Analysis of The Influence of Personal Factors and The
Quality of Health Facilities Services and The Quality of Insurance Services on
The Intention to Pay Health Insurance Contributions With Participant
Satisfaction as an Intervening Variable
Sasongko Nugroho
Master of Management Study Program, Faculty of Economics
and Business, Esa Unggul University, Indonesia
*email: [email protected]
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Keywords |
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ABSTRACT |
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Willingness
to Pay, Personal Factors, Quality of Health Facilities Services, Quality of
Insurance Services, Customer Satisfaction |
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Willingness to pay BPJS Health contributions in a timely and
continuous manner is very necessary to ensure the sustainability of the JKN
program. Personal factors, quality of health facility services, quality of
insurance services and customer satisfaction are important factors that
influence JKN participants to pay BPJS Health contributions. The aim of this
research is to analyze the influence of personal factors and the quality of
health facility services as well as the quality of insurance services on the
intention to pay health insurance contributions with participant satisfaction
as an intervening variable. This research used a purposive sampling method
for 286 BPJS Health participants. This research uses an SEM approach using
the SmartPLS 3.0 program. The research results show
that the quality of insurance services and the quality of health facilities
services have a positive and significant effect on participant satisfaction.
Apart from that, personal factors also have a positive and significant effect
on participant satisfaction. In the context of intention to pay
contributions, insurance service quality, service quality and personal
factors have a positive and significant influence. The suggestion from this
research is to expand the sampling population and types of health facilities
to gain broader insight. The managerial implication is that BPJS Health must
maintain and improve the quality of services provided to participants, both
health facility services and BPJS insurance services themselves. Personal
factors of BPJS participants need to be considered, so that they can
influence satisfaction and intention to pay contributions consistently |
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INTRODUCTION
Willingness
to pay BPJS
Health contributions in a timely and continuous manner is very necessary to
ensure the sustainability of the National Health Insurance program which is
managed by this social health insurance scheme. The intention to pay these
contributions usually comes from BPJS Health participants who are in need of
health service coverage. In a study in Ethiopia, people who had heard about a
health insurance scheme were 2.5 times more willing to pay for it than those
who had not heard about it (Nguyen and Hoang, 2017) . In addition, increased intention
to pay health insurance contributions is also associated with increased desire
based on experience, education level, income, agreeableness, conscientiousness,
extraversion, and neuroticism (Nosratnejad et al., 2016; Hajek et al., 2020; Wu et al.,
2020; Batbold and Pu, 2021) .
An important factor influencing the
intention to pay contributions is the level of participant satisfaction,
however only 40% of participants are satisfied with social health insurance.
Low quality of service is a major source of dissatisfaction. Consumers who
intend to purchase health insurance policies expect better service quality (Bala et al., 2011; Agyapong et al.,
2017; Ameryoun, 2017; Pathak, 2018; Pinna et
al., 2018; Batbold and Pu, 2021) . The nature of service quality
will ultimately influence customer satisfaction (Rajamani
and Raj, 2021) .
Many
studies have been conducted regarding factors that influence the intention to
pay insurance contributions, such as health services, with the object of
research being health services in hospitals (Bala et al., 2011; Ahmad et al.,
2012; Agyapong et al., 2017; Pathak,
2018; Pinna et al., 2018) . Furthermore, there is also research related to health
insurance services (Nosratnejad et al., 2016; Hajek et al., 2020; Wu et al.,
2020; Batbold and Pu, 2021) . However, research is still
rare that analyzes personal status factors on the intention to pay
contributions, more specifically on BPJS health insurance objects in Indonesia.
BPJS
Health as the manager of Social Insurance has different fund management from
Commercial Insurance, namely in the National Health Insurance program financing
scheme, health service costs are financed using a tariff scheme according to
INA-CBG's without a ceiling scheme, while commercial insurance uses an annual
fee ceiling scheme. These financing conditions will greatly influence BPJS
Health as the manager of the Social Security Fund which originates from
participant contributions. If the cost of health services is greater than the
contributions collected, it will impact payments for health facilities, and
this will make it vulnerable for participants to receive health services so
that disappointed participants will think twice about paying the contributions
again.
Therefore,
the author wishes to examine in more depth the variables: personal factors,
intention to pay contributions, participant satisfaction and the quality of
health facility services as well as the quality of insurance services. The aim
is to analyze the influence of participants' personal factors on participant
satisfaction and intention to pay BPJS Health contributions (WTP), the
influence of health facility service quality factors on participant
satisfaction and intention to pay BPJS Health contributions, the influence of
insurance services on participant satisfaction and intention to pay
contributions as well as the influence of participant satisfaction on intention
to pay BPJS Health contributions
METHODS
The approach used in this research
is quantitative. Quantitative research is a research method that uses a numeric
database or numbers and carries out statistical analysis in testing (Sugiyono, 2016) .
