How patients choose hospitals: Using the stereotypic content model to model trustworthiness,warmth and competence

Abstract

In many countries, policy initiatives force the implementation of demand-driven healthcare systems to encourage competition among providers. When actively choosing hospitals, consumers can compare data on the quality of hospital performance among providers. However, patients do not necessarily take full advantage of comparative quality information but instead use a number of readily available proxies to evaluate provider trustworthiness. According to the stereotypic content model, organizational trustworthiness is built on stereotypical perceptions of hospitals' competence and warmth, reflected by visible hospital characteristics such as ownership and teaching status, and size. We introduce a theoretical framework on stereotypic quality perceptions that brings together fragmented findings in health services research on patient quality expectations of hospital characteristics. The model provides a basis for further research and recommendations for improved hospital communication strategies. The study suggests that researchers as well as hospital management should pay more attention to stereotypical patient quality perceptions and their impact on hospital choice to understand patients' quality evaluations better.

Keywords

firm stereotypes hospital characteristics hospital quality ownership status patient perceptions stereotypical content model teaching status theoretical framework

Introduction

Patient choice of healthcare providers is gaining importance in several countries¹ as more demand-driven healthcare systems emerge. The primary reason for a more active role by patients in provider choice is to encourage competition among providers² and thus make care more responsive to patient needs while improving efficiency and quality.^3,4

Increasing choice in healthcare implies greater information needs by patients,⁵ but, due to asymmetric distribution of information between patients and health services providers, patient choices are unlikely to be fully informed. However, the availability of information about quality and service levels can help to reduce the information asymmetry.¹ Consumers choosing hospitals in healthcare systems with free provider choice now have a wealth of information they can access.⁶

An ongoing discussion in health services research continues about which of these information sources patients actually use for provider selection and how they interpret information on quality.⁶ A recent review⁷ shows that attending physicians, social influences (e.g. recommendations of family and friends or word-of-mouth) and comparative quality information are the main determinants of hospital choice for elective surgery. Patients rely on third-party information to select a hospital for elective surgery because they usually have minimal direct personal experience.⁵

In exploring how patients actually make provider choice decisions, researchers have determined that patients often use shortcuts or intuitive heuristics for hospital selection due to a lack of interest and difficulty in interpreting the extensive and sometimes contradictory information on quality.^3,8 In their review, Victoor et al.⁷ conclude that behavioral economics and psychology findings may contribute to a better understanding of why patients sometimes make less rational decisions based on less data than expected.

According to Lubalin,⁹ patients consider single, easy-to-understand information cues (e.g. hospital characteristics rather than quality reports) when choosing a hospital, even though the data may be less precise or even inaccurate. Especially during earlier stages of a hospital search, pre-selection of hospitals for a consideration set may rely on little factual information and be heavily influenced by stereotypical perceptions.^10,11 Patients' stereotypical quality perceptions may thus act as peripheral information cues to evaluate the hospital's reputation and can be anticipated in the patient decision-making process.⁵ These stereotypical quality perceptions may be triggered by easily assessable, visible hospital characteristics such as a hospital's ownership status.

Aaker et al.¹² suggest that stereotypical assessments on the basis of warmth and competence are relevant in the health sector since trusting relationships between health service providers and patients are of major importance. They recommend applying the stereotypic content model, based on the belief that people quickly assess warmth and competence as fundamental dimensions when evaluating the social world around them,⁹ to the hospital context.

Against this background, this study attempts to combine existing knowledge in health services research on how patients perceive hospitals that have certain characteristics with findings of social psychology research on assessments of organizations according to the stereotypic content model (Figure 1). This theoretical framework leads to a better understanding of the hospital selection process by patients, encourages further research and has implications for healthcare managers.

Figure 1.

Conceptual framework.

Description of the stereotypic content model

The stereotypic content model has been used to investigate firm stereotypic associations with regard to different objects (e.g. companies) and even individuals.¹³ People judge organizations on the basis of warmth and competence as firm stereotypes produced by characteristics such as ownership status.¹² The model was first applied to the healthcare context by Drevs et al.⁵ An experimental study⁵ found that patients differentiate among hospitals with different ownership status on the basis of the stereotypical traits of competence, trustworthiness and warmth. Further, perceived trustworthiness and competence had a positive effect on selecting a hospital for a non-acute inpatient stay. Based on these fragmented findings, we propose that the stereotypic content model can be applied to research on how patients evaluate and select a healthcare provider.

