THE IMPACT OF HEALTHCARE SERVICE GUARANTEES ON CONSUMER DECISION-MAKING: AN EXPERIMENTAL INVESTIGATION ABSTRACT While examples of the successful use

of service guarantees in healthcare do exist, to-date, researchers have yet to examine this industry-specific application beyond a case study perspective. The results of this experiment begin to shed light on whether or not guarantees should be used, and if so, under what conditions are they appropriate. Respondents indicate that the thoughtful use of service guarantees can positively impact their perceptions of the healthcare providers reputation and, ultimately, their behavioral intentions towards the same provider. However, consideration must be given to the type of guarantee being offered and to whom the guarantee is targeted. Keywords: Ser !"e #$%r%&'ees( #$%r%&'ee s"o)e( e*)er!+e&'%, des!#&( e+er#e&"y roo+( )-ys!"%, '-er%)y( -os)!'%, +%r.e'!&# R$&&!&# -e%d: I+)%"' o/ He%,'-"%re Ser !"e G$%r%&'ees

THE IMPACT OF HEALTHCARE SERVICE GUARANTEES ON CONSUMER DECISION-MAKING: AN EXPERIMENTAL INVESTIGATION INTRODUCTION ervice guarantees, in essence, are !a policy, express or implied, advertised or unadvertised, that commits the operation to ma"ing its guests happy# $%vans, &lar", and 'nutson ())*, p. +,-. .ncreasingly, many guarantees also ma"e mention of compensation if a level of service is not achieved $&hen et al. /00)-. ince &hristopher Hart first wrote about the !1ower

of 2nconditional ervice 3uarantees# in the Harvard Business Review in ()44, service guarantees have received increasingly significant attention in the mar"eting literature $see Hogreve and 3remler /00) for a comprehensive review-. 3iven the abundance of real-world examples of the successful use of service guarantees by various companies $e.g., 5erry and 1arasuraman ())(6 %vans et al. ())*6 Hart ()44, ())(, ())76 Hart, chlesinger and 8ayer ())/6 9affe ())06 :iden and anden /00;6 8aher ())(6 Winston ())+-, it is not surprising that mar"eting academics turned their attentions towards investigating exactly how and why these service guarantees wor". .nterestingly, despite /0< years of research, consistent findings have yet to emerge $Hogreve and 3remler /00)-, and a gap between practice and theory has presented itself $=abien /00+-. The impact of a guarantee, and thus what guarantee would be most effective for a given company, seems to vary based on a host of internal and external factors including industry, company and purchase characteristics $=abien /00+6 'ashyap /00(-. 2nfortunately, for a company wanting to benefit from this stream of research, this inconclusiveness is problematic. ervice guarantees as applied in some industry settings $e.g., hospitality and tourism, overnight mail, and traditional retailing- have been well-researched, helping those industries fine-tune their uses of service guarantees. >t the same time, other industries have been neglected. 3iven this /

conundrum, Hogreve and 3remler $/00)- call for !further research in alternative service settings# $p. 77/-. ?ne such suggested industry is the healthcare industry, one of the largest industries in the 2. ., accounting for @/.* trillion in revenues, (,.+A of the 3B1 and (;.7 million Cobs $1lun"ett Research :td. /0(06 2. . Bepartment of :abor /0(0-. Bespite the industrys siDe and proCected growth, service guarantees historically have been the exception, not the rule, and to-date, it is believed that no researcher has empirically examined the use of service guarantees in this setting. >ccordingly, the purpose of this research is to examine the use of service guarantees in the healthcare industry through the use of a 7 $service guarantee type- x / $healthcare service usage Euantity- x / $healthcare setting- experimental design. The impact of various guarantees on perceived reputation and behavioral intentions is assessed. The implications of this research for those in the healthcare industry are discussed along with future research opportunities. SERVICE GUARANTEES IN THE HEALTHCARE INDUSTR0 8any of the arguments against offering guarantees in the healthcare industry center on the intangible and subCective nature of the service offering. =rance and 3rover $())/, p.7/characteriDe the healthcare industry as !probably the most intangible of services. .n addition to being unable to experience the product prior to purchase, the consumer often cannot evaluate it even after Fconsumption# $cited in :evy ()))-. The fact that healthcare is comprised mostly of credence Eualities ma"es the use of guarantees tric"y given a consumer who is ill-eEuipped to evaluate the service pre- and post-consumption. =urther, in the context of =abiens $/00+service guarantee development model, two external factors G legal aspects and uncontrollable aspects G lead to Euestions regarding the desirability of offering guarantees in this industry. WirtD $())4- stresses that any commitment or contract to the consumer results in legal