The independent variables from this research are personal factors,
health service quality and employee service quality with customer satisfaction
as the intervening variable and the dependent variable is the intention
to pay contributions.
In this
study, personal factor variables were measured with 5 statements adapted from (Hajek et al., 2020) . For the health facility service quality variable,
7 statements were adapted from (Ratnawati and
Kholis, 2020) and (Agyapong et al.,
2017) .
For the Insurance Service Quality variable, 35 statements were adapted from (Parasuraman et
al., 1985; Ratnawati and Kholis, 2020) .
For the customer satisfaction variable,
6 statement indicators were adapted from (Agyapong et al., 2017; Ahmed et al., 2017) For the variable intention to pay contributions, there are 3 statement
indicators adapted from (Casidy and Wymer,
2016; Jin et al., 2020) .
Data collection in this research
was through a survey, namely an online questionnaire using Google Form. The population is all research subjects related to the
problem to be studied (Nursalam, 2003; Arikunto, 2009) . The population of this study were BPJS Health participants in
the Central Java region. This sample was
selected using the purposive sampling method for
BPJS Health participants who meet the
following criteria : BPJS Health participants and
direct payers of BPJS Health contributions. Respondents have accessed health
services using a BPJS Health card. The initial data collection technique was
also carried out, namely by distributing an initial questionnaire (pre test).
This research uses the
Likert scale method in its measurement. On this Likert scale, the alternative
answers consist of five alternatives, Strongly Disagree, Disagree, Neutral,
Agree, Strongly Agree. Using the Structural Equation Model (SEM) approach by conducting validity and
reliability tests with factor analysis using the Smart PLS 3.0 program to
measure the intensity of each variable and a structural model analyzing the data and research
hypotheses. The validity test is carried out with the conditions usually used
to assess validity, namely the loading factor value must be more than 0.70.
Then, discriminant validity is related to the principle that measurements of
different construct variables should not be highly correlated. The way to test discriminant
validity is with reflexive indicators, which is shown by the cross
loading value for each variable must be >0.70 and the value is higher
than the other variables (Ghozali and Latan, 2015) . Reliability testing
uses a way to calculate composite reliability values. The condition
usually used to assess construct reliability is that composite reliability must
be >0.7 for confirmatory research and a value of 0.6 � 0.7 is still
acceptable for exploratory research. (Ghozali and Latan, 2015) .
From the results of the
pre-test questionnaire to 35 respondents, the personal factor variables
measured by 5 statements were all valid and reliable. For the health facility
service quality variable, all 7 statements are valid and reliable. For the
Insurance Service Quality variable, all 5 dimensions of service quality are
valid and reliable. For the customer satisfaction variable, all 6 statements
are valid and reliable. For the variable intention to pay contributions, the 3
statement indicators are all valid and reliable. Further details can be seen in
attachment 4.
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Respondents in this
study were BPJS Health participants and direct payers of BPJS Health
contributions. Respondents had accessed health services using BPJS Health cards
and. Of the 289 respondents, 89.27% were men and 10.73% women, with 8.30% aged
26-35 years, 23.53% aged 36-45 years, 36.33% aged 46-55 years and 31.83% are
over 55 years old. Respondent profiles can be seen in Appendix 5.
Construct Validity and
Reliability Tests on the reflective measurement model were carried out based on
recommendations from Hair, Hult, Ringle,
& Sarstedt (2017) where the loading factor value required
in SmartPLS 3.0 is ≥ 0.70. The results of the Convergent
Validity test in this study are acceptable and can be declared valid, because
all indicators for each variable have a loading factor value above 0.70 as shown as follows:
Figure 1. Loading Factor Test Results
The test results in the Fornell-Larcker Criterion table show that they are valid because
the variable correlation value is higher than the other variable values as in
the following table:
Fornell-Larcker
Criterion
Reliability testing
through Cronbach Alpha, Composite Reliability, and Average Variance Extracted
(AVE) testing has been carried out to evaluate the quality of construct
measurements in a research or survey. The results of this test show that the
measurement of this construct meets the established criteria for reliability
and internal validity. Cronbach Alpha testing is used to measure the internal
reliability of a scale or measurement instrument. Composite
Reliability testing also aims to measure internal reliability. The Average
Variance Extracted (AVE) test is used to measure construct validity or the
extent to which a construct can be explained by the items in the measurement
instrument. The results of reliability testing can be seen in the following
table:
Reliability Test
The results show that Cronbach Alpha reaches or exceeds the specified threshold value
(≥0.7). This shows that the scale or measurement instrument has a good
level of consistency between the items, so it can be considered a reliable tool
in measuring the construct. The test results show that Composite Reliability
reaches or exceeds the specified threshold value (≥0.7). The test results
show that the constructs measured by the instrument have a high level of
reliability in producing consistent data.