The stereotypical traits of warmth and competence are closely related to perceptions of trustworthiness since they cover different aspects of patient quality perceptions that determine whether a hospital is perceived as trustworthy or not.^14,15 Reputation as a general quality assessment of an organization reflects its trustworthiness,¹² an indicator essential for patients' willingness to seek care and evaluate healthcare providers during and after treatment.¹⁶ Drevs et al.⁵ and Handy et al.¹⁷ find that hospitals' trustworthiness as a measure for organizational reputation is a key criterion for hospital choice decisions.

Perceived competence can be defined as a dimension of trust that captures the ability to make correct decisions and avoid mistakes.¹⁵ Consequently, patient perceptions of competence may be related to whether a hospital uses advanced technology and new interventions¹⁸ to support diagnoses and decisions. Warmth can be defined as a trait that expresses whether a company will treat consumers fairly and whether relationships will be repaired if mistakes are made.¹² Perceptions of warmth are associated with other-focused and moral employee behavior.¹⁵ In the context of hospital quality perceptions, warmth reflects the caring dimension of health services.¹⁶ Perceptions of warmth are also related to the level of interpersonal competence patients attribute to the medical staff.¹⁴ The expectation of affectionate care is a key criterion used by patients to evaluate and differentiate hospitals.^19,20

Applying the stereotypic content model to relevant provider characteristics

Findings on how provider characteristics affect patient choices are mixed and sometimes contradictory.⁷ Ownership status^5,17,20 and teaching status^21,22 are the most discussed hospital characteristics in health services research. Some studies focus on university status and hospital size as other characteristics that may affect hospital choices.²³ In this study, ownership status, teaching status and hospital size are discussed as characteristics that are easy assessable and may evoke stereotypical thinking.

Ownership status

Hospitals can be differentiated by their ownership status as public, private for-profit and private nonprofit hospitals. However, the existence of hospitals with certain ownership status depends on the national health system. In two major health markets, Germany and the US, private for-profits compete with private nonprofits. In recent years, public hospitals have been increasingly replaced by for-profits,²⁴ although the market share of nonprofits in the US and in Germany has remained relatively stable over the past decades.^19,25

Public nonprofit hospitals are owned by federal, state or local governments. Private for-profit hospitals are owned by investors who expect them to generate profits, whereas private nonprofits have to follow a non-distribution constraint. Consequently, ownership status affects a hospital's mission, policies, finances and operations.²⁶ Ownership conversions in the hospital sector remain controversial and continue to attract media attention,²⁷ which shows the relevance of ownership status from the patient perspective.

Contract failure theory²⁸ provides a theoretical basis for ownership-related differences with respect to warmth and trustworthiness. Nonprofits are more likely to provide promised non-contractible quality,^28,29 while for-profit hospitals' profit motive may be expected to intersect with the altruistic values inherent in medical care.²⁸ The greater focus on reducing costs of treatment to increase profits may lower patients' beliefs in the trustworthiness and warmth of for-profits. Handy et al.¹⁷ find that most people believe nonprofits are more trustworthy than for-profit organizations, particularly in the health sector. Public institutions are presumed to support the public interest and public welfare by virtue of their ownership-related mission.⁵ Therefore, with respect to stereotypic images, public and nonprofit hospitals should be alike, although nonprofits enjoy a moderate comparative advantage in terms of humane and fair treatment and affectionate care²⁰ and nonprofits may seem to be more responsive to patient needs.³⁰

Consumers generally ascribe higher quality healthcare to for-profit hospitals than to nonprofits because the former have fewer resource constraints than nonprofit and public hospitals.²⁰ For-profit ownership is associated with the ability to provide sufficient financial resources, a greater focus on management practices and efficient organizational structures whose work practices make them more competent than nonprofits.¹²

We also find strong support for stereotypical perceptions related to hospital ownership status in Drevs et al.,⁵ who find in their experimental study that patients perceive nonprofit hospitals as warmer and more trustworthy but less competent than for-profits.

Teaching status

Hospitals' teaching status may signal a certain level of competence and warmth as another visible organizational characteristic. Teaching hospitals are involved in medical education and affiliated with an academic hospital. In teaching hospitals, medical students' contact with patients includes clinical observations, supervised practice and real case-based teaching.³¹ University medical centers as special types of teaching hospitals are involved in the initial training (preclinical and clinical studies) of medical students and are part of the university.

Unlike ownership status, teaching status evokes stereotypical perceptions if the hospital is a teaching hospital but not if it is a non-teaching hospital. The information that a hospital is not involved in clinical training may still evoke negative perceptions about its competence because it could be associated with a belief that the hospital is not qualified enough to become a teaching hospital.

