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Revisit
The effects of service quality and intention of
perceived price on revisit patients

intention of patients: the

Malaysian context 541
Kim Piew Lai Received 4 February 2019
Revised 11 April 2020
Faculty of Business, Multimedia University, Melaka, Malaysia 14 September 2020
Accepted 25 September 2020
Yee Yen Yuen
Multimedia University, Melaka, Malaysia, and
Siong Choy Chong
Accreditation Division, Finance Accreditation Agency, Kuala Lumpur, Malaysia

Abstract
Purpose – This paper aims to investigate the effects of service quality and perceived price (monetary and
behavioural price) on the revisit intention of patients to hospitals, as well as the mediating role of perceived
price on the relationship between service quality and revisit intention.
Design/methodology/approach – This paper distributes questionnaires to outpatients in three major
cities in Malaysia, namely, Penang, Melaka and Johor. Patients who were in the foyer, dispensary area and
waiting area were intercepted where their responses were sought. The responses obtained from 400 patients
were analysed using the structural equation modelling technique. Besides analysing the path coefficients, this
study has examined the common method variance, bias and indirect effects of the relationships.
Findings – The results suggest that patients pay more attention to certain values in their search for the best
health-care service and subsequently move on to new values. Pricing is an effective strategy to promote
favourable behavioural intentions amongst patients. Better service quality is reflected in the reasonableness of
monetary costs incurred by patients in acquiring health-care services. Patients who received poor services will be
more likely to compare such services to the medical costs incurred to ascertain the worthiness of the amount paid.
In addition, service quality also influences how patients perceive spending their time and efforts (waiting for
nurses and physicians, as well as queueing in hospitals) as worthy and vice-versa. Their revisit intention will also
be affected by the extent of which they invest their time, energy and efforts to search for relevant information.
Practical implications – The hospitals which desire to charge additional fees should enhance their service
quality to reflect price equity. This is imperative in view of the pricing structure which can be relatively complex
in subsequent follow-up treatments that may affect the decision of patients on the sources of health-care services.

Corrigendum: It has come to the attention of the publisher that Lai, K.P., Yee Yen, Y. and Siong Choy, C.
(2020), “The effects of service quality and perceived price on revisit intention of patients: the Malaysian
context”, International Journal of Quality and Service Sciences, Vol. 12 No. 4, pp. 541-558. https://doi.org/
10.1108/IJQSS-02-2019-0013, was published with the incorrect second and third author names. The second
and third authors are Yee Yen Yuen and Siong Choy Chong. It was also published with the incorrect
affiliation for Siong Choy Chong, who’s affiliation is ‘Accreditation Division, Finance Accreditation
Agency, Kuala Lumpur, Malaysia’. The authors sincerely apologise for this. The article should now be
cited as Lai, K.P., Yuen, Y.Y. and Chong, S.C. (2020), “The effects of service quality and perceived price on International Journal of Quality
revisit intention of patients: the Malaysian context”, International Journal of Quality and Service Sciences, and Service Sciences
Vol. 12 No. 4, 2020
Vol. 12 No. 4, pp. 541-558. https://doi.org/10.1108/IJQSS-02-2019-0013 pp. 541-558
The researchers would like to thank the Ministry of Education Malaysia for providing Fundamental © Emerald Publishing Limited
1756-669X
Research Grant Scheme (FRGS/1/2018/SS03/MMU/03/4) to support this research project. DOI 10.1108/IJQSS-02-2019-0013
IJQSS Originality/value – Given the inevitable increase in medical fees, the perceived price can be a key
determinant to the overall judgement patients had in terms of the health-care services received and the time
12,4 and efforts sacrificed. However, the importance of monetary price and the behavioural price is still relatively
unstudied, particularly their influence on revisit intention in the health-care setting.
Keywords Perceived value, Perceived service quality, Hospital performance,
Hospital service quality, Marketing of services, Service quality, Revisit intention, Monetary price,
Behavioural price, Perceived price, Hospitals
542
Paper type Research paper