The results also show that AVE reaches or
exceeds the specified threshold value (≥0.5). Testing indicates that the
construct being measured has high internal validity, meaning that the items in
the measurement instrument adequately represent the construct.
Table 3
R Square
From the Path Coeffiecient
results, all are positive, meaning that all independent variables have a
positive effect on the dependent variable. Path coefficient shows the strength and
direction of the relationship between two variables in the conceptual model
under study.
Table 4
Path Coefficient
Positive results
from the path coefficient indicate that there is a tendency for an increase in
the dependent variable when the independent variable increases. This means that
the greater the value of the independent variable, the greater the value of the
related dependent variable.
Based
on direct influence testing, this research shows that the hypothesis is
supported. H1 test results the quality of health facility services has a
positive and significant effect on BPJS participant satisfaction (T Statistics =
3.380, sig 0.001). H2 test results: Quality of Insurance Services has a
positive and significant effect on BPJS participant satisfaction (T Statistics =
5.999, sig 0.000). Test results H 3 Personal factors have a positive and
significant effect on BPJS participant satisfaction (T Statistics = 9.534, sig
0.000). H 4 test results: Participant satisfaction has a positive and
significant effect on intention to pay BPJS contributions (T Statistics =
2.909, sig 0.004. H 5 test results The quality of health facility services has
a positive and significant effect on the intention to pay BPJS contributions ( T Statistics = 3.084, sig 0.004). H 6 test results Personal
factors have a positive and significant effect on the intention to pay BPJS
contributions (T Statistics = 3.206, sig 0.001). H 7 Test Results The quality
of insurance services has a positive and significant effect on the intention to
pay BPJS contributions ( T Statistics = 4.742, sig
0.000). From the Path Coeffiecient results, all are
positive, meaning that all independent variables have a positive effect on the
dependent variable.
From the Hypothesis Test, the T-Value results are
as follows:
Table
5
Research
Model Hypothesis Testing
|
Hypothesis
Statement |
T-Value |
Information |
|
|
H1 |
The quality of health facility services has a
positive effect on participant satisfaction |
3,380 |
Data supports the Hypothesis |
|
H2 |
The quality of insurance services has a positive
effect on participant satisfaction |
5,999 |
Data supports the Hypothesis |
|
Hypothesis |
Hypothesis Statement |
T-Value |
Information |
|
H3 |
Personal Factors Have a Positive Influence on
Participant Satisfaction |
9,534 |
Data supports the Hypothesis |
|
H4 |
Participant satisfaction has a positive effect
on intention to pay dues |
2,909 |
Data supports the Hypothesis |
|
H5 |
The quality of health facility services has a
positive effect on the intention to pay contributions |
3,084 |
Data supports the Hypothesis |
|
H6 |
Personal Factors Have a Positive Influence on
Intention to Pay Contributions |
3,206 |
Data supports the Hypothesis |
|
H7 |
Quality of Insurance Services Has a Positive
Influence on Intention to Pay Contributions |
4,742 |
Data supports the Hypothesis |
Based
on the hypothesis test above, it is known that 7 hypotheses have a T-Value
value above 1.96 so that the data supports the research hypothesis that was
built.
This research examines the influence of Personal
Factors, Quality of Insurance Services, and Quality of Health Facilities
Services on Intention to Pay Contributions with the addition of Participant
Satisfaction as an intervening variable using 5 variables with 56 statement
indicators.
The results found that health facility service
quality had a positive effect on participant satisfaction. If detailed further,
the most influential indicators on the quality of health facility services are medical/hospital
staff and employees in providing services without distinguishing the social
status of BPJS patients, followed by indicators of hospital building comfort,
then indicators of extensive knowledge and experience of the hospital team. So,
if we conclude, these results strengthen previous research which states that the
quality of health services plays an important role in patient satisfaction (Jandavath and Anand, 2016; Agyapong et al., 2017;
Batbaatar et al., 2017; Taqdees
et al., 2017; Pathak, 2018 ; Pinna et al., 2018; Swain and Singh, 2021) .
