MEASURING SERVICE QUALITY IN THE HEALTH CARE INDUSTRY IN A DEVELOPING COUNTRY CONTEXT Baharak Mohabbat Talab DBA Student,

Southern Cross Business School Southern Cross University Locked Bag 4 Coolangatta 422 Australia

!a"ar U# Ah$ed% De&art$ent o" Marketing School o" Business

Lebanese A eri!an Uni"ersit#

'#(# Bo) *+,-. / -, Chouran Beirut ,,/2.20/,

Leban$n
1$ail+ 2a"aruah$ed3g$ail#co$ %4Corres&onding Author5

Craig C# 6ulian Southern Cross Business School Southern Cross University Locked Bag 4 Coolangatta 422 Australia

A%STRACT This study $easures service 7uality in the health care industry in a develo&ing country o" the Middle 1ast, na$ely 8ran, using the "ull S19:;UAL <a& Model develo&ed by 'arasura$an et al., ,=0 , via custo$ers> &erce&tions and e)&ectations in an out&atient section in a &rivate ?os&ital# The results o" the study suggest that all di$ensions o" the S19:;UAL <a&

Model, na$ely, tangibles, reliability, res&onsiveness, assurance and e$&athy @ere i$&ortant to achieve service 7uality and thereby $aintain so$e sort o" co$&etitive advantage# The study also &rovided suggestionsAreco$$endations to senior $anage$ent at the &rivate hos&ital to hel& enhance "unctional service 7uality and increase &atient>s satis"action# &e# '$r(s) S19:;UAL, tangibles, reliability, res&onsiveness, assurance, e$&athy#

INTRODUCTION 8n today>s global $arket, the service industry is gro@ing at a ra&id &ace# !eitha$l and Bitner 42//-5 suggested services are deeds, &rocesses and &er"or$ances @hilst 'adilla et al. 42//=5 suggested services are intangible not including &hysical &roducts or construction @hich is &roduced and consu$ed according to the needs and de$ands o" consu$ers# Botler et al# 4,===5 also clai$ed services are econo$ic activities or bene"its that are o""ered by one &arty to another that does not a""ect the &ossession o" anything# 8n last three decades service 7uality has been de"ined di""erently by $any researchers 4e#g#, 'arasura$an et al., ,=0 C Bitner et al., ,==4C Cronin and Taylor, ,==25# 'arasura$an et al, 4,=0 5 suggested service 7uality to be the di""erence bet@een e)&ectations and &erce&tions in a service encounter# Bitner et al. 4,==45 suggested service 7uality @as the overall i$&act o" the virtual inade7uacyAascendancy o" the service &rovided by a co$&any @hilst 9oest and 'ieters

4,==D5 suggested service 7uality @as a kno@n inconsistency a$ong e)&erienced.based nor$s and deeds relating to service bene"its# Eet Arnauld et al. 42//25 suggested service 7uality @as the custo$erFs evaluative verdict about the overall e)cellence in &roviding certain desired bene"its# ?o@ever, $any other researchers have de"ined service 7uality as an attitude o" the custo$er to &erceived 7uality# There have been several atte$&ts to $easure service 7uality in the services $arketing literature, ho@ever, 'arasura$an et als 4,=0 5 @ork in service 7uality and the S19:;UAL Model is &robably the $ost cited and acce&ted $easure o" service 7uality# As such, this study uses the S19:;UAL $easure o" service 7uality develo&ed by 'arasura$an et al 4,=0 5, na$ely, the di$ensions o" tangibles, reliability, res&onsiveness, assurance and e$&athy to assess service 7uality in the health care industry in 8ran, a develo&ing country o" the Middle 1ast# THEORETICAL *RAME'OR& 'al$er et al 4,==,5 suggested that 7uality in the healthcare industry @as as a result o" enhanced health and the satis"action o" residents surrounded by the construction o" e7ui&$ent, resources, and &atient>s conditions and situations# <rGnroos 4,=045 and Seth et al 42// 5 suggested that there @ere three as&ects o" 7uality in health care that @ere i$&ortant, na$ely, technical 7uality, "unctional 7uality and cor&orate i$age# Technical 7uality is the technical e)actness o" health Hudg$ent and &rocedures# Iunctional 7uality is the &rocesses and deeds that service and treat$ent is delivered by @ith cor&orate i$age being the service &rovider>s i$age that is develo&ed through technical and "unctional 7uality# 9ivers and <lover 42//05 suggested that the technical 7uality o" $edical services consists o" t@o sub.di$ensions# Iirstly, the suitability o" the service &er"or$ance and the skills @ith @hich that suitable service is &er"or$ed and that hos&itals need to build high.7uality services "or -

