Customers' satisfaction study on the products provided by the State Health Care Program and Private Insurance Companies in Tbilisi

Mariam Talakhadze1,?Nato Pitskhelauri2 , Nino Chikhladze3

Iv. Javakhishvili Tbilisi State University, Faculty of Medicine, Georgia

1 MPH; 2Supervisor, MD, PhD, Associate Professor; 3 Reviewer, MD, PhD, Professor

Summary

Aim: The aim of the study was to identify the strengths and weaknesses of public and private health care services based on the analysis of the results of the Customer Service Satisfaction Questionnaire under the State Universal Health Care Program and the products of private insurance companies, in order to develop recommendations for their improvement.

Methodology: A descriptive cross-sectional survey was conducted in a 3-month period with a total number of 599 respondents.?The criteria for inclusion in the study were: Age> 18 years, receiving medical services in Tbilisi. The collection of responses was using the electronic questionnaire. The data analysis was performed using the statistical program IBM SPSS version 26.0.

Results: The significant findings of the study are the following: A majority of participants living in Tbilisi were female 498 out of 599. 73.6% were employed. A large number of responders were in the 25-34 age group (n=235). About 59% of the participants had insurance packages, 29.9% used the Universal Health Care program, and 9.2% had none of the above. The first 3 most common services are planned outpatient services, medications and dentistry. From the list of the barriers that patients encountered while having medical services the most frequent (15%) is the lack of qualified medical staff, followed by the lack of providers (14.6%).

As for the paid premium, for insured people, 29.7% of the responders indicated that the received services do not fit properly with their needs. Study participants assess the medical services provided by the state as bad. Totally, 80.6% of the responders prefer to use a private insurance packages than the universal healthcare program.

Conclusions: The study results showed that the population is not properly satisfied with neither with their health insurance packages nor state Universal Healthcare Program. In comparison, it is obvious that private health insurance packages are preferred.

Abbreviations, OOPs - Out of-pocket payments, PHC - Primary health care, NCD - Noncommunicable disease

Keywords: state, insurance, customers’ satisfaction, services, Tbilisi

Problems Statement:

It should be noted that the attitude of the population of Tbilisi towards the quality of medical services received in terms of comparing insurance services and universal health care program has not been studied.

The State Program for Universal Health Care was launched in Georgia on February 28, 2013, with the aim of creating financial support and having access to medical services for the population of Georgia for those citizens living?without health insurance. (1)

The program provides planned and emergency outpatient services for all citizens of Georgia, emergency inpatient treatment, planned surgical operations (including day hospital) and related examinations within the relevant limit.

From May 1, 2017, differentiated packages were launched in the universal health program, according to this regulation, socially vulnerable people, pensioners, children aged 0-6, teachers, students, internally displaced persons, and persons with disabilities maintained the same targeted special services provided by the universal health program.

However, citizens with an income of less than 1000 GEL per month, self-employed, and citizens with irregular income can use a limited package, people who have health insurance, are maintained with emergency services, treatment of oncological diseases (chemotherapy, hormones and radiation therapy) and maternity / caesarean section.

Medium-income citizens with a monthly income of more than GEL 1,000 but the annual income does not exceed 40 000 GEL, who use either universal health care limited services or a private insurance package, receive treatment for oncology (chemotherapy and hormone therapy), Childbirth / Caesarean section.

Citizens whose income exceeds 40,000 GEL per year, will no longer be enrolled in the universal health care program. It should be noted that the universal health care program does not fund: high-tech studies such as PET (A positron emission tomography)/CT (A computerized tomography), refractive eye surgery, surgical treatment of the eye, laser eye surgery (except for diabetic eye), corneal transplantation, reimbursement of medication expenses (for target groups only), dentistry.

On the other hand, citizens of Georgia have the opportunity to join the insurance scheme and benefit from individual or corporate health insurance services by purchasing a package suited to their needs, based on the payment of the relevant premium. According to the Georgian Insurance Association, the number of medical insurance beneficiaries is growing every year. As of March 31, 2020, 17% of the population of Georgia (615,966) owns medical insurance.