Next, the Health Facilities Service Quality
variable also found a positive influence on the Intention to Pay Contributions.
Good service quality will create the view that the benefits obtained from using
BPJS Health Facilities are commensurate with the cost of contributions paid.
Patients who feel they get high value from health facility services will be
more likely to have a strong intention to pay BPJS contributions regularly.
This is in accordance with the results of previous research which stated that
the quality of health facility services, in this case the health service
benefit package, greatly influences the intention to pay (Gidey et al., 2019) .
Other results found that Insurance Service Quality
had a positive effect on Participant Satisfaction. Participants who feel served
by competent and experienced health workers tend to be more satisfied with
health facility services. Health workers' expertise in providing care,
providing accurate information, and interacting with empathy and understanding
can influence participant satisfaction. This is in line with research results
which state that insurance quality has a positive effect on participant
satisfaction. (Swain and Singh, 2021) .
Other results also found that Insurance Service
Quality was further divided into 5 dimensions of Service Quality (SERVQUAL),
the result being that the most dominant sub-variable was Responsiveness,
followed by Reliability, Empathy, Assurance and the lowest was Tangible. These
results validate previous research which stated that Responsiveness has the
greatest influence (Pathak,
2018) and the
biggest gap is in the tangibles dimension (Ameryoun,
2017) .
Subsequent results also found that the quality of
insurance services also had a positive effect on the intention to pay
contributions. Participants who believe that BPJS provides reliable, adequate
services and provide adequate protection guarantees have a stronger intention
to continue paying contributions regularly. Participant satisfaction is
realized from the staff's willingness to help and provide emotional support
which has a positive influence on the intention to pay contributions. This
shows that assurance and empathy factors influence participants' intention to
pay contributions consistently. The match between the expected insurance
service and the costs incurred by the participant will influence the
participant's intention to become an indicator that influences the loyalty
(intention to pay contributions) of the participant (Ratnawati and Kholis, 2020)
Other results found a positive influence between
personal factors and participant satisfaction. Personal factors related to
psychological aspects and individual views on social security and health
insurance influence BPJS participant satisfaction. A positive attitude towards
health protection and the view that BPJS provides important benefits increases
participant satisfaction. Individual expectations of BPJS and level of
self-satisfaction influence participant satisfaction. Participants who have
realistic expectations and are satisfied with the service they receive tend to
be more satisfied overall. Unrealistic expectations or disappointment with the
services received have a negative impact on participant satisfaction.
Individual personality factors, such as levels of neuroticism, extrovertism, orderliness, openness, and politeness,
influence insurance participant satisfaction (Cherry and Asebedo, 2022) . Individuals with personalities who tend to be
stable, extroverted, organized, open to new experiences, and polite in
interpersonal relationships are better able to adapt to the challenges that
arise in using BPJS. This contributed to participant satisfaction with the
program. The results of this study are in line with previous results stating
that personal factors greatly influence emotional responses and can influence
the cognitive component of patient satisfaction (Pinna et al., 2018) .
Other results also found that personal factors
positively influence the intention to pay contributions. The level of
individual involvement in utilizing health services provided by BPJS influences
the intention to pay contributions. Participants who actively use the health
services offered by BPJS, such as by regularly having health checks or
participating in prevention programs, tend to have a higher intention to pay
off participant contributions to continue receiving these benefits. Individuals
with a high level of agreeableness tend to be cooperative, friendly, and care
about the interests of others. In the context of intention to pay BPJS
contributions, individuals with a high level of agreeableness are more likely
to have a strong intention to pay contributions regularly, because participants
pay attention to collective benefits and shared interests in maintaining a
sustainable health insurance system. Individuals with a high level of conscientiousness
tend to have an orderly, disciplined and responsible nature.
In terms of paying BPJS contributions, individuals
with a high level of conscientiousness are more likely to have a strong
intention to fulfill their obligation to pay
contributions on time, because participants have a natural tendency to carry
out their duties and responsibilities well. Extroversion describes the level of
social activity, energy, and tendency to socialize. Although the direct
relationship between extraversion and intention to pay BPJS contributions is
not as clear as other factors, extroverted individuals are more likely to
receive information about the importance of paying contributions from social
interactions, and this influences participants' intention to do so. Individuals
with high levels of neuroticism tend to be more susceptible to negative
emotions, stress, and anxiety. The relationship between neuroticism and
intention to pay BPJS contributions is complex. On the one hand, individuals
with high levels of neuroticism are more likely to feel disturbed by health
uncertainty and encourage the intention to pay contributions. However, on the
other hand, high levels of stress or emotional problems associated with
neuroticism affect participants' ability to pay dues consistently. Individuals
with a high level of openness to experience tend to be more open to new ideas,
experiences and different views. The relationship between openness to
experience and intention to pay BPJS contributions is related to broader
knowledge and understanding of the benefits of social security and awareness of
the importance of paying contributions to obtain adequate health protection.