each and every &atient# Secondly, the skills @ith @hich suitable care is co$&lete and i$&le$ented including overall skill, decisions that are $ade, and the ti$eliness o" the i$&le$entation# ?o@ever, the 7uality o" the inter"ace bet@een $edical &roviders and &atients de&ends on a nu$ber o" consistent issues, including the 7uality o" co$$unication bet@een e$&loyees and &atients, the $edical &rovider>s ability to sustain the &atient>s trust and a ca&ability to delight the &atient @ith co$&assion, integrity and Hudg$ent# <rGnroos 4,==-5 noted that, &articularly in the healthcare industry, technical 7uality $ight be di""icult "or &atients to assess that do not have su""icient technical e)&erience and kno@ledge, ho@ever, "unctional services 7uality can be assessed as &atients have a &ro&ensity to rely on ho@ a service is delivered# Iurther$ore, Asubonteng et al 4,==J5 suggested that &atients Hudge "unctional service 7uality as the $ost critical "actor in service transactions co$&ared @ith technical 7uality due to a lack o" kno@ledge about technical as&ects# <rGnroos 4,==-5 also suggested that 7uality o" service in both technical and "unctional as&ects are the $ain constituents to success "or a service organi2ation and have a considerable relationshi& @ith &ro"itability, custo$er satis"action and custo$er retention# Singh 4,==,5 "urther suggested that @hen assessing hos&itals &er"or$ance technical as&ects $ust be elaborated on to include "unctional 7uality &erce&tions as @ell as technical 7uality &erce&tions @hich lends su&&ort to the use o" the 'arasura$an et al 4,=0 5 S19:;UAL <a& Model @hen $easuring service 7uality in such an environ$ent# Many researchers have a si$ilar vie@&oint in relation to a &atient>s &erce&tion o" 7uality in the healthcare sector and believe that the variation in culture in"luences the assess$ent o" 7uality by custo$ers and service &roviders# Ior instance, Mattila 4,===5 contended that cultural "actors have a great in"luence on a custo$er>s assess$ent o" service than on their assess$ent o"

tangible bene"its because o" the inter"ace bet@een custo$ers and "ront line sta"" @hen services are delivered 46ulian and 9a$aseshan, ,==45# 'arasura$an et al. 4,=0 5 noted the &erce&tion o" 7uality is an outco$e o" the co$&ression o" custo$er e)&ectations @ith the actual service they receive "ro$ the service &rovider# Ku$erous studies have sho@n that high service 7uality in the healthcare industry is related to a &atient>s satis"action and their intention to be loyal and be retained by the service &rovider# Ta$ 42//D5 suggested that a &atient>s satis"action is thought to be a signi"icant indicator o" service 7uality# Bolton and Dre@ 4,=005 $entioned that &erceived 7uality by custo$ers is the $ost signi"icant variable a""ecting a custo$er>s &erce&tion o" value and satis"action and in their intention to &urchase a &articular good or service# This @as also noted by 9oss et al 4,=0D5 @hen they "ound that the initial e)&ectation by &atients is the "irst ele$ent that deter$ines satis"action and i" the &erceived care and treat$ent "all short o" their e)&ectations, then the conse7uence @ill be a &atient>s dissatis"action# Donabedian 4,=0/5 illustrated that &atient satis"action is an i$&ortant contributor to the $eaning o" servicesA&roducts 7uality "ro$ the &ers&ective o" &atients> values and their e)&ectations and a signi"icant ele$ent o" care 7uality because &atients @ho are satis"ied are $ore @illing to act in accordance @ith the $edical &roviders and to collaborate or continue a relationshi& @ith that &articular &rovider# Due to di""erences in e)&ectations, it is also &ossible that a &atient>s satis"action $ay vary "ro$ the sa$e &rovider 4Ta$, 2//D5# (ne o" the barriers "or healthcare service &roviders is to be able to learn "ro$ their &atients and this @as identi"ied by Lensing et al 42//-5 as an issue as it is di""icult to $eet all o" the &atients> needs and desires# (ther "actors including increasing @orkloads, busy ti$etables, cost i$&lications and ti$e constraints o" the service &rovider to