Introduction
Being one of the most prosperous industries in Malaysia (Mohd Suki et al., 2011), the health
care industry has hit an impressive annual growth rate of 9.3% between 2010 and 2014.
Ahmed et al. (2017) found that Malaysian citizens, irrespective of educational
background and income bracket, are spending a substantial yet soaring amount of money
on medical services in both private and public hospitals.
As of 31 December 2017, there were 35 government hospitals, 200 private hospitals and 9
Special Medical Institution with Overall Bed Occupancy Rate (BOR) of 60.32% (Ministry of
Health Malaysia, 2018). Many Malaysians found that hospitals that they originally visited could
not provide the expected quality of health-care services (Sohail, 2003). Some patients who are
dissatisfied with the long waiting time, insufficient medical staff and crowded waiting area of
their originally visited hospital have, as migrated to new health-care service providers in the
country for better treatment and services (Ahmed et al., 2017; Gowing et al., 2017). All these facts
accentuate the importance of focusing on the revisit intention of outpatients to the same hospital.
In view of the aspiration of Malaysia to become a major medical hub of Asia, it creates an
interesting research proposition to examine the relationships between service quality,
perceived price and revisit intention to the same hospital in the country.
Health-care service is an intangible product and cannot physically be touched and felt like
retail and tourism products (Malaysia Health System in Transitions, 2013). Retail and tourism
industry allows sampling and testifying of tangible products for quality enhancement
throughout the production process, which is not applicable to the health care industry. Health-
care service quality depends on direct diagnosis and treatment process with direct customer
and health-care service provider interactions (Abdalla Sirag, 2016). Quality health-care service
refers to providing on-spot efficacious, effective and efficient services according to the latest
clinical guidelines and standards, delighting patients through unique service elements such as
availability, accessibility, affordability, competency and timeliness, adequately measured by
the SERVQUAL model (Abdalla Sirag, 2016; Parasuraman et al., 1988).
Malaysia National Health Expenditure Report (2018) indicate that expenditure on
medical goods already comprised 8% or RM4.55bn, of total expenditure (Malaysia National
Health Expenditure Report, 2018). Spending on health-care remains below the average for
upper-middle-income countries. Public hospital medical service in Malaysia is financed
thoroughly general revenue and taxation collected by the federal government, while the
private hospital medical service is funded through private health insurance and out-of-
pocket payments from consumers (Ministry of Health Malaysia, 2018).
In a developing country such as Malaysia, list-price data is usually not relevant to patients
who do not purchase individual services from hospitals and usually do not know exactly what
they will need during their hospital stay (Malaysia Health System in Transitions, 2013; The
Commanwealth Fund, 2019). Patients cannot properly interpret pricing information without
having information about the quality of different health-care services. Price transparency
absence in corresponding with service quality, as well as out-of-pocket-cost data contributes to Revisit
poor health-care choices and higher medical costs in Malaysia, which will ultimately reduce intention of
their revisit intentions to the same hospitals (Malaysia Health System in Transitions, 2013).
The objectives of this research are twofold:
patients
(1) to examine the possible effects of service quality and perceived price on revisit
intention in the health care industry; and
(2) to test the mediating effects of perceived price. To achieve these objectives, this 543
paper is organised as follows.

We continue with a section on a literature review that resulted in the development of a series
of hypotheses. This is followed by the methodology used and an analysis of the results
obtained. Theoretical and practical implications arising from the findings are discussed
before the paper is concluded with future research directions.

Literature review
Revisit intention
Revisit intention can be defined as an act of repeat patronage (Zarei et al., 2012). It represents
the thoughts or motives of consumers to experience the same product, brand, place or region
(Lee et al., 2012), including the decision to form long-lasting relationships with service
providers in the future (Lan et al., 2016).
In this sense, revisit intention is the degree of which hospital administrators developed
plans, including providing quality services and pleasant experience to induce certain
behaviour in patients to establish long-term relationships with them, resulting in them
coming back to the same provider (Shin and Park, 2015; Zarei et al., 2012) for medical
services. As determining the revisit intentions of patients is very important to hospital
management for reasons such as competition, reputation and profitability, revisit intention
has been identified as the dependent variable in this study.

Service quality
We adopted the SERVQUAL model (Parasuraman et al., 1988) as the independent variable to
measure the five-dimensional effects of service quality to capture the expectations of patients
on the levels of service offered by the same hospital they have patronised, namely, tangibility,
reliability, responsiveness, assurance and empathy. Tangibility captures the appearance of
hospital facilities, visibility of medical equipment, medical attendants and staff, as well as
information resources (Teas, 1993). Reliability represents the delivery of accurate and
dependent health-care service (Grönroos and Gummerus, 2014), while responsiveness reflects
on the willingness of medical attendants and staff to provide feedback and assistance to
patients (Cronin and Cronin, 2016). Assurance measures the competency, knowledge and
courtesy of the medical attendants and staff, while empathy suggests the ability to provide
individualised attention and care to patients (Cronin and Cronin, 2016).