ramifications. Healthcare industry experts have Euestioned whether mar"eting messages such as guarantees elevate customer expectations to an unrealistic level which escalates the volume of malpractice lawsuits $8ac travic ()4)-. E*),!"!' G$%r%&'ees Bespite these valid reservations concerning the use of service guarantees in this industry, some healthcare providers do offer explicit guarantees. ?ne of the first documented uses is the Belta Bental 1lan of 8assachusetts offer of a !3uarantee of ervice %xcellence# $Hart, chlesinger, and 8aher ())/-. >ccording to Belta Bentals comprehensive service guarantee program, patients receive refunds when they experience dissatisfaction, including situations where their Euestion is not immediately resolved, when their transition to Belta Bental is not smooth, or even when their .B card is not accurately and Euic"ly delivered. >nother example is discussed by 1aEuette $/00(- who examines the use of service guarantees by assisted living facilities. These facilities guarantee residents on-going care regardless of the level needed. .n other words, as a residents health declines, he or she will be allowed to continue to stay at the assisted living facility and not have to see" new healthcare options. :evy $()))- outlines several examples of service guarantees offered by various healthcare providers. The 2nited Weight &ontrol &orporation implemented a service guarantee card system whereby instances of dissatisfaction could be reported and awards of up to @(0 handed out as compensation. 5lue &ross and 5lue hield of 8assachusetts offered a guarantee that compensated members expressing dissatisfaction through a written letter up to the cost of ( month of insurance premiums. 'aiser 1ermanentes outheast region guaranteed service received at the chec"-in des" and in the waiting rooms. Bissatisfied customers were offered a variety of compensation including, but not limited to, a telephone call from the offending employee to having their co-pay

refunded to them. The 8ission ?a"s Hospital in :os 3atos, &alifornia guarantees the wait in its emergency room. .f your wait is more than + minutes, /+A of your bill will be refunded. imilarly, 8ercy Hospital in 8iami, =lorida guarantees an emergency room wait time of under 70 minutes to see a healthcare professional. .f a patient waits longer than 70 minutes, he or she will receive a letter of apology from the 1resident and &%? along with a first aid "it $8ercy Hospital /0((-. >s can be seen from the above examples, these service guarantees run the gamut from limited $e.g., the 8ission ?a"s Hospitals and 8ercy Hospitals emergency room wait- to unlimited $e.g., the Belta Bental 1lans service excellence guarantee-, thus highlighting the scope of the guarantee. The scope refers to what is covered by the guarantee. > guarantee can be unlimited in nature, and, hence, customer satisfaction pertaining to all aspects of the service is guaranteed. > guarantee can also be limited in nature. > limited guarantee only guarantees certain aspects of the service $Hart ())7-. These explicit guarantees also highlight variability in the outcome of invoking the guarantee. .f a consumer is not satisfied with the guaranteed aspects of the service, what will the service provider do to rectify the situationH I+),!ed G$%r%&'ees .n addition to explicit guarantees, many in the healthcare industry choose to offer what are essentially implicit guarantees of service. .n other words, while the service guarantee is not expressly stated, consumers perceive that a guarantee is still being offered. .mplicit guarantees are usually offered by companies that have built a strong positive reputation for offering Euality service and for caring about their customers satisfaction. =or instance, the RitD-&arlton does not offer an explicit service guarantee, but at the same time, its customers perceive the existence of