s&end ti$e @ith their &atients @ere all cited as issues i$&acting service 7uality in the healthcare industry 4Ta$, 2//D5# 6ayanti and Burns 4,==05 also suggested that &atients &lay an i$&ortant role in achieving 7uality treat$ent and services# As a result, &atients $ust be $ore &roactive in their o@n care and treat$ent 4'rice et al., 2//J5# Ku$erous studies have also re&orted issues &ertaining to the co$&etitive i$&act and &ers&ectives in the healthcare industry# Ior instance, several studies have investigated the relationshi& bet@een co$&etitive intensity and healthcare 7uality 4e#g#, !@an2iger and Melnick, ,==JC Chassin, ,==D5, bet@een health care costs and co$&etition 49obinson and Lu"t, ,=0 5 and bet@een &atient satis"action and co$&etition 4Miller, ,==J5# 8n their studies, they stated that traditional co$&etition in the healthcare sector involves 7uality, &rice, e)&ediency, and e)cellence in &roducts or services, although it can also be through the ado&tion o" ne@ and advanced technologies and innovative servicesA&roducts# 9ivers and <lover 42//05 suggested that a $ain co$&onent o" co$&etition in the healthcare sector is the ability to &roduce a $ethod "or reducing $edical costs# Co$&etition co$$only reduces the ine""iciencies o" high &roduction costs that eventually lead to high healthcare service 7uality and &rocedures i$&rove$ents# This leads to cost reduction, @hich in turn i$&roves custo$er satis"action# Iolland et al 4,==-5 noted that in the healthcare industry $arket "ailures also e)ist due to a lack o" co$&etition# ;uality co$&etition is an as&ect o" an oligo&olistic $arket but &rice co$&etition generally is not# As co$&etition increases, in order to survive, service &roviders need to &ay $ore attention to increasing custo$er satis"action and retaining e)isting custo$ers# According to Shahin 42//J5 the $easure$ent o" service 7uality allo@s "or the co$&arison o" be"ore and a"ter certain service encounters and the $easure o" service 7uality should be the di""erence bet@een the e)&ectations o" the service encounter by the custo$er and @hat @as actually delivered#

There are $any $odels, @hich are available to $easure service 7uality, &articularly in the healthcare industry, na$ely, S19:;UAL 4'arasura$an et al., ,=0 5 and S19:'19I 4Cronin and Taylor, ,==25 to na$e Hust a "e@# The S19:;UAL Model is the $ost @idely acce&ted $easure o" assessing service 7uality in the healthcare industry and that is @hy it has been selected to assess service 7uality in a &rivate hos&ital in 8ran# S19:;UAL @as used to evaluate custo$ers> e)&ectations be"ore a service @as delivered and their &erce&tions o" the service a"ter it @as delivered 4'arasura$an et al., ,=0 5# 'arasura$an et al. 4,=0 5 identi"ied 22 state$ents in the S19:;UAL $odel, across "ive di$ensions, na$ely tangibles, reliability, res&onsiveness, assurance and e$&athy# A s&eci"ic advantage o" the S19:;UAL $odel @as that it is a &roven reliable and valid $easure o" service 7uality 4Brysland and Curry, 2//,5#

METHODOLOGY This @as an e)&loratory study conducted in a &rivate hos&ital in 8ran using 'arasura$an et als 4,=0 5 S19:;UAL $easure to deter$ine service 7uality and its e""ect on the healthcare industry in a develo&ing country conte)t o" the Middle 1ast, na$ely 8ran# The 7uestionnaire @as designed in accordance @ith the 22 original state$ents "ro$ the S19:;UAL $odel develo&ed by 'arasura$an et al 4,=0 5 intending to $easure "ive di$ensions o" service 7uality, na$ely, tangibles, reliability, res&onsiveness, assurance and e$&athy# A D.'oint Likert Scale @as used to $easure custo$er>s e)&ectations and &erce&tions against the "ive di$ensions o" service 7uality# The D.&oint Likert Scale ranged "ro$ strongly disagree 4,5 to strongly agree 4D5# ;uestionnaires @ere hand delivered to the &rivate hos&ital>s &atients in the out&atient de&art$ent# A total o" , /