With respect to spending on providers, low-income countries face five challenges. First, the lack of good membership data limits the capacity to identify vulnerable groups. Second, the lack of good data on cost-effectiveness limits the capacity to obtain value for money spent. Third, private providers dominate the ambulatory sector, and public hospitals dominate the inpatient sector, limiting the choice of providers. Fourth, weak management and lack of institutional capacity limit the sophistication of performance-based payment systems that can be used. Fifth, lack of good cost data limits the transparency of prices charged by public and private providers. (2)

Determinants of patient satisfaction

In the increasingly competitive healthcare sector market, healthcare managers should concentrate on achieving good patient satisfaction ratings to enhance the quality of service delivery. Experts recommend that medical institutions should focus on areas that have fundamental importance in quality assurance, management and improvement when evaluating quality. (quality core components are shown in graph 2). By conducting patient satisfaction surveys, they can easily detect the problems and start to improve the drawbacks. Kaneet et al. (1997) and Marley et al. stated that measuring satisfaction should "incorporate dimensions of technical, interpersonal, social, and moral aspects of care". (3)

Aim of the study and objectives :

The study aims to identify the strengths and weaknesses of public and private health care services based on the analysis of the results of the Customer Service Satisfaction Questionnaire under the State Universal Health Care Program and the products of private insurance companies, in order to develop recommendations for their improvement.

Based on the literature review, according to quality determinants, the objectives of the study are to analyze the answers to the questions in the questionnaire to determine: which age and gender category use the planned and emergency medical services; How well citizens are informed about their own health care packages; Whether disease prevention measures are being implemented; What do people consider to be the disadvantages of the programs proposed by the public and private sectors.

Study population

A descriptive cross-sectional survey was conducted in 3-month period, from 01.05.2020 to 01.08.2020 with a total number of 599 respondents.?The criteria for inclusion in the study were: Age> 18 years, receiving medical services in Tbilisi. The study persons were different from each other by socio-demographic characteristics to objectively determine their satisfaction with medical services.

Data collection and analyzing

The database was collected by distributing a questionnaire online - in electronic format, by using Google Docs. Participation in the survey was voluntary and confidential, each responder was informed about the purpose and methods of the survey and was given an Informed Consent form. Both IC and questionnaires were presented to applicants in Georgia. The questionnaire contains 20 multiple choices both qualitative and quantitative questions, 4 of which (on health service deficiencies, barriers and communication channels) may indicate an open-ended answer according to the applicant’s desire.

The data analysis was performed using the statistical program IBM SPSS version 26.0.

Results of the study:

A total number of 599 respondents completed the questionnaire. A majority of participants living in Tbilisi were female 498 out of 599. (shown in Pie chart 1)

?

?Study participants are presented in following 6 age groups: 18-24; 25-34; 35-44; 45-54; 55-64; 65+. The majority of responders were in the 25-34 age group (n=235) and the least quantity of participants were in 65+ (n=15). The mean age fluctuates between 35-44 years. (shown in Bar chart 1)

About 59% (353 out of 599) of the participants had insurance packages, 29.9% (179 out of 599) used the Universal Health Care program, 9.2% (55 out of 559) had none of the above, 2% (12 out of 599) of responders did not answer the question. (shown in Pie chart 2)

Totally, 73.6% of the study population were employed. (shown in Pie chart 3)

As was expected, mostly, employed people have insurance packages and non-employed people seem to use more Universal Health Care packages. (shown in Bar chart 2)

??The service that people use the most frequently is planned outpatient services (38.6%) followed by medications and dentistry. The least number of study participants indicate that they use oncology services. (shown in Pie chart 4)

The majority of the responders – 50.4% said that they use healthcare services several times a year. only 1.2% of them indicated that the?frequency – was once a week. (shown in Bar chart 3)

?Participant satisfaction with medical services

?The majority of study participant seems to be partly satisfied with a 5-scale rating of the quality of medical services during the last 1 year.?

The majority of study participants indicated that they needed less than a week but more than 1 day to book a visit to a family doctor/a specialist. (shown in Bar chart 5)67.4% of responders answered that they feel the allocated time for visiting a doctor is enough for them. (shown in Bar chart 6)

Barriers to Accessing Quality Health Care for patients

?

From the list of the barriers that patients encountered while having medical services the most frequent (15%) is the lack of qualified medical staff, followed by the lack of providers (14.6%) (shown in Pie chart 5).?