an implicit guarantee of service. These customers assume that if they are dissatisfied for any reason that the RitD-&arlton will remedy the situation. 5asically, many companies are striving to be the RitD-&arlton of the healthcare industry by putting the mechanisms in place to establish an implicit guarantee in the minds of its current and future customers. =or instance, the Iorth ?a"s Health ystem in outhern :ouisiana received significant publicity resulting from achieving the 3old eal of >pproval for healthcare Euality accreditation from the 9oint &ommission on >ccreditation of Healthcare ?rganiDation $Hammond Daily Star /007-. This 3old eal announcement wor"s to build up Iorth ?a"s image in the consumers minds. .n an informal Euery of consumers who were as"ed to read a newspaper article discussing the 3old eal, it was uncovered that most felt that they would receive higher Euality healthcare from this organiDation. ?ther hospitals, such as :a"eside Hospital in 8etairie, :ouisiana, hint at a guarantee in their advertising, but do not come out and actually explicitly state one. !&onsidering the time some hospitals ma"e you wait, its no wonder they call you the patient# is one :a"eside Hospital advertising slogan. :a"eside does not promise that a patient would have a shorter wait at :a"eside, but it is most certainly implied $:a"eside Hospital advertisement /007-. H0POTHESES :i"e their counterparts in other service industries, healthcare mar"eters are constantly see"ing means by which to differentiate themselves from their competition, to improve the Euality of their offerings, and to increase customer satisfaction. ervice guarantees offer the

potential to accomplish these obCectives $Hays and Hills /00*6 Hogreve and 3remler /00)6 :ewis ())7-. .n order to better understand the use of service guarantees in todays competitive healthcare industry, three hypothesiDed relationships are presented. These relationships, in

totality, focus on what drives the consumers intention to choose a given healthcare service provider and are rooted, in part, in economic and mar"et signaling theory which suggests that warranties and guarantees can serve as cues for reliability and Euality $'elley ()446 'ennett, neath, and 8enon ()))6 Tsuar and Wang /0(0-. .n their review of twenty years of service guarantee research, Hogreve and 3remler $/00)- note that only + of (0) studies examine a guarantees impact on purchase intention despite the Fcritical nature of this relationship. The bottom line is that a healthcare mar"eter has to decide what type of guarantee to offer. These choices often include whether to offer a limited explicit guarantee, unlimited explicit guarantee, or an implied guarantee. The success or failure of a guarantee as a mar"etplace signal depends, in part, on whether or not the target mar"et finds the guarantee to be believable. >n unbelievable guarantee may result in the guarantee having no impact, or even a negative impact, on the consumers evaluation process while a believable guarantee has the potential to positively impact the consumers choice process. .n the context of healthcare, an unlimited guarantee such as a hospitals promise to guarantee a patients complete satisfaction seems more li"ely to be perceived as being !too-good-to-be true# $or T3T5T- than a hospitals guarantee that an emergency room wait will be less than 70 minutes. The T3T5T perception is rooted in cognitive response theory which states that defensive cognitive responses will arise when a guarantee exceeds or deviates from the consumers standard $3reenwald ()*46 himp and 5earden ()4/6 Wright (),7-. .n addition, a limited explicit guarantee is expected to have a more positive influence on consumer intention than an implied guarantee. >s documented in the consumer learning and inference literature, consumers generally rely on information that is salient at the time of decision ma"ing unless they deliberately see" particular information $Hutchinson and %isenstein