Perceived price
In the literature, the perceived price has often been conceptualised and associated with other
constructs such as benefits, costs, utility, value and quality. Despite the availability of studies
on these constructs, their relationships remain largely inconsistent. In particular, some
consumer behaviour researchers assume that perceived price is similar to perceived value
(Yoon et al., 2014), utility (Wu et al., 2015) and quality (Campbell et al., 2014). Perceived price is
the consequence of an evaluative assessment (Lee and Han, 2015), whereas perceived value,
IJQSS utility and quality are the socially acceptable standards or goals that serve as the foundation
12,4 for such an evaluative assessment (Sweeney et al., 1999; Zeithaml, 1988).

Service quality and perceived price

Service quality drives perceived price as apparent in prior studies (Amin and Nasharuddin,
544 2013; Basu et al., 2016; Gowing et al., 2017). Perceived price, which mirrors the actual
experience of customers vis-a-vis the exact performance of service, brings the assumption
that service quality impacts on the monetary and non-monetary costs paid by customers
for the services consumed. Monetary cost is defined in this study as the cost of the
outpatient treatment programme. The more intensive the treatment programme is, the more
expensive the monetary cost will usually be. Non-monetary or behavioural cost is defined as
the time and efforts the patients spent in waiting for nurses and physicians, as well as
queueing in both public and private hospitals.
When the perceived level of overall service quality is higher, patients are more willing to
pay more for such services (Dobre et al., 2013; Nunkoo et al., 2017) and perceive spending
their time and efforts as worthy (Cheng and Monroe, 2013; Ryu et al., 2012). These premises
led to the following hypotheses:

H1. Service quality affects the monetary price.

H2. Service quality affects behavioural price.

Service quality and revisit intention

Service quality affects behavioural intention and may serve as the dominant factor leading
to favourable buying intention (Aliman and Mohamad, 2013; Amin and Nasharuddin, 2013;
Büttner et al., 2015; Gowing et al., 2017). Applying this argument to the context of this study,
the satisfaction and loyalty of patients is attributed to their perceptions towards the quality
of services received from the same hospital, and hence shape their revisit behaviour (Moon
et al., 2013; Petrick, 2002; Prajimutita et al., 2016). It can, thus, be hypothesised that patients
with positive service experience will revisit the hospital again. As a result, the following
proposition ensues:

H3. Service quality affects revisit intention.

Perceived price and revisit intention

Perceived price has been found to have a significant relationship with revisit intention or
repeat purchase (Amin and Nasharuddin, 2013; Liu and Lee, 2016; Pick and Eisend, 2014). In
fact, the perceived price has been highlighted as a significant factor in future behavioural
intention (Lee and Han, 2015). In this study, it is posited that monetary and behavioural
price will affect revisit intention of patients to hospitals (Liu and Lee, 2016; Wu et al., 2016).
We expect that higher assessment of monetary price and behaviour price will lead to greater
revisit intention. For this, we propose the following relationships:

H4. Monetary price affects revisit intention.

H5. Behavioural price affects revisit intention.
The mediating role of perceived price on service quality and revisit intention Revisit
Zhang et al. (2017) found that the higher the expected benefits of services compared to the intention of
sacrifices that consumers will have to make to acquire those benefits, the higher would be the
degree of revisit intention, suggesting a mediating role of perceived price. Specifically, Liu and Lee
patients
(2016) reveal that the perceived price affects service quality and intentions indirectly, which
implies the contribution of perceived price as a mediator. Prajitmutita et al. (2016) share the same
view where service quality drives the perceived price to influence the satisfaction of patients and
their behavioural intention indirectly. Service quality, in fact, is a key factor which drives the 545
perceived price to influence the satisfaction and behavioural intentions of patients indirectly
(Prajitmutita et al., 2016). This implies the need to consider the mediating effects of the perceived
price (monetary and behavioural) on the relationship between service quality and revisit intention.
Wu et al. (2016) explain that when individuals become more involved in their choice of service
preference, they tend to choose service providers that offer higher beneficial value and more
satisfactory services to them. With the presence of an expected level of service quality, patients will
evaluate the monetary and non-monetary costs of acquiring such services to form their behaviours
(Han and Hyun, 2015). Accordingly, they will develop higher expectations in terms of the price
they pay for the services offered, the time taken to acquire such services, as well as the ease of
physical and mental efforts. To some extent, comparisons are made with the services offered by
the public, as well as other hospitals to justify their evaluation, and hence their revisit intention.
While studies have shown that favourable behaviour is linked to perceived price,
particularly monetary price (Büttner et al., 2015; Forgas et al., 2010), there has been no study that
assesses the relationship between monetary price and behavioural price in their mediating roles
against revisiting intention (Jin et al., 2017). In addition, taking the cue from Zarei et al. (2012)
that behavioural price has the same beneficial value as monetary price, it is interesting to look at
whether the behavioural price has a mediating effect on monetary price and revisit intention
relationship. The following hypothesis and three sub-hypotheses are put forth to be tested:

H6. Monetary price affects behavioural price.

H6-1. Monetary price mediates the service quality-revisit intention relationship.
H6-2. Behavioural price mediates the service quality-revisit intention relationship.
H6-3. Behavioural price mediates the monetary price-revisit intention relationship.

Methodology
Respondents, sample and measures
The population frame includes all outpatients in 10 public and 10 private hospitals of three
major cities in Malaysia, namely, Penang, Melaka and Johor. A high number of price-
sensitive outpatients are attracted by the public and hospitals in Penang, Melaka and Johor,
which provide lower medical tourism costs than those of its main competitors in the region
(Malaysia National Health Expenditure Report, 2018).
Accordingly, outpatients who were in the foyer, dispensary areas and waiting areas of
public and private hospitals were approached and their cooperation was sought to
participate in this study. To ensure voluntary participation, permission was also sought
from public and private hospital administrators before the questionnaires were distributed.
This study determined the sample size of 400 to arrive at valid and reliable outcomes
following the suggestion of Hair et al. (2010). This is because the model will become sensitive
and result in poor-fit when the sample size is larger than 400. The sample size of this study
was proportionated evenly based on gender and sampling areas.
IJQSS Table 1 shows the demographic profiles of respondents, where men and women are
12,4 almost equally represented. Almost all of the respondents are between 41 and 60 years old.
Those with high school qualifications make up the majority. Most of them also reported an
annual income of between RM20,0001 and RM40,000, followed by those between the
brackets of RM40,001 and RM60,000.
As shown in Table 2, the questionnaire consisted of 32 items to measure the variables as
546 adapted from several studies via a five-point Likert scale. These exclude four questions on the
background information of the respondents. The patients completed the questionnaires within
the premises of the hospitals. Data were collected between November 2016 and February 2017.

Results
Confirmatory factor analysis is performed to obtain measurement scale adequacy and
validity (CFI > 0.90, AGFI > 0.80, x 2/d.f.<5.00; RMSEA < 0.080) (Hair et al., 2010). It is a
statistical technique used to verify the factor structure of a specific independent or
dependent variable and allows researchers to confirm the link between a specific variable
and its underlying latent construct (Hair et al., 2010). The initial analysis highlighted a poor
fit [ x 2(df = 456), n = 400) =1,630.599, p < 0.001; CFI = 0.884, AGFI = 0.757, x 2/d.f.=3.576;
RMSEA = 0.080], and hence re-specification was required. To improve on the model, the
researchers located the sources of a misfit by assessing the standardised regression weights.
As a result, two items (RES1 and EMP5) with regression weights of less than 0.50 were
dropped (Bagozzi and Yi, 1988). In addition, the researchers also made reference to the
modification indices for possible cross-loading items. Four items (BEH4, RES2, REL1 and
REL4) were further dropped. Table 2 shows the regression weight of each item.
The final CFA model statistics showed an adequate fit [ x 2(df = 288), n = 400) =713.020,
p < 0.001; CFI = 0.943, AGFI = 0.852, x 2/d.f.=2.76; RMSEA = 0.061]. The researchers
evaluated the univariate normality assumption in which the threshold value of skewness
(63.0) and kurtosis (65.0) were met. No potential outliers were detected using squared
Mahalanobis distance (D2) (Byrne, 2016). The five service quality dimensions were later

Variables Frequency (%)

