Abstract
Advances in healthcare service research emphasize a value-driven approach in healthcare by pressing the need to acknowledge what matters to the patient against the conventional approach of what should be provisioned in the service. This research study adopts a consumer-centric perspective of value creation, and explores consumer value preferences in healthcare services, using netnography of online consumer reviews of cancer patients. Six different types of consumer value are identified, which carry varying consumer expectations. These are excellence, novelty, spirituality, ethics, privacy and control. The research findings confirm that all types of consumer values are not positive; rather, there is a presence of positive and negative (or must-be) elements. Privacy and ethics are identified as the negative or must-be type of consumer value, which creates not much satisfaction, but their absence is dissatisfying. Novelty and control are identified as positive value types whose absence may not be that problematic, but their enhancement creates greater customer satisfaction. The findings provide shreds of evidence to the claim that all value types are not positive, and consumers often make trade-offs between positive and negative value types while evaluating services. Future research is suggested in different healthcare contexts (e.g., chronic vs. non-chronic disease) to develop value-centred management strategies.
Introduction
Emerging healthcare practices emphasize a value-driven approach in healthcare management by pressing the need to highlight more at what matters to the patient against what is generally offered in the service provision (Agarwal et al., 2020; Lynn et al., 2015; Keiningham et al., 2017). Agarwal et al. (2020) observed that the healthcare landscape is shifting towards emphasizing value over volume (service provisions) as consumer preferences and experiences play a central role in determining healthcare experience. This shift is paralleled by long-standing research focus on consumer value (Gallarza et al., 2017; Holbrook, 1999) and a ground breaking academic shift within services marketing driven by ‘service-dominant logic’ (SDL; Vargo & Lush, 2004), which claims that value is co-created by a joint effort of service providers and consumers. All of the researchers agree that consumers are seen as empowered actors whose involvement in value creation phenomenologically determines the final value in terms of their experiential outcomes (Gummerus, 2013; Holbrook & Hirschman, 1982). Research on patient choice management facilitates value-sensitive consumer decisions in healthcare (Chen et al., 2018).
Research on ‘consumer value in healthcare’ has been scant with some exceptions (such as Dagger et al., 2007, Dodds et al., 2018; Frow et al., 2016; McColl-Kennedy et al., 2012, 2017; Zainuddin et al., 2016), and very little is known about the role of a consumer’s value preferences in value creation process. To extend knowledge contribution in this area, this study attempts to examine various forms of consumer value and their nature (positive or negative), which are likely to shape consumer value preferences. The study has multifold contributions. First, it provides empirical evidence to the claim that all value types are not positive. Consumers often make trade-offs between positive and negative value types while evaluating the services. Thus, the study underscores the trade-off perspective of consumer value. Second, aligning with the emerging academic advances in transformative service research (TSR; Anderson, & Ostrom, 2015), the research emphasizes consumer well-being outcomes as an essential component of value in healthcare services. Well-being has subjective traits that depend on in process value experience (Davern et al., 2007; Rask et al., 2002). Every individual defines his well-being based on personal cognitive and emotional perceptions. Thus, it is implied that if the healthcare consumer perceives himself in a positive state of well-being (during or post treatment), then his overall experience of healthcare value would also be positive. The importance of well-being is also echoed in a recent framework for value-centred marketing (Agarwal et al., 2020), where well-being outcomes take the central role in delivering value-based care. To add utility for practitioners, the research study provides an insight to create value in service provisions as per the consumer preferences. This understanding of value preferences could also mitigate over-provision or under-provision of services (Porter & Kaplan, 2016).
Literature Review
Consumer Value
The nature of value is ‘contextually bound’ (Grönroos & Voima, 2013), and its meaning took different forms in research studies across various contexts, such as ‘value in exchange’, ‘value added’, ‘consumer lifetime value’, ‘value in use’, etc. The research study on consumer value has evolved through the past few decades in services marketing literature, touching through both macro- and micro-level analyses. There are various perspectives on the conceptualization of consumer value. Gallarza et al. (2017) report three different approaches to conceptualize value, that is, trade-off approach, dynamic approach and experiential approach. Trade-off approach has been one of the most cited approach, which involves defining value as a process of balancing benefits (offered in service provisions) and the costs (sacrificed by the consumers). The dynamic view of value assumes that consumer value is interactive and unconscious, aligning with the distinctions across value-in-exchange and value-in-use (Sandström et al., 2008). Dynamic view of value also parallels the contemporary research on value creation and value co-creation (Grönroos & Voima, 2013). The experiential approach of value is driven by phenomenological perspective, which focuses at hedonic, symbolic and aesthetic aspects (Holbrook & Hirschman, 1982).