/004-. 5ecause information becomes more salient when it is explicitly, as opposed to implicitly, presented, it is predicted that the limited explicit guarantee will be more effective than the implied guarantee. Therefore, the following relationship between the type of guarantee and intention to choose the promoted healthcare service is hypothesiDedJ H1: Consumers intention to choose the promoted healthcare service will be higher in the presence of a limited e plicit !versus unlimited e plicit and implicit" service guarantee. >n important issue when offering a service guarantee is to ensure that the guarantee covers aspects of the service that are important to the targeted customer $?strom and .acobucci ())4-. &onsumers understanding of a service and their needs with respect to a service should evolve with experience $8urray ())(6 1arasuraman, Keithaml, and 5erry ()4+6 Largo and :usch /004-. Iot surprisingly, experience plays a moderating role in many consumer studies $e.g., 5ennett, Hartel, and 8c&oll-'ennedy /00+6 &astaneda, 8unoD-:eiva and :uEue /00,6 harma and 1atterson /000-. .t is hypothesiDed that a consumers healthcare experience will moderate the relationship between type of guarantee and purchase intention. > more experienced healthcare consumer will have more "nowledge on which to rely when assessing a guarantee. H2: #he influence of a limited e plicit !versus unlimited e plicit and implicit" service guarantee on consumers intention to choose the promoted healthcare service will be moderated by their healthcare service usage $uantity in the past as follows% H2a: &or consumers with high healthcare service usage' their intention to choose the promoted healthcare service will be positively impacted by an limited e plicit !versus unlimited e plicit and implicit" service guarantee

H2b: &or consumers with low healthcare service usage' their intention to choose the promoted healthcare service will be less likely to be impacted by a limited e plicit !versus unlimited e plicit and implicit" service guarantee. 3iven the role of reputation and image in the healthcare decision $%xworthy and 1ec"ham /00*6 'im et al. /004-, the reputation of the healthcare provider offering a given guarantee is included as a final, critical consideration. &onsumers form reputations based on information and experience $&arauana ()),-. Reputation, in turn, has been shown to impact buyer response $Torres, LasEueD-1arraga, and 5arra /00)6 Moon, 3uffey, and 'iCews"i ())7-. ervice guarantee researchers have documented the role of company reputation on the evaluation process $i.e., :iden and %dvardsson /0076 WirtD, 'um, and :ee /000- and conclude that firm reputation does impact the ability of service guarantees to influence customer evaluations both positively or negatively $'ashyap /00(-. 5ecause, compared to naNve healthcare consumers, more experienced healthcare consumers are more li"ely to understand the diagnostic value of corporate reputation in assessing service guarantees, they should be expected to be more sensitive to the role of reputation and image $%lbei" ()4*6 'im et al. /004-, and as such, the following hypothesis is proposedJ H3: #he influence of a limited e plicit !versus unlimited e plicit and implicit" service guarantee on consumers intention to choose the promoted healthcare service will be more likely to be mediated by their perceived reputation of the hospital if their healthcare service usage $uantity was high' rather than low as follows% H3a: &or consumers with high healthcare service usage' the influence of a limited e plicit guarantee on consumers behavioral intention will be mediated by their perceived reputation of the hospital

H3b: &or consumers with low healthcare service usage' the influence of a limited e plicit guarantee on consumers behavioral intention will be less likely to be mediated by their perceived reputation of the hospital METHOD P%r'!"!)%&'s %&d Des!#& Three hundred six people participated in this study. Bata was collected using a variation of snowball sampling in which undergraduate students at two outheastern 2. . universities were given extra credit for securing responses from Eualifying adults. The students, themselves, were not allowed to participate in the research. Random chec"s to ensure reliability of responses received were employed. The demographic profile of the participants is summariDed in Table (. > maCority of them were &aucasian and aged /+ or higher with an annual household income of @;),))) or less. >bout half of the participants were females and singles. ------------------------------------------1lace Table ( about here ------------------------------------------The current study used a 7 $service guarantee typeJ implicit vs. limited explicit vs. unlimited explicit- x / $healthcare service usage EuantityJ high vs. low- x / $healthcare settingJ emergency care vs. physical therapy rehab- between-subCects design. The service guarantee type and healthcare setting were manipulated while participants healthcare service usage Euantity was measured. The service guarantee type was manipulated using three scenarios that differed in explicitness and scope of the service guarantee of a promoted hospital. 1articipants in the implicit service guarantee condition in the emergency care $physical therapy- setting readJ

