends to be information asymmetry within the health care service, and customers may be seeking to reduce uncertainty with regard to the treatment process by the way of building up confidence benefit.
Hierarchical Multiple Regression
Residuals plot shows research data that meet the assumptions of linearity and normality. The total of the variance inflation factors of the independent variables was less than 10. Subsequently, when we performed the hierarchical multiple regression analysis, only age, monthly household income, treatment department, and number of hospital OPD visits were found to be significant with regard to the control variables (Table 4).
As for the perception toward customer relational benefit, the relationship commitment of each construct was found to be significant in model two, especially the perception toward confidence benefit (β = .41), which was followed by the perception toward social benefit (β = .23) and the perception toward special treatment benefit (β = .14). When the perception and importance of customer relational benefit were added to the model simultaneously (model four), only the PCB (β = .52) was significantly and positively correlated with relationship commitment; however, the perception of social and special treatment benefit did not influence relationship commitment (Table 5). The customer relational benefit had both positive and negative influence on relationship commitment as was also found in previous related research. Research on physicians and the insurance industry carried out by Cote and Latham (2006) showed that customer relational benefit had a positive influence on relationship commitment. Moreover, Morgan and Hunt (1994) emphasized that the economic benefit of customer relational benefit had a positive influence on relationship commitment. The empirical results of Hennig-Thurau et al. (2002) indicated that confidence, social benefit, and special treatment benefit had a directly or indirectly positive influence on relationship commitment.
Regarding the importance of customer relational benefit, every construct had a positive influence on relationship commitment, especially social benefit (β = .34), which was followed by special treatment benefit (β = .27) and confidence benefit (β = .18) in relation to model three. When both the perception and the importance of customer relational benefit were added to the model (model four), each construct of customer relational benefit was significant, but only the importance of confidence benefit had a significant and negative influence on relationship commitment (β = −.14), and the importance of social (β = .39) and special treatment (β = .22) benefits was still significantly positive. The reason for this may be that when customers place great importance on confidence benefit, their first consideration is choosing health service organizations whose medical personnel are considered to be highly skilled. If other health service organizations are more competent and provide better medical treatment, customers will immediately opt for such organizations. The more the customers emphasize confidence benefit, the more reluctant they will be to build up the relationship commitment with health service organizations (the importance of confidence benefit has a negative influence on relationship commitment); hence, managers of health service organizations should try to ensure improvement in medical techniques and the right of treatment. If these steps are taken, customers will have high PCB and will seek to establish a long-term relationship commitment with health service organizations. According to the abovementioned findings, Hypotheses 1-3, as used in this study, were only partially supported.
Conclusions and Implications
Most people seem to regard confidence benefit as more important than social and special treatment benefit. Although the public receives few special treatment benefits from health service organizations under the current system, they still think such benefits are important. This means that when people seek medical treatment, they do expect to receive economic or customized benefit. In the case of social benefits, individuals may experience social benefit when interfacing with health service organizations; however, this may not be of high priority in people's minds. In fact, the perception level of confidence benefit is the key positive influence on relationship commitment. In addition, the great importance of social and special treatment benefits for outpatients also have a positive impact on relationship commitment. However, when the customers place more importance on the confidence benefit, they are less likely to establish a long-term relationship commitment with the hospitals.
Management Implications and Suggestions
Our research found that customer relationship benefit can indeed be considered as an important strategic dimension to reduce the risk of customer switching. When managers try to establish strategies to manage the delivery of relational benefits to customer, they should decrease some "efficiency-oriented" works that are against the delivery of these benefits. For example, employees of health service organizations are often encouraged to be quick in dealing with customers. Although this will improve operational efficiency, it may also reduce the opportunities for health service organizations to providing customer relational benefit.
Confidence benefit serves as the most useful barrier in preventing customers from switching over to another health service organization. Therefore, when health service managers develop marketing strategies using customer relational benefit, they still need to enhance the PCB, which is the most important way to improve customer relationship commitment to the hospital. Some specific ways to manage the PCB can be suggested on the items of confidence benefit. First, managers should try to ensure that "right of treatment" is provided. For example, privacy should be given high priority. When a customer trusts that the hospital will protect his treatment rights, he or she would feel more confident on the hospital, and the perception of customer relational benefit would also be effectively improved. Second, health service competence and quality are the foundation stones for success in health services over the long term. Customer trust, in relation to the expectation that health service staff will provide the best service, can help create a sense of "release and relief" in customers. In addition, the upgrading of health service quality in hospitals can create greater confidence and trust among customers to the extent that customers will be assured that the medical staff are honest and reliable. When conflicts arise with regard to similar benefits experienced by customers, health service organizations should take a neutral position by dealing with the problem publically and honestly by informing customers about the reason for the conflict or negligence on the part of the health service organization.
The importance of social and special treatment benefits may also have a great influence on their relationship commitment. In the event when health service managers seek to install resources for establishing and maintaining a good relationship commitment with customers, the crucial factors of social and special treatment benefits should not be ignored. If customers could understand the confidence, social, special treatment value of staying in the relationship, then they may realize the much higher switching cost and would be less inclined to leave the relationship with a health service organization. Thus, health service organizations need to focus on issues concerning social and special treatment benefits for reinforcing their effectiveness. With respect to social benefits, as most people undergo medical treatment due to illness, health service organizations should request medical personnel to present a warm and caring demeanor similar to that existing between friends. In this respect, for a small organization, it would also be advantageous for health service personnel to remember an individual's first or last name to reduce his or her anxiety. However, for larger health service organizations, they can create a more personal service encounter through the adoptions of several customer relationship management technologies.
With respect to special treatment benefits, health service organizations should consider simplifying the medical procedures and should provide faster care services and form lasting relationships with customers, except to provide customers with better facilities. Accordingly, the different needs and preferences of customers should be taken into account when providing additional health services and latest treatment information as well as in cases where patients might be unfamiliar with particular services (e.g., the premium expense of treatment for customers). However, health service managers should note that special treatment benefits are the most easily duplicated benefit and do not provide a sustainable source of competitive advantage. Confidence benefit and social benefits may be more useful to create differentiation strategies because they can be harder for other health service organizations to copy in the short run.
Research Limitations and Suggestions for Future Research
Whether the results of this study can be extrapolated to the entire health service industry require further verification. In particular, there are many differences between the Taiwanese and the North American health care environment. Therefore, the analysis results with respect to the outpatients of the Taiwanese hospitals may also be different from those of North American hospitals. We suggest that researchers investigate a large-scale data set from other national health care facilities and control some factors that are derived from the differences of different health care systems. In this study, we used the connotation of customer relational benefit to explore its influence on relationship commitment in the health service industry as proposed by Gwinner et al. (1998). Other researchers can extend the approach of Gwinner et al. to study further topics relating to the health service industry. Finally, this study used a cross-sectional research design. We suggest that researchers collect information using longitudinal data to clarify the influence of relationship commitment over a longer period.
The authors would like to thank the editor and the anonymous reviewers for their constructive comments and recommendations.
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Keywords:Copyright © 2010 Wolters Kluwer Health, Inc. All rights reserved
customer relational benefit; health service; relationship marketing; relationship commitment