Several types of value are conceptualized by researchers in general marketing area, for example, aesthetic (Arnold & Reynolds, 2003); emotional and social (Zainuddin et al., 2016); procedural and personnel (Gounaris et al., 2007); ethical, efficiency, spiritual, societal and ecological value (Willems et al., 2016). Holbrook (1999) provides in-depth knowledge about these values through his consumer framework. Holbrook’s (1999) conceptualization is lately followed by the development of a multidimensional measurement instrument by Gallarza et al. (2017), in which the researchers have attempted to validate the eight categories of consumer value identified earlier. These eight categories include efficiency, excellence, status, esteem, play, aesthetics, ethics and spirituality. Leroi-Werelds (2019) has advanced Holbrook’s typology in the light of technological advances and claimed that not all the consumer values are positive, which is indicated by Holbrook’s classification. In her attempt to differentiate and classify consumer value, the researcher has proposed a set of positive and negative value. Among the positive set, Leroi-Werelds (2019) has proposed five new elements—personalization, control, novelty, relational benefits and social benefits. These five sets of values are considered more important for the service delivery process in the era of technology. For example, personalization and control are highly related to the opportunity and flexibility provisioned for consumers’ involvement in the service process. In addition, the researcher has also proposed a negative set of values like price, efforts, time, various forms of risks, societal costs and ecological costs. These negative values are not the low-rated positive values; rather, they are distinct constructs, which may be the candidates for consumer sacrifice, invoking the importance of the trade-off view of consumer value.
Consumer Value in Healthcare Services
Before discussing value in healthcare, it is interesting to observe that ‘Health’ itself is a kind of intrinsic value (Duncan, 2010), and it could be reasonably deduced that that those who value health derive more value from healthcare services. Value in healthcare services spans far beyond the joint co-creation spaces of customer and provider. Instead, consumer value finds more relevance in the long-term outcomes manifested over time, such as degree and speed of recovery, time taken in return to normal activities, health sustainability and emotional well-being (Zanetti & Taylor, 2016). Some of the newly orchestrated aspects of value, such as social aspects, ethical aspects and emotional aspects, are visible within TSR literature (Anderson & Ostrom, 2015; Black & Gallan, 2015).
Dagger et al. (2007) explored customer value in terms of quality of care offered in healthcare services and attempted to translate the quality in terms of customer value. Zainuddin, et al. (2016) have investigated the consumer value self-creation process in the context of preventive (traditional) healthcare, where consumers take the primary responsibility for value creation without the involvement of service providers. McColl-Kennedy et al. (2017) adopt value-in-use perspective to explore value co-creation by consumer’s own activities of resource integration. Park et al. (2016) conceptualize ‘value in healthcare’ under two dimensions—extrinsic and intrinsic. Extrinsic value comprises functional and extrinsic social value, and intrinsic value comprises active emotional, reactive emotional, epistemic and intrinsic social values. Few researchers have attempted to modify Holbrook’s value typology to apply in healthcare (Zainuddin et al., 2016). Most researchers directly borrow the concept of value from Holbrook’s value typology (Sweeney & Soutar, 2001), while few of them customized it before using it in healthcare (Chahal & Kumari, 2012).