Most of the study participants said that they are well informed about their healthcare packages. Median=4, Mode=5, SD=1.3 (shown in Bar chart 7)

Disease prevention events

?49.1% of the study participants said that they were not suggested to do disease prevention measures. 46.9% said that they were and 4% gave no answer. (shown in Pie chart 6).

?Almost half of the study participants said that they apply disease preventive measures once a year where 32.6% never apply. (shown in Pie chart 7).

?Participants’ satisfaction with their healthcare packages

?Most of the study participants assessed the matching of their healthcare package to their needs as 3 on a 5-scale rating. (shown in Bar chart 8)

?As for the paid premium, for insured people, 29.7% of the responders indicated that the received services do not fit properly with their needs. (shown in Bar chart 9)

Study participants assess the medical services provided by the state as bad. (shown in Bar chart 10)

Main drawbacks of health insurance and health state program

?The majority of study participants (23.1%) stated that main drawback of the health insurance packages is their affordability. Followed by insufficient limit for treatment. (20.2%) (shown in Pie chart 9)

As for the drawbacks of the Universal healthcare program, responders show that the biggest disadvantage seems to be having focus on quantity, not quality. Followed by the qualification of medical staff.?(shown in Pie chart 10)

Health insurance package or Universal healthcare program?

?Totally, according to the previous answers, as it was expected, 80.6% of the responders prefer to use private insurance packages than the universal healthcare program. (shown in Bar chart 11)

Discussion

?A priority is the delivery of high-quality health services to ensure universal access to health care. Health for all is a global priority. (4)?Furthermore, as quality in health care is closely linked to the quality of the health workforce, targeted capacity-building and medical staff training strategies need to be placed in place.

Since, about 74% of the study population is employed, it was expected, that the majority of them (59%) would own private and/or corporate insurance packages. 9.2% is a high percentage of citizens who do not use neither insurance nor state programs. That makes the increase of OOPs.

Marmara University Goztepe Campus suggests that the most common healthcare services are planned outpatient visits, dentistry and nutrition counselling. (5) The study conducted in Tbilisi partly meets the above-mentioned trends. The first 3 most common services are Planned outpatient services, medications and dentistry.?

According to the results of the study, the most needed service is planned outpatient visits which should be carried out in order to contribute to maintaining the health of individuals through vaccinations, screening?tests, physical examinations, counselling and health education.

50.4 % of responders said that they use healthcare services several times a year, but, 10.7% generally do not use medical services at all. While regular medical checkups should be implemented and controlled. The majority of the responders said that their family doctor do not suggest getting disease preventive measures such as instrumental and laboratory tests, and vaccination. Though, usually almost every health insurance plan provides carrying out check-ups at least once a year.

The Partnership for Prevention explored the economic and social advantages of clinical preventive services. The analyzes, which examined the efficacy, effects and expense of preventive interventions, led to targeted recommendations for increased access to services that would improve health outcomes for significant segments of the population at a reasonable cost. (6)

Dr?Andreas Ullrich, cancer expert at WHO Earlier diagnoses have the ability to deliver improved clinical results, in particular for cardiovascular disorders and some cancers. (7)

As for the awareness about the healthcare packages, of the participants, 31.4% reported that they are very well informed about their healthcare packages. The most common way to get information about current promotions, discounts and various events in medical institutions is social network where they easily come across advertisements and campaigns. Followed by SMS, TV, Mail, and Websites. Also, they get some information during their visiting time to a doctor.

Evidences indicate that existing barriers may discourage people to receive medical services. Especially in low- and middle-income countries, relatively little attention is paid to ways of mitigating their impact, by policymakers, healthcare managers, medical staff and researchers. These barriers are likely to be more important for the poor and other vulnerable groups, where the costs of access, lack of information and cultural barriers impede them from profiting from public spending. (8) The 3 most common barriers responders face up to while/before receiving medical services are: lack of qualified medical staff (15%), lack of providers (14.6%) and insufficient financial limit for treatment (13.4%).

We may say that the above-mentioned trends for the most part met the ones that were outlined by extensive research of northern populations (Finland, Iceland, Norway, Russia, Sweden and the USA). the influence of physical geography, healthcare provider-related barriers, the importance of culture and language, and the impact of systemic factors. Together, these factors negatively influence patient health outcomes. (9)

According to responders, less than 1% (n=8) said that they did not face barriers while having medical services.