7uestionnaires @ere hand delivered to out&atients and ,// @ere returned indicating a res&onse rate o" JDM and considered to be ade7uate# All res&ondents @ere less than / years old# The a$ount o" in"or$ation re7uested in the 7uestionnaire @as reasonable because &artici&ants @ere only re7uested to s&eci"y their level o" agree$ent or disagree$ent @ith the 22. state$ents in the S19:;UAL $odel designed to $easure custo$er>s e)&ectations and &erce&tions against the service 7uality di$ensions o" tangibles, reliability, res&onsiveness,

assurance and e$&athy# Background in"or$ation @as re7uested "ro$ the &artici&ants in order to the di""erentiate the$# The average ti$e taken by &artici&ants to co$&lete the 7uestionnaire @as less than , $inutes# DATA ANALYSIS The data @ere initially analysed using &rinci&al co$&onents analysis to assess the &sycho$etric &ro&erties o" the instru$ent# (ur &ri$ary concern @as to ensure all state$ents loaded onto their a&&ro&riate "actors# The service 7uality di$ensions, na$ely, tangibles,

reliability, res&onsiveness, assurance and e$&athy all loaded a&&ro&riately and no cross loadings above #2 @ere identi"ied @ith only "actor loadings o" above # being acce&ted# The "inal

reliabilities "or all scales @ere greater than #D/# The &reli$inary results indicated that the &sycho$etric &ro&erties o" the scales @ere acce&table and as such it @as a&&ro&riate to e)a$ine the ga& bet@een custo$er e)&ectations and &erce&tions @ithin the o" tangibles, reliability, res&onsiveness, assurance and e$&athy# 'atients @ere asked to sho@ the e)tent to @hich they believed the &rivate hos&ital had the "eature described in the state$ent# Lith a nu$ber "ro$ , to D that sho@ed their level o" e)&ectation and &erce&tion against the service 7uality di$ensions &atients res&onded to 22 service 7uality di$ensions and 22 service 7uality di$ensions

state$ents $easuring custo$er e)&ectations against the 0

state$ents $easuring custo$er &erce&tions against the

service 7uality di$ensions a"ter being

e)&osed to the service# The di""erence bet@een custo$er e)&ectations and &erce&tions @as used to $easure the ga& in service 7uality that e)isted in the &rivate hos&ital on the di$ensions o"

the S19:;UAL $odel $easuring service 7uality, na$ely, tangibles, reliability, res&onsiveness, assurance and e$&athy 4'arasura$an et al., ,=0 5# Data collection involved a su$$ary o" ty&ical values @ith Nty&icalO being the $ean res&onse @hen the distribution @as sorted "ro$ lo@est to highest 4Coo&er and Schindler, 2//-5# All data collected "ro$ &atients @as entered into an S'SS s&read sheet in order to $easure the service 7uality ga&s as result o" < 4service 7uality ga&5 P ' 4&erce&tions5 .1 4e)&ectations5 "or each state$ent# The total ga& @as then calculated based on the distribution o" state$ents in each di$ension, na$ely, tangibles, reliability, res&onsiveness, assurance and e$&athy 4'arasura$an et al., ,=0 5# A"ter the "inal result @as calculated "or each di$ension, as is the re7uire$ent o" the S19:;UAL $odel, all the data @as averaged "or each di$ension "or each single &atient# The results are described in Table ,#

TABLE # 1SERVQUAL MEASURE OF SERVICE QUALITY IN HEALTHCARE.

Di ensi$n State ent A"era+e E A"era+e P A"era+e G Di ensi$n Ga, A"era+e Di ensi$n Ga,

Tan+ibles

State$ent , State$ent 2 State$ent State$ent 4 State$ent State$ent J State$ent D State$ent 0 State$ent = State$ent ,/ State$ent ,, State$ent ,2 State$ent ,State$ent ,4 State$ent , State$ent ,J State$ent ,D State$ent ,0 State$ent ,= State$ent 2/ State$ent 2, State$ent 22

J# 2 J# = J#J J#42 J# 0 J# 4 J#J J#JJ J#J0 J#J4 J#J, J# J J#JJ#J J#0D J#0

# 2 #J # = #,J -#2-#,J #2J 4#24 2## 2 2#-0 #JJ -#,D -#2 # 2 -#-J 4#,, 4#-2 2#-D -#24 4#D 4#DD

., ./#=4 .,#/, .,#2J .-#.-#-0 .,#-4 .2#42 .4#-.,#,2 .4#2./#= .-#4J .-#4 .,#.-#44 .2#D.2#20 .4#2 .-#-= .,#0= .,#0= .4#2, .,#/4D