Gender
Male 196 49
Female 204 51
Age
Below 40 years old 8 2
41–50 years old 180 45
51–60 years old 176 44
Above 61 years old 36 9
Highest education level
Primary school 40 10
High school 230 57.5
Degree and above 130 32.5
Annual income
Below RM20,000 60 30
RM20,001–RM40,000 79 39.5
Table 1. RM40,001–RM60,000 43 21.5
Demographic profile RM60,001–RM80,000 10 5
of respondents RM80,001–RM100,000 5 2.5
(n = 400) Above RM100,001 3 1.5
 Revisit
Regression
Indicators weight Source(s)
intention of
patients
1) Service quality
Tangible (4 items)
TAN1 This hospital has preserved and modern equipment 0.832 Amin and Nasharuddin
TAN2 Physical facilities of this hospital are visually 0.847 (2013) and Parasuraman
appealing et al. (1988) 547
TAN3 Staff at this hospital has neat appearance and 0.779
outfits
TAN4 Physical facilities are consistent with the services 0.784
provided
Reliability (5 items)
þþ
REL1 This hospital carries out its activities on time
þþ
REL2 This hospital shows a sincere interest in solving
problems of patients
REL3 This hospital provides the services promptly 0.867
REL4 This hospital provides the services within the time 0.695
promised
REL5 This hospital ensures the correctness of reports and 0.700
documents
Responsibility (4 items)
*RES1 The staff at this hospital acknowledge the patients
when the services will be performed
þþ
RES2 The staff at this hospital meets promptly the needs
of patients
RES3 The staff at this hospital is willing to help 0.908
RES4 The staff at this hospital is willing to respond to 0.817
requests from patients
Assurance (4 items)
ASS1 The behaviour of staff instils confidence in patients 0.844
ASS2 Patients feel secure with the services provided 0.859
ASS3 The staff at this hospital treats patients politely 0.813
ASS4 The staff at this hospital has the knowledge to 0.720
answer questions from patients
Empathy (5 items)
EMP1 This hospital pays individual attention to each patient 0.870
EMP2 The staff at this hospital gives personal attention to each 0.893
patient
EMP3 The staff at this hospital understands the specific needs 0.861
of patients
EMP4 This hospital has employees who give personal attention 0.908
to patients
*EMP5 This hospital has operating hours that are convenient to
patients
2) Monetary price (3 items)
MON1 The medical cost of this hospital allows me to 0.705 Liu and Lee (2016)
distinguish its services from other hospitals
MON2 If I think the medical cost is reasonable, I will have a 0.871
higher willingness to visit this hospital
MON3 I will prefer this hospital because the medical cost is 0.782
reasonable and there are many lines of treatments Table 2.
in this hospital Measurement scales
(continued) and regression
weight
IJQSS
Regression
12,4 Indicators weight Source(s)

3) Behavioural price (4 items)

BEH1 In choosing this hospital, I spend a lot of time 0.893
collecting information about the hospital and
medical cost
548 BEH2 In choosing this hospital, I spend a lot of time 0.895
seeking the best available health-care cost
BEH3I spend a lot of time in searching about the total 0.866
health-care cost of this hospital
þþ
BEH4 To choose a very intensive health-care plan of this
hospital, I sacrificed time or other efforts
4. Revisit intention (3 items)
REV1 If this hospital provides good quality of services, this 0.736 Eggert and Ulaga (2002)
will help to establish a close relationship with me
REV2 Taking my past experience with this hospital into 0.884
account affects my willingness to visit this hospital again
REV3 When I feel my experience with this hospital is not the 0.885
same, it will affect my willingness to visit again

Table 2. Note: * <0.60 regression weights; þþcross-loading items

incorporated as a second-order construct because they are often considered as an

independent factor (Liu and Lee, 2016) and that they are related sub-dimensions that can be
accounted for a common underlying second-order construct (Wu and Cheng, 2013).
The construct validity exceeded the benchmark value of 0.70 and that convergent
validity was achieved, as the AVE values exceeded the squared correlation coefficients.
Table 3 shows the details.
As the experience with service quality might be different between the hospitals involved in
the study and that the observations of respondents could be partially attributed to different
environments, the researchers carried out further tests for any possible false internal consistency
and false inter-correlational value by following the procedures of detecting the presence of
common method variance (CMV) and common method bias (CMB) (Richardson et al., 2009).
Accordingly, CMB occurs when respondents failed to distinguish the difference between
monetary price and behavioural price. For this, a marker variable comprising the demographic
information of respondents (age, education level and income) was built (Williams et al., 2010).
Subsequently, following the procedures of Richardson et al. (2009) and Williams et al.
(2010), we estimated five models (CFA, baseline, C-, U- and R-models) and compared:
 baseline and C-model for obtaining evidence of CMV; and
 U- and R-models for obtaining evidence of CMB.