The issue of healthcare packages matching the beneficiaries’ needs, still seems to be a challenge. They assess their attitude towards their health insurance and state packages as not good.?

In general, the patient's vision regarding the quality of medical care is very important because a satisfied patient is more likely to agree to treatment and continue to receive primary care.

It should also be noted that the public is not always aware of their own medical needs. Especially in the case of preventive services and do not have the ability to adequately assess technical competence. Patients often do not know what kind of service is good. What the standard for providing a specific medical service is and what good service means.

But they can compare the services provided by insurance companies and by the state in light of flexibility and affordability.

Among the responders, most of them (23.1.2%)?consider affordability, followed by insufficient limits (20.2%) for treatments?the biggest drawback of the insurance packages, since they say that they can not easily afford to buy insurance packages and the financial limits provided by the insurance companies for inpatient treatment, medication, oncology and other needed services are not sufficient for them.?As for the Universal Health Care program, the main drawbacks are:?the focus is on quantity, not quality (30.4%); Qualification of medical staff (21.1%); Lack of providers and medical staff (17.6%). Georgia has a discrepancy between the ratio of physicians and nurses. A number of physicians exceed the number of nurses is almost 1.5 times more. (10)

Several important drawbacks were revealed while analyzing this study's results, it is obvious that private insurance packages are more adapted to the needs of beneficiaries, have a more flexible system for compensation and have more medical providers.

Conclusions and Recommendations

The study results showed that the population is not properly satisfied with neither with their health insurance packages nor state Universal Healthcare Program. In comparison, it is obvious that private health insurance packages are more preferred.

Recommendations for future work would be:

·????????Strengthen PHC - realization of health care as primary objective is necessary. There is a need to build financial viable and sustainable PHC based on rational principles to fulfill the goals of providing quality health services on an affordable and equitable basis in light of the growing number of NCDs.

·????????Support health financing by: revenue-raising (sources of funds, including government budgets, compulsory or voluntary prepaid insurance schemes, direct out-of-pocket payments by users, and external aid), pooling of funds (the accumulation of prepaid funds on behalf of some or all the population), purchasing of services (the payment or allocation of resources to health service providers)

·????????Improving the post-diploma/continuous medical education system – on one hand, it will improve the results of patients’ satisfaction and preventive measures and, on the other hand, it will reduce expenses for healthcare facilities.?

·????????Establish a supporting policy to increase coverage of insured people. especially on the bases of people who work and have their income and their family members who can be included in the insurance plans. As a result, they will not be a burden to the state since they have the financial resources to buy the insurance packages that mostly meet their needs.

·????????Improving health insurance packages, in the way that people who buy them, could be able to ensure their elderly family members. One of the complaints was about the age limit, some insurance companies do not insure family members above certain age limits.

References:

1.?????Resolution of the Government of Georgia, №36,21 Feb,2013 , Tbilisi.

2.?????Alexander S. Preker Richard M. Scheffler Mark C. Bassett, Private Voluntary Health Insurance in Development, 2007 (pg.4)

3.?????Kathryn, A.,M., David A., C., Susan, M., G.(2004). The Role of Clinical and Process Quality in Achieving Patient Satisfaction in Hospitals, Decision Sciences, Vol: 35, NO.3, pp.349-369

4.?????WHO priorities (https://www.who.int/dg/priorities/en/)

5.?????Sevim AKSOY KARTCI, Senem BUGDAYCI, Burcin KAVAKLI, Ebru ATICI, Serap CIFCILI, Cigdem APAYDIN KAYA.?The most common health care services needed by university students and employees, 2019, p.32

6.?????Ron Z. Goetzel, Do Prevention Or Treatment Services Save Money?, 2009

7.?????Prevention is better than cure, say Romanian doctors; Bulletin of the World Health Organization?2011;89:248–249

8.?????Tim Ensor,?Stephanie Cooper, Overcoming barriers to health service access: influencing the demand side, abstract, 2004.

9. S. Huot,H. Ho,A. Ko, S. Lam, P. Tactay, J. MacLachlan, and R. K. Raanaasd, Identifying barriers to healthcare delivery and access in the Circumpolar North: important insights for health professionals, 2019.

10.????The Core Healthcare Indicators, Geostat, 2018 (https://www.geostat.ge/media/5607/jandacva-2017.pdf)