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!When you need emergency care $physical therapy-, turn to the (mergency Care Center $)hysical Rehab Center- at River 1ar" Regional Hospital. We offer high-Euality, caring nurses and doctors $therapists- and state-of-the-art triage rooms $rehabilitation facilities- and eEuipment to the citiDens of southeastern :ouisiana. ?ur personnel are professionally Eualified and board-certified, and our award-winning hospital is fully accredited by the >merican Hospital >ssociation.# .n contrast, participants in the two different explicit service guarantee conditions were presented with an additional statement that openly guaranteed a certain level of services provided by a hospital. While Hill and 9oonas $/00+- find that patients wait time negatively influences their Euality perception and satisfaction, a maCority of them considered 70 minutes or less an acceptable amount of wait time to see a doctor. To maintain the perceived attractiveness of the service guarantee within a reasonable range, the current study used 70 minutes and (0 minutes as thresholds for the guaranteed wait time in the emergency care and physical therapy settings, respectively. Thus, participants in the limited explicit service guarantee condition were informed that the hospital guaranteed that they would not have to wait more than *+ minutes $,+ minuteswhen they needed emergency care treatment $physical therapy-. Those in the unlimited explicit service guarantee condition, on the other hand, were notified that the hospital guaranteed that they would feel assured by its caring, professional staff when they needed emergency care treatment $physical therapy-. >dditionally, healthcare service usage Euantity was measured by how often participants visited their doctors office over the last year. 1eople in the high healthcare service usage condition were defined as those who visited the doctors office multiple times while people in the low healthcare service usage condition were defined as those who visited the doctors office

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no more than once in the previous year. This dichotomiDation procedure led to a larger number of consumers in the high $- O */A-, as opposed to low $- O 74A-, healthcare service usage conditions. Met, these categorical distinctions mirror the modal number of healthcare visits within a (/ month period by 2. . citiDens where ;,A of the interview respondents actually visited the doctors office ( to 7 times in /00) $2. . Bepartment of Health and Human ervices /0(0-. Pro"ed$re 1articipants were told to read a scenario and then provide their thoughts about a hospital described in the scenario. To ensure that respondents opinions reflected their genuine reactions to the information presented, a hypothetical hospital name, River 1ar" Regional Hospital, was used. >fter participants read the scenario, they were presented with Euestions about the hospital and its service guarantee messages. =irst, perceived explicitness of the guarantee was measured by an open-ended Euestion $!.f you are not satisfied with the Euality of care received and you expressed your dissatisfaction to management, what do you thin" would happenH#-. 1articipants responses were recorded on a dichotomiDed scale, ranging from ( $problems are examined and corrected, .ll get refunded, .ll be satisfied- to 0 $nothing will happen-. econd, perceived scope of the service guarantee was measured on a ,-point semantic differential scale with ; items $!. feel that the hospital in this scenario isPhas QQQ#- to see if an unlimited explicit service guarantee was perceived to offer a broader range of caring and professional services than a limited explicit service guarantee. The scale ranged from ( $lac"s complete services, uncaring Rreverse scaledS, unprofessional Rreverse scaledS, incompetent physicians- to , $offers complete services, caring, professional, competent physicians$&ronbachs T O .,0-.

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Third, perceived reputation of a hospital was measured on a ,-point semantic differential scale with ; items $!. feel that the hospital in this scenario isPhas QQQ#-. .t ranged from ( $poor reputation, uninvolved in the health concerns of the community, inconvenient to use, discourteous employees- to , $excellent reputation, involved in the health concerns of the community, convenient to use, courteous employees- $&ronbachs T O .*4-. These measures are adapted from the hospital image measures employed by 'im et al. $/004-. =ourth, behavioral intention to select a promoted hospital was measured on an ((-point semantic differential scale with one item $!.f you needed emergency care $physical therapy-, how li"ely would you be to choose this particular hospitalH#-. .t ranged from 0 $very unli"ely- to (0 $very li"ely-. =inally, various demographic Euestions were measured. >mong them, participants age and the presence of a primary $personal or family- physician were included as covariates in the hypothesis test below. RESULTS M%&!)$,%'!o& C-e".s To chec" for a manipulation of explicitness of the service guarantee, a logistic regression analysis was run on perceived explicitness of the guarantee. >s expected, the result showed that the participants in the explicit service guarantee conditions $- O *+.7A- were more li"ely to mention successful resolution when their dissatisfaction was brought to the hospitals attention than those in the implicit service guarantee condition $- O +;.*A, / O 7.0;, p U .0)-. This finding was consistent with the manipulation of explicitness of the service guarantee of the study.