Table 3. Construct Items CR 1 2 3 4

Construct reliability
(CR), average Service quality 5 0.915 0.688
Monetary price 3 0.831 0.635 0.622
variance extracted Behavioural price 3 0.916 0.291 0.152 0.783
(AVE) and squared Revisit intention 3 0.875 0.391 0.337 0.182 0.702
correlation
coefficients Note: Italic – AVE
Table 4 implies that: Revisit
 CMV is not present because there is no significant difference between Method-C and intention of
the baseline model; and patients
 CMB is not present because U-model and C-model are statistically not different
(Richardson et al., 2009).

It gave validity support to the study, showing that: 549

 collecting data from the three major cities does not inflate any false correlations
between constructs; and
 asking the respondents on monetary price and behaviour price at the same time
does not introduce bias.

Structural equation model

Structural equation modelling is a multivariate statistical analysis technique that is used to
analyse structural relationships between the independent and dependent variables. This
technique combines factor analysis and multiple regression analysis to analyse the
structural relationship between latent constructs (Hair et al., 2010). Figure 1 shows the
equation model, while Table 5 shows the standardised path coefficient.

Model x2 df CFI
CFA 962.834 392 0.926
Baseline 1,090.898 399 0.910
Method-C 1,088.391 398 0.910
Method-U 956.865 373 0.924
Method-R 958.011 379 0.924
Assessment Method x 2 and df x 2 critical value at Remarks
differences 0.05
Evidence of CMV in the Baseline vs method- ~ x 2 =2.507a 3.841 No evidence of
data C ~ df = 1 CMV
Evidence of CMB in the Method-U vs ~ x 2 =1.146a 12.592 No evidence of
Table 4.
data Method-R ~ df = 6 CMB Common method
variance and bias –
Note: aNot significant at p < 0.05 models comparison

Figure 1.
The structural model
IJQSS The results show that service quality has a significant positive effect on the monetary price,
12,4 behavioural price and revisit intention. Hence, H1, H2 and H3 are supported. Monetary
price and behavioural price also affect revisit intention significantly in a positive and
negative direction, respectively. As such, H4 and H5 are supported. Monetary price is also
found to affect behavioural price positively, hence H6 is supported.
To test the mediating effects of monetary and behavioural price, we followed the multi-
550 model analysis procedures of Hair et al. (2010) in testing the relationships between:
 the predictor and dependent variables;
 the predictor and mediator; and
 the mediator and dependent variable.

Table 6 shows the results.

Both monetary and behavioural price is found to significantly mediate the relationship
between service quality and revisit intention. Table 6 indicates that service quality has a
positive effect on the monetary price, a consequent positive effect on revisit intention and
that they are significantly related, lending support for H6-1. Intriguingly, service quality
affects behavioural price positively as a negative consequence effect on revisit intention,

Causal path Direct model Mediation model

H1. Service quality ! monetary price 0.635*

H2. Service quality ! behavioural price 0.291*
H3. Service quality ! revisit intention 0.529* 0.391*
H4. Monetary price ! revisit intention 0.524* 0.337*
H5. Behavioural price ! revisit intention (0.182)*
H6. Monetary price ! behavioural price 0.152*
R2 of monetary price 0.403
R2 of behavioural price 0.164
R2 of revisit intention 0.280 0.370
x2 495.747 713.020
df 164 288
RMSEA 0.071 0.061
CFI 0.943 0.943
Table 5. AGFI 0.853 0.852
Standardised path
coefficient Note: Standardised path coefficient (significant at 0.05 significance level)

Hypothesised path B SE b c.r. p Remarks

Direct model
Service quality ! revisit intention 0.733 0.097 0.529 7.557 <0.001 S
Table 6. Full mediation model
Service quality ! monetary price 1.023 0.124 0.635 8.246 <0.001 S
Mediation analysis of Monetary price ! revisit intention 0.287 0.061 0.337 4.684 <0.001 S
monetary price on Service quality ! revisit intention 0.537 0.105 0.391 5.090 <0.001 S*
path service quality
! revisit intention Notes: S – significant (p < 0.05); *decrease in beta value and remain significant
suggesting that behavioural price has an inconsistent effect on the relationship between Revisit
monetary price and revisit intention (Table 7). Similarly, the monetary price has a positive intention of
effect on behavioural price and the later affects revisit intention negatively (Table 8). Hence,
patients
H6-2 and H6-3 are also supported.