Because teaching hospitals use more advanced technology and have greater access to new interventions^18,32 to support their diagnoses and decisions, they should be perceived as more competent. Patients admitted to university hospitals expect high-quality service and give the hospitals higher quality assessments.²³ Victoor et al.⁷ conclude from their literature review that patients generally prefer hospitals with complex, high-quality services. But the greater risk associated with medical education and inexperienced physicians would seem to argue for lower patient perceptions of competence.¹⁸ Lynöe et al.'s²¹ study finds that patients perceive treatment in a teaching hospital as somewhat risky, troublesome and painful. The perceived higher priority given to the training goal in teaching hospitals may be translated by some patients as poor quality of care.³³ Varkevisser and van der Geest²² find that patients are more likely to bypass the nearest hospital when it is a university medical center or a tertiary teaching hospital. However, medical decisions and treatment by medical trainees are supervised by more experienced physicians so that patients can expect a higher quality of care.³² Lynöe et al.²¹ find that the expectation of a very thorough examination is one of the main motives of patients in allowing medical teaching during treatment. According to Shahian et al.,³⁴ patients have high expectations of teaching hospitals' competence.

Teaching status may also affect patients' perceptions of a hospital's warmth. The presence of medical students during consultations in a teaching hospital is associated with improved and more thorough consultations and a better understanding by patients of their condition.³⁵ Aspects of privacy constitute the main negative argument of patients against being involved in medical education.²¹ Because teaching hospitals must advance professional development, education and research, patients sometimes connect this goal with limited patient-physician continuity.^23,34 Chiong³² adds that patients' sense of the continuity or coordination of care and interpersonal performance is negatively affected by teaching status. However, patients participating in medical education also reflect feelings of empowerment leading to increased knowledge about their condition and an improved doctor–patient relationship.³⁶

We conclude that a hospital's teaching status can be a double-edged sword from the patient perspective. Patients do not want to be treated by inexperienced doctors who are still in medical school and they do not want to be guinea pigs or have groups of doctors around their bedside discusssing their ailments.³² But they want to receive the leading edge treatment that supposedly comes with medical school affiliation.²³

Hospital size

Hospital size is usually measured by the number of beds.³³ Larger, high-volume hospitals typically treat a greater variety of illnesses, which implies greater complexities and organizational challenges as well as more impersonal and intimidating atmospheres compared with smaller institutions.^23,37,38 These factors have a negative influence on patient experiences.^37,39,40 Williams et al.⁴¹ find that patients attribute greater familiarity to smaller hospitals. In the framework of the stereotypic content model, these aspects are related to the warmth trait so that larger hospitals may be expected to have a size-related disadvantage with respect to patients' perceptions of warmth. Because larger hospitals are generally responsible for more cases and special examinations,³⁹ patients may consider them more competent than smaller hospitals. Victoor et al.⁷ conclude in their literature review that results on preferred provider size are mixed, possibly because hospital size is strongly related to teaching status or ownership status³⁷ so that the effect of hospital size cannot be separated from the effects of other hospital characteristics.

Discussion and conclusions

The study contributes to the ongoing research about which information sources patients use for healthcare provider selection and how they interpret information on quality. Although some researchers suggest that stereotypical quality perceptions may be highly relevant in the healthcare market,^12,17 the study is the first to present a broad conceptual framework of patients' stereotypical quality perceptions of hospitals with certain visible characteristics.

We applied findings from social psychology and organizational behavior research on how people evaluate organizations' trustworthiness based on the stereotypical traits of warmth and competence in the context of health services research. The current state of research suggests that patients often use shortcuts or intuitive heuristics for hospital selection.⁸

We argue that visible hospital characteristics as easily accessible, informational cues generate certain levels of warmth and competence as stereotypical perceptions of the trustworthiness of a hospital. In turn, a higher trustworthiness gives a hospital a better reputation, which can be regarded a general quality indicator that patients consider for hospital selection.^16,17

We show that certain manifestations of a hospital's ownership status, teaching status and size may evoke different and contradictory levels of competence and warmth. Therefore, it remains an empirical question whether the stereotypical quality perceptions related to hospital characteristics positively or negatively affect hospital selection. However, the conceptual framework makes a significant theoretical contribution to an understanding of consumer choice behavior and psychological attitudes toward hospitals.

Future research

Qualitative approaches are a first promising step to discover patients' perceptions of hospitals with certain characteristics (e.g. ownership status). Studies by Lynöe et al.²¹ and Schlesinger et al.^19,20 are important contributions in this context. The results of these qualitative studies could be used to validate the relevance of the stereotypic content framework to support that these traits capture a broader range of patients' quality perceptions.