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To chec" for a manipulation of scope of the service guarantee, perceived scope of the service guarantee was assessed. >s anticipated, the participants in the unlimited explicit service condition $- O +.,+, SD O .),- felt that the service guarantee coverage was generally broader than those in the limited explicit service guarantee condition $- O +.;*, SD O (.0;-, & $(, ())- O ;.(;, p U .0+. Thus, the manipulation of the service guarantee scope was also successful. The results below were collapsed across two different scenario settings $emergency room and physical therapy- because they did not interact with "ey predictors of behavioral intention. A& I&/,$e&"e o/ % Ser !"e G$%r%&'ee Ty)e o& % Be-% !or%, I&'e&'!o& 1H23 >s predicted, a limited explicit service guarantee positively influenced consumers li"elihood to choose the promoted healthcare service, compared to unlimited explicit and implicit service guarantees. &onsumers were more li"ely to pic" the promoted healthcare service when they were presented with the limited explicit service guarantee $- O ,.*+, SD O (.4;-, rather than the other service guarantees $- O ,.//, SD O /.0+, & $(, 700- O 7.7/, p U .0,-. Thus, H( was marginally supported. A Moder%'!&# Ro,e o/ % He%,'-"%re Ser !"e Us%#e 4$%&'!'y 1H53 > / $service guarantee typeJ limited explicit vs. unlimited explicit and implicit- x / $healthcare service usage EuantityJ high vs. low- >I?L> was conducted to test H/. >s expected, the influence of a service guarantee type on consumers behavioral intention depended on their healthcare service usage Euantity in the past $&$(, /),- O 7.0/, p U .0)-. &onsistent with H/a, for consumers with high healthcare service usage, their intention to choose the promoted healthcare service increased when they were presented with a limited explicit guarantee $- O ,.)*, SD O (.)*-, rather than unlimited explicit and implicit guarantees $- O ,.(*, SD O /./,, $&$(, (+)- O +.0;, p U .07-. Thus, H/a was supported. > post-hoc

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comparison was performed to understand the source of the difference in behavioral intention. .t revealed that consumers in the limited explicit guarantee condition exhibited significantly higher behavioral intention than those in the implicit guarantee condition $- O *.,;, SD O /.*/, &$(, (0*- O ,.,+, p U .00*- $see Table /-. ------------------------------------------1lace Table / about here ------------------------------------------=urthermore, consistent with H/b, for consumers with low healthcare service usage, their intention to choose the promoted healthcare service did not change, regardless of the service guarantee type $limited explicit guaranteeJ - O ,.70, SD O (.*76 unlimited explicit and implicit guaranteesJ - O ,.7/, SD O (.,+6 &$(, (7*- U (, p V .)- $see Table /-. Thus, H/b was also supported. A Med!%'!&# Ro,e o/ Per"e! ed Re)$'%'!o& 1H63 2sing the analytic procedure suggested by 5aron and 'enny $()4*-, the current study tested whether consumers perceived reputation of the promoted healthcare service would mediate the impact of a service guarantee type $limited explicit guarantee vs. unlimited explicit and implicit guarantees- on behavioral intention. This study examined if the mediating role of perceived reputation would be Eualified by the Euantity of consumers healthcare service usage in the past $i.e., mediated moderation-. >s expected, the interaction between the service guarantee type and healthcare service usage Euantity had a significant influence on consumers perceived reputation $b O .(/, S( O .0*, t O /.04, p U .0;- and behavioral intention $b O ./(, S( O .(/, t O (.,;, p U .0)-. 1erceived reputation also increased behavioral intention $b O (.0+, S( O .(0, t O (0.0;, p U .000(-. The direct interactive effect between the service guarantee type and