Method
The study adopts a netnography approach and analyses online consumer reviews of cancer patients (Heinonen & Medberg, 2018). After going through different online platforms (Healthgrades, Vitals, RateMDs, Yelp) offering online patient reviews, ‘HealthGrades’ (
The initial sample had 7,124 consumer reviews, which were filtered by applying several criteria in different stages. At the first stage, the reviews with no ratings were removed. Next, reviews with extreme ratings (e.g., rated 1, 2, 4 and 5 stars out of 5) were retained and those of moderate ratings (i.e., 3 stars) were removed because those did not provide any additional information. Short reviews (less than 10 words) were removed because of lack of rich content. The same exclusion criteria were reported in earlier healthcare review study also (Bardach et al., 2016). The resulting data set had 762 reviews of many doctors. However, for few of these doctors, there were some 100 or more reviews. Thus, to avoid the data to be confined within handful of doctors’ reviews, thereby giving biased information, only 10 reviews per doctor have been retained. This would result in 410 reviews, which makes the data set broader and representative. Further, reviews that were sponsored (by hospital/polyclinic/third party) in nature were eliminated. This resulted in 353 reviews consisting of 200 positive (having 4 and 5 stars) and 153 negative reviews (having 1 and 2 stars). These reviews were further screened by the researchers for relevancy, that is, it should reflect the opinion about direct healthcare service provider only. The reviews, which were talking about indirect healthcare stakeholders like government or insurance company, were eliminated. This finally resulted in 200 reviews comprising 104 positive and 96 negative reviews. Majority of these reviews belonged to post-treatment stage, that is, after completing the treatment. However, since cancer is a recurring multiphase disease, some of the reviews were observed to be written during the course of treatment (e.g., after completing chemotherapy, the review is written, and radiotherapy is currently going on). The extracted reviews were published between March 2020 and June 2020. The textual data obtained from online reviews were qualitatively analysed using Nvivo Qsr-12 to extract the relevant themes pertaining to consumer value in healthcare services. For overall brief understanding of data (customer reviews) selection, refer to Figure 1.
Research Findings: Consumer Value Types
A qualitative analysis of the data is performed in which the themes are extracted according to value types earlier identified in the work of Holbrook (1999), Gallarza et al. (2017) and Leroi-Werelds (2019). The various perspectives on consumer value, such as value as a trade-off (sacrifice vs. benefits), dynamic view (co-creation, a shift from value-in-exchange to value-in-use) and experiential (hedonic, symbolic and aesthetic) have been taken into account during the analysis. The research has identified the following types of consumer value that have got patients’ attention during their treatment and recovery process.
Excellence
Service excellence is one of the dimensions of consumer value found in the empirical study conducted by Gallarza et al. (2017). This type of value finds similarity with the concept of service quality conceptualized earlier (Cronin, 2016). Excellence is partially indicated in the Leroi-Werelds’ (2019) typology of consumer value, but the researchers have conceptualized excellence primarily in terms of human contact. A broader conceptualization of excellence is considered in this study where consumer’s value not only includes the quality of interaction between health staff and consumer but also the physical and extended social surroundings of the service environment. One of the reviews indicating social interaction in the service environment quotes:
Supporting staff was wonderful. Whenever I interact with them, they provide me moral support and relieve my anxiety; Thus, we (patients) discuss lot of jokes in general ward which turn the serious environment into humorous atmosphere. This helps me to remain calm during frightening times (like before going for my chemo).
The service environment is made up of both physical space and social surroundings. Another key attribute of service excellence considered important by healthcare consumers is the physical space of service consumption, which is broadly conceptualized as ‘Healthscape’ (Hutton & Richardson, 1995). Healthscape involves emotional, affective, cognitive and physiological influence caused by tangible elements of the service encounter. Service excellence also includes other interactional elements such as responsiveness of the service provider, competence of employees, empathy and compassion, speed and time in service delivery (Gallarza et al., 2017; Weinstein, 2020).
Novelty
A large number of consumers wrote about their interest in novel methods, particularly those involving latest technology in treatment. Novelty is introduced as a new value type in Leroi-Werelds’s (2019) work, which explains the influence of technology in consumer’s value-seeking behaviour. Novelty-seeking behaviour emphasizes at the utility acquired as a result of a consumer’s ability to arouse exercise of the intellect (Mansori et al., 2015). Here, intellect means the ability to learn and enhance the knowledge about treatment and understanding of new technologies used in the treatment. Novelty not only explains the consumer choice of a particular product or service but also explains the specific beliefs or value underlying that choice. Many consumers admit that novel practices enhance their learnings and help to develop drug compliance habits. When the consumers observe that the doctors are using new treatments or procedures, it evokes their curiosity to learn more about them. For example, one of the review quotes:
I was diagnosed with a left kidney carcinoma on 12/23/16; I saw Dr. ............. on 1/3/17 for a second opinion and on 1/11/17, Dr. .............. performed a robotic partial nephrectomy. Due to the location of the mass, he explained to us that he would perform the surgery in an unconventional manner by going through the back and side of the kidney to get to the mass using the shortest distance. Later, I myself learnt a lot about such unconventional techniques.