Based on this qualitative groundwork, further studies could analyze the relevance of stereotypical quality perceptions using quantitative approaches. Drevs et al.'s study⁵ is the first to analyze the effects of perceived warmth, trustworthiness and competence on hospital attractiveness empirically. The experimental design of the study, with hypothetical scenarios, concludes that a hospital's ownership status evokes these perceptions of warmth, trustworthiness and competence. Scenario techniques where hospital characteristics are manipulated experimentally are useful to test characteristic-related differences (e.g. nonprofit vs. for-profit) in stereotypical quality perceptions among patients.⁴² Future studies should account for possible interaction effects among hospital characteristics on stereotypical perceptions. Some hospital characteristics are related to each other in hospital markets. For example, hospital size is strongly related to teaching status or ownership status.³⁷ Patient perceptions toward a for-profit teaching hospital may be different from those toward a nonprofit teaching hospital.

Future research should consider the impact of different and conflicting information about hospital quality. Using conjoint analyses, the importance of hospital characteristics and related stereotypical perceptions in addition to other informational sources such as the recommendation of a physician or a hospital quality report could be investigated conjointly. Conjoint analysis has already been applied to studies of patients' hospital selection.^6,43

In addition, researchers could study patients' actual choices to validate the impact of hospital characteristics on hospital choices in real-world settings,⁷ even if these studies are complex and costly.

To identify patient segments that differ in the perceptions and weighting of hospital characteristics as information cues, studies should validate their empirical findings in sub-samples of visible or identifiable patient characteristics such as age, sex or previous experience. For example, ownership status-related perceptions and preferences vary according to sociodemographic and psychographic characteristics¹⁷ and the effect of stereotypical quality beliefs on trustworthiness and hospital choice may vary depending on the hospitalization type.⁴⁴ In some cases patients may attach more importance to perceptions of competence and in other cases the perceived level of warmth may become more relevant.

Analyzing patients' post-hospitalization ratings of actual experiences with respect to hospial characteristics would be another fruitful area of future research. Patients' stereotypical perceptions trigger certain quality expectations of a hospital which can be confirmed or disconfirmed by actual experiences during the hospital stay.²³ Patient satisfaction data or ratings on hospital rating platforms could be analyzed with respect to differences due to hospital characteristics.

Physicians also serve as outside endorsers who can increase patients' quality perceptions of a hospital.⁴⁵ Hence, researchers might examine the relevance of hospital characteristics to physicians, who are important decision-makers in healthcare markets.⁷

Practical implications

In a highly competitive market for healthcare services, effective communication strategies must be an integral part of hospital marketing.⁴⁶ This study implies that hospitals should take advantage of their organizational characteristics to improve their images and compete more effectively. Implementing these communication strategies is not difficult and the cost is relatively low. It may include visible placement of the status associated with positive stereotypical associations (e.g. teaching or nonprofit hospital) on websites, letterheads and brochures.⁵

Second, this study suggests that hospitals must be aware of patient perceptions of their competence and warmth as healthcare providers and address negative perceptions. Such a strategy might include a more patient-centered focus and patient-physician continuity to improve perceptions of warmth.

Third, hospitals may account for consequences in organizational-related patients' stereotypical quality perceptions in case of organizational changes, e.g. ownership conversions or becoming a teaching hospital.³⁵

Fourth, hospitals must be aware that patients' higher quality expectations of competence and warmth bear the risk of negative disconfirmation effects when actual quality during the hospital stay fails expectations. For example, a stereotypical competence-based competitive advantage of hospitals may increase complaints and patients' retaliatory behavior because patients expect fewer service failures by a hospital perceived as competent. Consequently, a service failure may lead to higher disconfirmation of expectations about service quality and higher dissatisfaction.²³

The possible effects of stereotypical perceptions on post-choice evaluation has implications for managed care and gate-keeping systems. In these health systems where patients cannot choose a hospital themselves, their stereotypical quality perceptions are still relevant because patients compare actual perceived quality during the hospital stay with expectations, which influences patient satisfaction as an important outcome for health plan or healthcare insurance providers.⁴⁷

In the long run, hospitals should develop and extend their brand management. Strong brands increase trust in intangible products and help customers evaluate service quality.⁴⁸ In the framework, a strong hospital brand would positively affect a hospital's trustworthiness which in turn would lower directed information searches by patients about hospital quality.

Hospitals with high brand awareness as well as positive brand associations can overcome competitive disavantages due to negative stereotypical perceptions related to their characteristics. Patients' perceptions toward hospitals with low brand awareness may be shaped mainly by stereotypical perceptions related to their characteristics.⁴⁹

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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