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healthcare service usage Euantity on behavioral intention became insignificant $b O .04, S( O .((, t O .,7, p V .;- after controlling for perceived reputation $ obels . O (.)*, p O .0+-. pecifically, it was predicted that the meditating relationship would be observed only when consumers healthcare service usage Euantity was high, but not when it was low. The results of a series of regression analyses to test H7a and H7b are presented in =igure (. ------------------------------------------1lace =igure ( about here ------------------------------------------=or consumers with high healthcare service usage, the presence of the limited explicit service guarantee, compared to the unlimited explicit and implicit guarantees, significantly increased consumers perceived reputation $b O .(4, S( O .04, t O /./+, p U .07- and behavioral intention $b O .;0, S( O .(4, t O /./+, p U .07-. 1erceived reputation also showed a significant effect on behavioral intention $b O (.0,, S( O .(*, t O *.4/, p U .000(-. The direct effect of the service guarantee type on behavioral intention became insignificant $b O .//, S( O .(*, t O (.7;, p V .(- after controlling for perceived reputation $ obels . O /.(/, p U .0;-. Thus, the tests supported full mediation consistent with H7a. =or consumers with low healthcare service usage, the service guarantee type did not influence consumers perceived reputation $b O -.0*, S( O .04, WtW U (, p V .;- and behavioral intention $b O -.0(, S( O .(+, WtW U (, p V .*-. 1erceptual reputation did not mediate the influence of the service guarantee type on behavioral intention. Thus, H7b was also supported. DISCUSSION AND IMPLICATIONS ervice guarantees have long been viewed as beneficial mar"eting tools. However, the use of these guarantees in healthcare is considered ris"y due to the nature of the industry. While examples of the successful use of guarantees in healthcare do exist, to-date, researchers have yet

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to examine this industry-specific application beyond a case study perspective. The results of this study begin to shed light on whether or not healthcare service guarantees should be used, and if so, under what conditions are they appropriate. The findings suggest that the thoughtful use of service guarantees can positively impact the consumers perceptions of the healthcare providers reputation and ultimately, their behavioral intentions towards the same healthcare provider. However, consideration must be given to the type of guarantee being offered and to whom the guarantee is targeted. >s seen in H(, a limited explicit guarantee results in higher behavioral intention. This is not surprising since a limited explicit guarantee intuitively seems more believable. &ognitive response theory suggests that consumers will discount unbelievable guarantees and that unbelievable guarantees can even negatively impact the decision process $3reenwald ()*46 himp and 5earden ()4/6 Wright (),7-. >lso, a limited explicit guarantee is the most concrete of the guarantee offerings resulting in a higher li"elihood of inclusion of the guarantee in this same decision process as shown in consumer learning and inference literature $Hutchinson and %isenstein /004-. :astly, as manipulated in this study, the limited explicit service guarantee is focused on the businessoriented aspects of the service offering as opposed to the medicine-oriented applications $:ewis ())7-. .t will always be critical for healthcare mar"eters to guarantee what can be controlled. .n general, the results of this study indicate that healthcare providers should gravitate toward the offering of a limited explicit guarantee. The impact of this limited explicit guarantee on purchase intention is moderated by the consumers healthcare service usage. &onsumers categoriDed as having high healthcare usage were more positively swayed by the limited explicit service guarantee than those consumers who reported low healthcare service usage. Therefore, the use of a guarantee may be particularly

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meaningful when targeting the experienced healthcare consumer and less successful when targeting consumers with limited experience. imilarly, the experienced healthcare consumer seems to rely on the service guarantee as an indicator of the providers reputation which in turn impacts behavioral intention. The mediating effect of provider reputation is not apparent for consumers with little to no healthcare experience. .f targeting experienced healthcare consumers, healthcare providers that have established reputations in a mar"etplace must thin" about how the guarantee interacts with existing reputation. However, this interaction is less of an issue if targeting inexperienced consumers andPor if the provider has no discernable reputation. 2nder the right conditions, a service guarantee can serve not only to increase immediate purchase intention, but to enhance image. >ccording to the &enters for Bisease &ontrol and 1revention $/004-, the number of visits to physician offices and hospital outpatient and emergency departments has increased by twentysix percent over a ten year period. The result of this trend is more experienced healthcare consumers. :ogically, healthcare mar"eters should be able to leverage the use of service guarantees to attract this experienced populace. =urther examination of trends among specific segments of the mar"et $i.e., HispanicP :atino and >frican->merican healthcare consumersshould help to craft relevant guarantees and ma"e related promotional decisions $e.g., >s"im:ovseth and >ldana /0(06 5all, :iang, and :ee /00)-. :astly, results of this study also indicate the ability to generaliDe the findings across various healthcare settings. The experiment was conducted using emergency room and physical therapy applications. Io differences in results were found across settings. The impact of the