Discussion
The result of H1 implies that a hospital which offers better service quality should reflect on 551
the reasonableness of monetary costs incurred by its patients in acquiring such services (Liu
and Lee, 2016; Rajaguru, 2016; Zarei et al., 2012). Accordingly, the more tangible and reliable
services offered in terms of responsible staff, more assurance in delivering services and
more responsive to the needs of patients, the more they signify the willingness of patients to
pay for such services (Dobre et al., 2013; Nunkoo et al., 2017). This makes sense as to when
the level of service quality is higher, the perceived monetary cost will drop by definition. On
the contrary, patients who received poor services will be more likely to compare such
services to the medical costs to ascertain the worthiness of the amount paid. The findings
suggest that hospitals with a favourable service quality are in a better position to impose
additional charges. It also implies that hospitals which desire to charge additional fees
should enhance their service quality to reflect on price equity. This is imperative in view of
the pricing structure which can be relatively complex in subsequent follow-up treatments
that may affect the decision of patients on the sources of health-care services (Ginsburg
et al., 2009).
The outcome of H2 is also in line with prior studies (Cheng and Monroe, 2013; Ryu et al.,
2012) where patients perceive the time and efforts taken to acquire information about the
hospital and medical cost, as well as the efforts spent in queueing up for acquiring
the reasonable medical treatment as worthy when the level of service quality is good. The

Hypothesised path b SE b c.r. p Remarks

Direct model
Service quality ! revisit intention 0.733 0.097 0.529 7.557 <0.001 S
Full mediation model Table 7.
Service quality ! behavioural price 0.610 0.159 0.291 3.840 <0.001 S
Behavioural price ! revisit intention (0.119) 0.034 (0.182) (3.468) <0.001 S
Mediation analysis of
Service quality ! revisit intention 0.537 0.105 0.391 5.090 <0.001 S* behavioural price on
path service quality
Notes: S – significant (p < 0.05); *decrease in beta value and remain significant ! revisit intention