Reliabilit#

.,4#02

.2#=J4

Res,$nsi"eness

.=#D,

.2#42D

Assuran!e

E ,at-#

J#04 J#J J#J2 J#JJ# = J#JJ A"era+e Un.ei+-te( SERVQUAL S!$re

.,/#=2

.2#D-

.,-#D

.2#D4

.2#-0,0

,/

DISCUSSION A"ter analysing &atients> &erce&tions and e)&ectations o" the service 7uality at the ?os&ital, it @as 7uite clear that there @as a higher e)&ectation o" service 7uality co$&ared to the actual &erce&tion o" service 7uality a"ter &atients had been e)&osed to the service# The average e)&ectation o" service 7uality @as at J#JAD @hile the average &erce&tion o" service 7uality a"ter being e)&osed to the service @as 4#2AD# This suggests that the &rivate hos&ital @as unable to $eet custo$er e)&ectations as the &atients at the &rivate hos&ital did not &erceive the service 7uality at the hos&ital to be at the level they e)&ected# The overall ga& bet@een e)&ectations and &erce&tions o" service 7uality re$ained negative "or all di$ensions o" the S19:;UAL $odel in the out&atient de&art$ent at the hos&ital# The tangible di$ension indicated a negative ga& o" Q ,#/4D AD, @hich suggests that the hos&ital @as unable to &rovide &hysical "acilities, e7ui&$ent and the a&&earance o" their &ersonnel at a level e)&ected "ro$ &atients# ?o@ever, this negative ga& o" .,#/4D AD @as $uch less than the ga&s in the other S19:;UAL di$ensions i#e# reliability 4.2#=J4AD5, res&onsiveness 4.2#42D AD5, assurance 4.2#D-AD5 and e$&athy 4.2#D4AD5 @ith the reliability di$ension having the highest negative ga&# Lhen analy2ing the i$&ortance o" the di""erent di$ensions o" the S19:;UAL $odel, it sho@ed that the res&onsiveness di$ension @as regarded as the $ost i$&ortant di$ension "ollo@ed by reliability, assurance, tangibles and "inally e$&athy# RE*ERENCES Arnauld, 1#, 'rice, L# and !inkhan, <#, 42//25, Consumers, 2nd edition, Mc.<ra@.?ill, Ke@ Eork# Asubonteng, '#, Mc Cleary, B#6# and S@an, 6#1#, 4,==J5, S19:;UAL revisited+ a critical revie@ o" service 7uality, Journal of Services Marketing, ,/4J5+ J2.0,# Binter, M#6#, Boo$s, B#?# and Mohr, L#A#, 4,==45, Critical service encounter+ the e$&loyee vie@&oint, Journal of Marketing, 0445+ = .,/J# Bolton, 9#K# and Dre@, 6#?# 4,=005, A $odel o" &erceived service value, technical note, 88420.1, <T1 Laboratories, Laltha$, MA# Brysland, A# and Curry, A#, 42//,5, Service i$&rove$ents in &ublic services using S19:;UAL, Journal of Managing Service ualit!, ,,4J5+ -0=.4/,#

,,

Chassin, M#9#, 4,==D5, Assessing strategies "or 7uality i$&rove$ent, Journal of "ealth #ffairs, ,J4-5+ , ,.,J,# Coo&er, '#S# and Schindler, D#9#, 42//-5, $usiness research metho%s, 0th ed#, Mc<ra@.?ill, Ke@ Eork# Cronin, 6#6# and Taylor, S#A#, 4,==2&, Measuring service 7uality+ a re.e)a$ination and e)tension, Journal of Marketing, J4D5+ .J0#

Donabedian, A#, 4,=005, NThe 7uality o" careC ho@ can it be assessedRO Journal of the #merican Me%ical #ssociation, 2J/4,25+ ,D4-.,D40# Iolland, S#, <ood$an, A#C# and Stano, M# 4,==-5, 'he (conomics of "ealth an% "ealth Care, -rd ed#, Mac$illan 'ublishing Co$&any, Ke@ Eork# <rGnroos, C# 4,==-5, A service 7uality $odel and its $arketing i$&lications, (uro)ean Journal of Marketing, ,0445+ -J . #