This is in accordance with research results on psychological factors showing
that personal emotions and subjective norms are related to payment intentions (Ma et al., 2021)
Other results found a positive influence of participant
satisfaction with their intention to pay contributions. Participants who are
satisfied with BPJS services and benefits tend to have higher awareness and
motivation to pay off their contribution payment obligations. BPJS participant
satisfaction is related to their views on ease of access to health services,
speed of service, and quality of services provided.
Participants who are satisfied with BPJS services
tend to have a higher intention to pay contributions regularly. This is in
accordance with the results of previous research, namely when customers are
satisfied with the entity's services, they tend to express their intentions in
positive ways such as recommendations and positive words of mouth, choose the
entity over rivals, increase their purchasing volume or pay a higher premium (Marcos and Coelho, 2022) and To make customers feel satisfied with the
quality of service provided, the entity must formulate a strategy to improve
service quality so as to create customer satisfaction, and satisfied customers
will come back to buy the products or services offered (Mirza and Ali, 2017) .
The
results of this research found that health facility service quality, insurance
service quality and personal factors had a positive effect on participant satisfaction.
Participant satisfaction has a positive effect on the intention to pay BPJS
Health contributions. Furthermore, the intention to pay the contribution is
directly influenced by the health facility service quality, insurance quality
and personal factors. In the Central Java region itself, it was found that
personal factors had a positive and significant influence on participant
satisfaction and intention to pay BPJS Health contributions (WTP).
The
factors that most influence the intention to pay BPJS Health contributions
(WTP) in sequence are the Insurance Quality factor, Personal Factors followed
by the Health Facilities Service Quality factor, and the Participant
Satisfaction Factor. The factor that influences this variable is Insurance
Quality is Responsiveness, the most influential Personal Factor is Conscientiousness
(prudence), the most influential Factor of Health Facilities Service Quality is
the factor that employees of BPJS partner health facilities in serving do not
differentiate (equally) with non-BPJS patients, Factors The most influential
participant satisfaction is satisfaction with the facilities owned by BPJS
partner health facilities where participants seek treatment.
This
study still has several limitations or limitations that need to be corrected.
First, the sample is small compared to the total coverage of BPJS Health
participants which has reached more than 240 million people, so it is possible
that the results still contain bias which could be a potential problem. Second,
the research carried out on the quality of health facility services does not
necessarily describe the specific category of health facilities in question,
namely First Level Health Facilities (FKTP) or Advanced Level Referral Health
Facilities (FKRTL) with types D to Type A.
Suggestions
for further research are First, a similar research can
be developed with a sampling population so that this research can better
describe the results of the relationship between the Quality of Health
Facilities Services, Quality of Insurance Services, Personal Factors,
Participant Satisfaction and Intention to Pay Contributions in a more real way.
Second, future health facility specifications can still be developed on
specific types of health facilities to gain broader insight into the influence of
health facility quality services on participant satisfaction and intention to
pay contributions.
The managerial implication of this research is
that BPJS Health must always think about the sustainability of this program,
BPJS Health must focus on increasing the Intention to Pay Contributions (WTP)
of its participants. The way to increase the intention to pay contributions
(WTP) is to improve the quality of insurance services, through increasing
outreach and education to participants. Furthermore, BPJS Health must always
improve the quality of its services through innovations that can increase
participant satisfaction and participants' intention to pay (WTP). BPJS
participants need to be given a good understanding of the contribution payment
mechanism, including the payment schedule, available payment methods, and the
consequences of being in arrears. This information can be conveyed through
brochures, leaflets, or clear payment guides, both printed and easily
accessible digital platforms, so that it can increase the Intention to Pay
Contributions (WTP). BPJS Health must ensure that services to its
participants are implemented as they should without any doubts and feelings of
discrimination that can influence personal factors. BPJS Health participants
consider social insurance with noble aims to be unsatisfactory so that
BPJS Health participants have no intention of paying contributions regularly.
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