Hypothesised path b SE b c.r. p Remarks

Direct model
Monetary price ! revisit intention 0.434 0.052 0.524 8.356 <0.001 S
Full mediation model Table 8.
Monetary price ! behavioural price 0.198 0.096 0.152 2.057 0.010 S
Behavioural price ! revisit itention (0.119) 0.034 (0.182) (3.468) <0.001 S
Mediation analysis of
Monetary price ! revisit intention 0.287 0.061 0.337 4.684 <0.001 S* behavioural price on
path monetary price
Notes: S – significant (p < 0.05); *decrease in beta value and remain significant ! revisit intention
IJQSS finding highlights that patients form behavioural responses when they experience the
12,4 services provided which further act as their reference point to determine how much time and
effort they should spend. Hospitals can take advantage by introducing online checking
services which include information on treatment cost and waiting time for confirming
medical appointments for better financial planning where patients can estimate the required
waiting time and fees for each appointment.
552 However, it is noted that the coefficient value of service quality to behavioural price is
lower than monetary price, reinforcing the earlier argument on price equity (Lee and Han,
2015; Ryu et al., 2012). This is not difficult to understand given the stronger influence of
increasing medical costs (Ginsburg et al., 2009) over the non-monetary price. What is
interesting is that the meaning of behavioural price in terms of perceived price has a
developmental character. Some patients pay more attention to certain values in their search
for the best health-care services, and subsequently, move on to new values. In other words,
patients tend to move from service quality to price/cost and subsequently time/efforts as
new values (Liu and Lee, 2016). This is apparent when behavioural price mediates the
relationship between monetary price and revisit intention. Once the non-monetary price
satisfies them, the extent of price reasonableness becomes a major consideration, which may
change the values they have constructed on the non-monetary aspects. The findings
reinforce the importance of displaying a clear structure of medical pricing to enable patients
to effectively spend their time and efforts in finding out about a particular hospital (Boonen
et al., 2016).
The literature also lends support to H3 that service quality has a causal relationship with
revisit intention (Amin and Nasharuddin, 2013; Aliman and Mohamad, 2013; Kesuma et al.,
2013; Lee et al., 2012). The finding implies that the hospital management should pay
attention and invest notable resources in providing a high, differentiated level of service
quality to their patients (Shabbir et al., 2017). Hospitals should be sensitive and attentive
enough to the feedback provided by their patients. Investment in recruitment, training and
development to raise the quality of service and maintaining a record of patient satisfaction
index are some possible measures that can be taken.
Corroborating previous studies (Jin et al., 2015; Shen et al., 2016; Wu et al., 2016), the
monetary price has been found to affect revisit intention in a positive direction, thus the
support for H4. Monetary price represents the reasonableness of monetary costs incurred by
patients, and hence, the more reasonable the price (monetary cost) is perceived to be, the
higher the likelihood of revisit intention. This suggests that optimal pricing is one effective
strategy to promote favourable behavioural intention amongst patients, taking into account
the level of service quality offered. Hospitals must make their pricing list available to
patients with as many details as possible, as Houk and Cleverley (2014) found that only 24%
of the websites of hospitals communicate medical charges to patients. The availability of
such information will enable patients to determine the value and justify the price they pay.
In addition, the hospital management can consider some incentives for returning patients
such as issuing a guarantee letter on price locks for future visitations and/or special
payment packages such as interest-free instalment plan (Martin et al., 2016).
However, the result of H5 contradicts prior studies (Ng and Russell-Bennett, 2015; Ryu
et al., 2012; Zarei et al., 2012) which shows that by spending more time, energy and efforts to
search for the required medical information will actually weaken revisit intention. As
behavioural price is found to be conceptually distinct from monetary price, it would be
intriguing to note the inconsistent relationship. We acknowledge the involvement in
searching and collecting information about the medical cost in terms of their risk-reduction
anticipation level of the given information. When patients need to undertake extra
involvement in acquiring information about medical cost, their time spent on any particular Revisit
activity may have been so important compared to the monetary price, that their involvement intention of
influences their next anticipation. This could occur in the health-care setting as patients are
dealing with situations associated with high risks (Lupo, 2016). In other words, it may
patients
indicate that the sense of risk reduction completely dominates the benefits of searching for
reasonable medical cost. Perhaps, the patients perceived that the time wasted trying to find
information about the medical cost only lead to more uncertainties or confusion over what
they had initially suspected whether they would be treated adequately (Silver, 2015).
553
Hospitals, as the for-profit organisations, should take cognisance by considering post-
benefit convenience to their patients. Patients should be given the opportunity to assess
easily whether or not the treatment plans are the best working.
H6 is supported and consistent with the findings of Liu and Lee (2016) that monetary
price predicts behaviours of patients. Further, H6-1 shows that the mediating effects of
monetary price on the relationship between service quality and revisit intention is apparent.
Specifically, they reinforce the importance of considering medical costs along with the level
of service quality offered by the hospitals. The findings complement the study of Johnson
et al. (2016). Hence, hospitals should not take the active role played by their existing patients
to seek for more information on medical services and compare prices with the services they
receive for granted. Besides enhancing information on their websites, the hospitals can
allocate a special area within their premises to accommodate patients with needed care,
provide medical cost comparisons and suggestions for cost-effective treatment plans.
Physicians and nurses can also play a role to foster close and continuing relationships with
their patients by providing them with relevant information on treatment cost, duration and
recovery plan.
H6-2 and H6-3 suggest that behavioural price has significant mediation effects on
the service quality-revisit intention and monetary price-revisit intention
relationships. The finding of H6-2 reinforces H2 that the time and efforts spent on
searching or assessing health-care services are compatible with their perception of
service quality. Patients are likely to spend a considerable amount of time in
searching for a hospital that provides tangible, reliable, responsible and assured
medical services (Liu and Lee, 2016). However, when taken together with H5,
improving information navigability can reduce the time and efforts taken by patients
to search for a hospital with good service quality, which improves the likelihood of
their revisit intention. With a greater proportion of patients who are technology
literate today, social media and smartphone applications could serve as important
tools to hospitals to push relevant information to patients as part of the customisation
of treatment plans (Anton et al., 2017).
H6-3 reveals that patients are likely to spend more time and efforts searching for
information when the medical expenses of a particular hospital are high. This suggests
for monetary benefits to be given to returning patients. Along with the issuance of
guarantee letter on price locks for future visitation and special payment package for
existing patients, these can reduce the sensitivity of patients towards the price charged
for their treatment and enable the hospitals to develop an emotional bond with their
patients.

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Corresponding author
Yee Yen Yuen can be contacted at: yyyuen@mmu.edu.my

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