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limited service guarantee should be relevant for all healthcare mar"eters regardless of the specific services they are mar"eting. LIMITATIONS AND FUTURE RESEARCH The current study assesses the impact of the scope of the guarantee on discernible consumer perceptions and behaviors. .t does not examine the outcome of invo"ing the guarantee and how it impacts these same variables. =uture researchers are encouraged to extend the current experimental design to include an outcome of invo"ing the guarantee manipulation. 1revious research indicates that this manipulation and its interaction with the scope of the guarantee can be meaningful $'ennett, 5ernhardt and neath ()))-. .t would be enlightening to extend the current research to examine not only what type of guarantee should be offered, but also to understand what a healthcare provider should offer if the guarantee is invo"ed. .f, for instance, someone waits longer than 70 minutes in an emergency room, how should the consumer be made wholeH .s an apology sufficientH mentionedH =uture researchers are also encouraged to replicate the existing research using consumers in other geographical settings. .t is plausible that uniEue mar"eting approaches employed by healthcare providers in a given geographic mar"et might heighten or lessen the impact of a guarantee. =or instance, respondents in this study live in a mar"et in which healthcare service guarantees have been employed. Would consumers in a mar"et in which healthcare service guarantees are not employed react differently to the introduction of a guaranteeH .t is conceivable that consumer experience not only with healthcare in general, but with healthcare guarantees, is an important moderating variable. hould a co-pay be refundedH ?r should no outcome be

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T%;,e 2 Des"r!)'! e S'%'!s'!"s /or V%r!%;,es !& '-e S'$dy &haracteristic 3ender =emale 8ale Total >ge (4 G /; /+ G 7; 7+ G ;; ;+ G +; ++ < Total 8arital tatus ingle 8arried eparated Bivorced ?ther Total Race >frican >merican Hispanic >sian &aucasian ?ther Total Household .ncome @(),))) or less @/0,000 G @;),))) @+0,000 G @,),))) @40,000 G @)),))) @(00,000 < 8issing Total =reEuency 1ercentage

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$a- High Healthcare ervice 2sage &onditions $(:imited explicit guarantee ample siDe 5ehavioral intention $((-point scale1erceived reputation $,-point scale+, ,.)* a $(.)*+.4; a $.4)$/.mplicit guarantee $72nlimited explicit guarantee +7 ,.+4 $(.,4+.*( $(.00$;O $/- < $7-

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4otesJ :ower case letters a and b within the same row denote statistical significance at p U .0+. %ven though only the numbers in two shaded columns $(- and $;- were used for hypothesis testing, the data in columns $/- and $7were also compared against those in column $(- to better understand the main source of mean differences between columns $(- and $;-.

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F!#$re 2 Med!%'!o&%, A&%,yses $a- High Healthcare ervice 2sage &onditions

1erceived reputation b O .(4]] ervice guarantee type b O .;0]] b O .// b O (.0,]]]

5ehavioral intention

$b- :ow Healthcare ervice 2sage &onditions

1erceived reputation b O -.0* ervice guarantee type b O -.0( b O .0* b O (.0/]]]

5ehavioral intention

4otesJ The beta weight below the line from the !service guarantee type# $(O limited explicit service guarantee6 -(O unlimited explicit and implicit service guarantees- to !behavioral intention# represents the impact of the former on the latter when the impact of perceived reputation is controlled for. ]]] p : .0(, ]] p : .0+, ] p U .(0.

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