Spirituality
Spirituality was one of the value types proposed earlier by Holbrook (1999). Spiritual value has become an essential element of consumer value across many other services, including healthcare (Husemann & Eckhardt, 2019). Spiritual value is gaining high importance in TSR with increasing emphasis on well-being. The underlying idea is that consumers getting treated as a whole is much better than being treated for just an ailment. Earlier, spiritual value was discussed along with ethical value under a broader category of altruistic value (Sánchez-Fernández et al., 2009). Spiritual value in this context may be explained as compassionate and holistic care for the consumers that spans beyond their physical, emotional and social dimensions. This idea of ‘being treated holistically’ aligns with the notion of self-oriented spiritual value conceptualized within healthcare services (Dodds et al., 2018). Few other consumers perceive spirituality in terms of realizing meaning or purpose of life and inner harmony or feeling of peace. For example, some of the consumers wrote:
I was terrified, diagnosed w/triple negative breast cancer at 35 but Dr. ....... ignited a feeling of hope in me that I’ve held onto ever since. It gives me reason to live and help me understand my true inner self.
Spiritual value reflects the importance of existential traits like ‘meaning in life’ or ‘purpose for life’ for healthcare consumers. The same existential features are representative of health gain or well-being at the psychological level (Fry, 2000; Steger, 2013). Thus, it infers a logical well-being–value link and the implied possibility that consumers who experience spiritual reinforcement in healthcare service interactions often realize more holistic value creation.
Ethics
Another important value within healthcare services identified through this study is ethical value. The ethical value identified in this study represents the broader view of consumer value contrary to the narrow view depicted through altruisms in earlier studies (Sánchez-Fernández et al., 2009). Smith (1999) explains that ethical value is a consequence of an affirmative act of goodness that leads an individual to form one or more moral values. Many consumer reviews revealed that consumers are often interested in consuming healthcare services that are truly ethical due to self-oriented reasons, that is, personal well-being or overall quality of life. Consumers assume that the doctor is honest if he recommends the patient to other doctor, especially when he cannot manage the disease of his own or if the area of expertise falls beyond his domain. The ethical value is self-oriented; contrary to the altruistic value, which is the other’s oriented (Smith, 1999). Here, the consumer assumes that the doctor is non-deceptive, and his act of recommending the patient to other doctor with appropriate expertise will help to improve the overall well-being outcomes. The study also observes a few negative statements regarding the ethical value such as those mentioning doctors manipulating the patient by hiding the fact, charging more money, confusing the family and cheating emotionally. This is indicated by the following comments:
We were deceived by the doctor. He told my husband he had plans A, B, C, D etc. Don't worry I can treat your cancer he said, you're doing very well. Go back to your home state. There is a big difference between offering hope and outright lying
Privacy
There is rising concerns for privacy after the advent of digitization of healthcare services (Bansal & Gefen, 2010). Privacy is reported as a new consumer value type by Leroi-Werelds’s (2019), which was not mentioned in Holbrook’s typology. It represents how healthcare consumers consider privacy in service encounters as an essential component of their overall experience. The study observes that consumers, who perceive that their privacy is compromised, most often reported their overall experience as negative even if everything else went well during the interaction. The kind of importance consumers give to privacy value is reflected by strong statements such as:
Bunch of quack ‘Doctors’ that do not comply with HIPAA. Loudly speaks about a pt's private medical and personal information among each other or on the phone … like they're screaming across a field.
Control
Control is a new value type proposed by Leroi-Werelds (2019) in the wake of technological advances, which emphasize at consumer’s perceived control on their service environment. Kleijnen et al. (2007) describe control as the extent to which consumers are able to determine the timing, content and sequence of transaction. Control provides an opportunity to the consumer to personalize their service experience during the process of value creation (Grönroos & Voima, 2013). Control over decisions and actions in healthcare further leads to more involvement of consumers in learning and empowerment (Ben Ayed & El Aoud, 2017). Flexibility and choice during service interactions are the factors, which modern technology has provided, and empowered consumers to exercise a higher level of control. Flexibility and choice are expected by everyone, absence of which creates an overall bad impression and perhaps due to which this kind of value expectations are primarily reflected in negative consumer reviews. For example, one of the quotes says:
I was offered options including active surveillance, radiation, and robotic prostatectomy. I elected surgery.