6ayanti, 9# and Burns, A# 4,==05, The antecedents o" &reventive health care behavior+ an e$&irical study, Journal of the #ca%em! of Marketing Science, 2J4,5+ J., # 6ulian, C#C# and 9a$aseshan, B# 4,==45, The role o" custo$er.contact &ersonnel in the $arketing o" a retail bank>s services, *nternational Journal of +etail an% ,istri-ution Management, 224 5+ 2=.-4# Botler, '#, Ar$strong, <#, Saunders, 6# and Long, :# 4,===5, .rinci)les of Marketing, 2nd ed#, 'rentice.?all, London#

Mattila, A#S#, 4,===5, The role o" culture and &urchase $otivation in service encounter evaluations, Journal of Services Marketing, ,-44A 5+ -DJ.-0=#

Miller, 9#?#, 4,==J5, Co$&etition in the health syste$+ good ne@s and bad ne@s, Journal of "ealth #ffairs, , 425+ -,2.-2/# TeHeida.'adilla, 9#, Ilores.Cadena, M#, Morales.Mata$oros, (# and Badillo.'iSa, 8# 42//=5, 8n search o" a viable syste$ $odel "or a"ter.sales s&are &arts service in Teleco$ "ir$s# Available ,2

"ro$+ Thtt&+AAHournals#isss#orgAinde)#&h&A&roceedings -rdAarticleAvie@A,2,4A42, 'al$er, 9#?#, Donabedian, A# and 'ovar, <#6#, 4,==,5, Striving for ualit! in "ealth Care/ #n *n0uir! into .olic! an% .ractice, ?ealth Ad$inistration 'ress, Chicago, 8L# 'arasura$an, A#, !eitha$l, :#A# and Berry, L#L#, 4,=0 5, A conce&tual $odel o" service 7uality and its i$&lications "or "uture research, Journal of Marketing, 4=+ 4,. /# 'rice, S#, Ste@art, M# and Mac'herson, ?#, 42//J5, 'ractitioner e$&athy, &atient enable$ent and health outco$es+ a &ros&ective study o" acu&uncture &atients, .atient (%ucation an% Counseling, J-4,5+ 2-=.24 # 9ivers, '# and <lover, S#?# 42//05, ?ealth care co$&etition, strategic $ission, and &atient Satis"action+ research $odel and &ro&ositions, Journal of "ealth 1rgani2ation an% Management, 224J5+ J2D Q J4,# 9obinson, 6#C# and Lu"t, ?#I# 4,=0 5, The i$&act on hos&ital $arket structure on &atient volu$e, length o" stay, and cost o" care ,=D2.,=02, Journal of "ealth (conomics, 4445+ ---.- J# 9oest, ?# and 'ieters, 9# 4,==D5, The no$ological net o" &erceived service 7uality, *nternational Journal of Service *n%ustr! Management, 0445+ --J Q - ,# 9oss, C#B#, Iro$$elt,<#, ?a2el@ood, L# and Chang, 9#L# 4,=0D5, The role o" e)&ectation in &atient satis"action @ith $edical care, Journal of health care marketing, D445+ ,J.2J# Seth, K#, Desh$ukh, S#<# and :rat, '# 42// 5, Service 7uality $odels+ a revie@, *nternational Journal of ualit! 3 +elia-ilit! Management, 224=5+ =,-Q=4=# Singh, 6# 4,==,5, Understanding the structure o" consu$ers> satis"action evaluations o" service delivery, Journal of the #ca%em! of Marketing Science, ,=4-5+ 22-.44# Ta$, 6#L#M#, 42//D5, Linking 7uality i$&rove$ent @ith &atient satis"action+ a study o" a health service centre, Marketing *ntelligence 3 .lanning, 2 4D5+ D-2.D4 # Lensing, M#, :ingerhoets, 1# and <rol, 9# 42//-5, Ieedback based on &atient evaluations+ a tool "or 7uality i$&rove$entR Journal of .atient (%ucation an% Counseling, ,425+ ,4=., -, !eitha$l, :#A# and Bitner, M#6#, 42//-5, Services Marketing, -rd ed#, Mc<ra@.?ill, Ke@ Eork# !@an2iger, 6# and Melnick, <#A#, 4,==J5, Can $anaged care &lans control health care costsR Journal of "ealth #ffairs, , 425+ ,0=.==#

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