Time is one of the crucial elements sacrificed by the healthcare consumers. Here, a consumer not only acknowledges the importance of a quick medical response but also the flexibility to select the time and method for treatment, and sometimes to personalize the delivery of services. For example, one of the reviews quotes:
He was kind enough to allow me to plan my follow up visit a month later (as I have to attend my sister’s wedding) and instructed me properly about the precautions till the visit.
Discussion and Practical Implications
Theoretically, this work evinced the need for a trade-off perspective of consumer value by incorporating the ‘value-in-use’ aspect of service consumption (Sandström et al., 2008). The findings provide empirical support to the recent developments in consumer value frameworks by identifying six different value types in the healthcare context. Aligning with the phenomenological nature of consumer value, the study has identified some aspect of consumer value, which is experiential in nature. Consumer experiences are mostly shaped by the interaction during service encounters not only during the treatment but also during the pre-treatment (planning stage) and post-treatment (follow-up) stage (Grönroos, 2017). The research study does not confirm that all types of consumer value are positive; instead, there is a presence of negative elements as well. For example, there are ‘must-be’ types of consumer value elements, that is, those which create not much satisfaction, but their absence can annoy consumers. Value types like privacy and ethics generally appear in negative consumer reviews. This privacy and ethics represent the ‘must-be’ element that consumers expect without explicitly demanding it. Novelty and control indicate a positive consumer value type, which is driven by innovation in services and creates curiosity and learning among the consumer. It is also to be noted that this value type may be treated as useful primarily for those consumers who like to adopt innovative methods. However, it is to be noted that consumers do not prefer novelty and excellence over basic functional skills (treatment ability of service provider). It means there is no point of novelty attributes if the treatment is not at all provided or provided with poor standards. Thus, consumers see novelty and excellence as an add-on trait but not as superior to basic functional expectations with the service provider. Novelty and control further enhance the quality of consumer involvement in the treatment process. Service excellence is a kind of in-process (dynamic) value that is configured by the service provider but largely shaped by the consumers. Consumers influence the ‘service excellence’ in the treatment process by their active involvement. The relationship of consumer value with consumer satisfaction may be linear or non-linear and depends on which side of the value typology (positive or negative) it falls. This is an area of future exploration. Moreover, researchers argue that patient’s value choices are context-based (Chen et al., 2018); further investigations should be conducted to understand which value sets are important in different contexts and how does the value expectations change over time. Fuzzy Quality Function Deployment (QFD) methods are likely to be suitable approaches to assess such value combinations (Rahman & Qureshi, 2008).
Our research enlightens healthcare managers to understand their consumers’ minds, regarding their preferences for key values and service attributes in designing services. An appropriate understanding of positive and negative value types is essential for configuring the composition of value in the service offerings as per the needs of various consumer segments. Our study surely will help the healthcare service providers design the value components for their consumers, keeping in mind the way consumers create and experience them. Learning about consumer value preferences may avoid negative experiences and value (co)destruction in services. It is recommended that health professionals pay attention to the consumer ecosystem to understand their value preferences and create plans for value-centred marketing (Agarwal et al., 2020)
Conclusion, Limitations and Future Research
Consumer perception of value in healthcare is subjective and self-oriented in nature. Understanding the changing perception of value from consumers’ perspectives is important to have insights into their future value preferences. The dual perspective of consumer value is adopted, including both the process and expected outcome (Gummerus, 2013). The study adopts the modern qualitative approach ‘netnography’ for this work, where consumers’ lived experiences during their treatment and recovery are analysed. The study identifies various forms of healthcare consumer value, which are important for patient-centred management. The study had few limitations, which can be addressed to extend the current work. One limitation is that the study pays limited attention to patients’ caretakers or close ones (e.g., family and relatives who play an active role in the value creation process through their frequent participation in service encounters along with patients). The customer-to-customer (C2C) perspective of service literature may provide further avenues to explore the broader network and ecosystem at the consumer’s side. Second, the geographical coverage of this study is restricted to one particular town of a developed country. A similar analysis could be planned for the developing countries, considering a vast variation in the country’s culture and healthcare systems.
