The Role of The Marketing Mix Factors in Hospital Selection

Background: The problems faced by Soerojo Hospital is currently decreasing the number of outpatient visits and decreasing customer satisfaction. Marketing mix analysis based on satisfaction surveys which on average are good based on hospital customer perceptions and targeted revenue targets from out-of-pocket sources of 30 percent require the right marketing mix tactics for potential customers in the comunity. This study will help Soerojo Hospital choose dominant factor of the marketing mix in hospital selection for making optimal marketing strategy. The aims of this study was to identify the role of the marketing mix factors on people's decisions in hospital selection. Materials and Methods: This study was conducted with a descriptive, quantitative approach, cross sectional research design, 385 respondents were surveyed with questionnaires and data analysis was carried out with program packages. Results: The components of the marketing mix that occupy the top three positions are the location component with a median of 4.67(1-5), the process component with a median of 4.60 (1-5) and the cost component with a median of 4.50 (1-5). There was a significant difference between the groups who choose and did not choose Soerojo mental hospital in the doctor/staff and promotion (p value <0.05). Conclusion: The location, process and cost components are the components of the marketing mix that most influence the decision to choose a hospital. Suggestions for improvements that can be made by RSJ Prof. Dr. Soerojo Magelang based on the results of this study.


1.
Introduction A hospital is an organization that provides services in the health sector has a social mission as well as a business function in order to grow and develop and survive to continuously provide services to the community.One of the external factors faced today is the COVID-19 pandemic which has changed customer behavior so that they are reluctant to go to the hospital and tend to delay services that are not emergency in nature.This change in behavior led to a decrease in the number of outpatient visits and resulted in a decrease in hospital revenue (1,2).Another external factor taken into account by hospitals is the increasing number of hospitals in an area which automatically adds to the competition between hospitals in an effort to retain their customers (3,4).
RSJ Prof. Dr. Soerojo Magelang implements a financial management system as a Public Service Agency is required to be able to provide good services to the community.The other side Soerojo Hospital must be able to manage their finances well and can reduce dependence on financing sourced from the state.Every year the hospital has operational, quality and financial performance targets that are prepared based on the hospital's Business Strategic Plan.Hospitals are required to be able to explore sources of income from health insurance / BPJS / other guarantees as well as sources of income from Non-Guarantee / out of pocket by 30 percent.The problem faced by RSJ Prof. Dr. Soerojo Magelang at this time is the problem of decreasing hospital operational performance, namely a decrease in the number of outpatient visits.Decreasing outpatient visits include in psychiatric patients, as we know that number of mental health problem in society increase due to COVID-19.People with COVID-19 will stay at home, have no social activity dan feel isolated increasing depression, but they do not go to hospital to take their medicine.Another problem faced is the problem of decreasing hospital customer satisfaction.Based on the research of Richter and Muhlestein it is known that a positive patient experience is associated with an increase in hospital profitability and conversely that a negative patient experience has an even stronger relationship to a decrease in hospital profitability (5).So that if no improvement efforts are made, it can be predicted that there will still be a decrease in outpatient visits in the following year.
The marketing mix analysis based on community satisfaction surveys is considered quite good by hospital customers and the revenue target from out-of-pocket sources of 30 percent is why hospitals need to learn how people perceive the hospital's marketing mix and how to make improvements.Previous research stated that there is a relationship between marketing strategy and hospital performance and the advantages that can be obtained from implementing marketing strategies include increasing hospital competitiveness and offering a better patient experience (6,7).The right marketing strategy ensures that customer needs can be met profitably both from the consumer side and the hospital.To support the right marketing strategy, it is necessary to choose the right marketing tactics so that the product communication strategy, price, distribution and marketing can be achieved.This marketing tactic is known as the marketing mix.The marketing mix function is one of the information that customers use in making the decision to buy or not to buy a particular product (8).
Previous research on the effect of marketing mix on hospital selection suggests that the physical environment and staff have a dominant influence (9).The results of research in Oman show that there is a relationship between the selection of hospitals and hospital services and the cost of services offered.The study also revealed that in private hospitals patients can easily establish relationships including registration officers and all provide the necessary assistance.In addition, private hospitals are equipped with modern equipment, and doctors treatpatients in a friendly manner (10).
According to Moscelli et al., important factors that can influence customers' choice of health facilities include: distance, quality of service, ceteris paribus, and short service time.Other factors that can influence customers in choosing a hospital include: quality of service, hospital reputation, quality of published information, quality and market structure.Significant factors in hospital selection according to Fischer et al., expertise and quality of care, waiting time, ease of access, reputation, family and friend experience, personal experience, and other people's experience/patient satisfaction.According to Motwani and Shrimali, hospital managers must know what factors most influence patients' choice in choosing a hospital.His research divided the four dimensions of hospital choice, including location, price transparency, staff behavior, processes and the use of technology.(11).Other studies have shown that there are differences in dominant factors between public hospitals and private hospitals (12).
Research on how the marketing mix that customers want to be for hospital service products and what kind of marketing mix information customers use to choose a particular hospital has never been done by RSJ Prof. Dr. Soerojo Magelang.Therefore, it is necessary to conduct research to obtain information on the role of factors in the marketing mix to people's decisions in choosing a hospital.

Materials and Methods
This research is a descriptive study, with a quantitative approach using a cross-sectional research design.The research location is the City and Regency of Magelang with the research time carried out after the approval of research ethics and research permits are obtained.The implementation of the research may to June 2021.The population of this research was all residents of Magelang City and Regency with inclusion criteria: residents of Magelang City and Regency, aged 20 to 59 years, have a job, minimum high school education, and per capita expenditure per month of at least 1.5 million rupiah.Meanwhile, the exclusion criteria: hospital employees, hospital foundation owners/administrators and hospital directors.This research used consecutive sampling, where the research sample was selected according to the inclusion and exclusion criteria until the minimum number of samples was met by 385 respondents.The research instrument used is an online questionnaire consisting of three parts, namely the first part contains questions about the demographics of respondents, the second part about the decision to choose a hospital and the third part contains 32 questions about the 7 components of the marketing mix consisting of 5 product-related questions, 3 location-related questions, 5 questions related to doctors and staff, 5 promotion-related questions, 4 cost-related questions, 5 process-related questions and 5 physical environment related questions.The questionnaire was selected by the researcher based on previous studies.The questionnaire scale uses a Likert scale of 1-5.(13).The data analysis method used is descriptive analysis.Non-parametric statistics (calculate the median, minimum and maximum) are used because the data obtained have an abnormal distribution.A comparative analysis of the two groups was carried out with the Mann Whitney test.Data analysis is carried out using program packages.( 14)

Results a. Characteristics of the respondent
From the results of a study of 385 respondents, demographic data on respondents' characteristics were obtained as follows .Based on data from the respondents' preferred hospitals, RSJ Prof. Dr. Soerojo Magelang ranked second.These options include the first choice when sick, the choice of hospitals with attractive costs and the choice of hospitals with reliable service speeds.

c. Influential factors in the marketing mix
Factors in the marketing mix of respondents' decisions were assessed using a five-interval Likert scale with the following interpretations: Based on the analysis of factors in the marketing mix that play a role in the decision to choose a hospital, the median component of the location occupies the first position followed by the components of the process and costs.Close location and easy transportation were the factors that most influenced respondents' decisions on the location component.Factors that are very influential in the components of the process include: advice is considered, detailed explanation, discipline and care and prompt service.Factors that greatly influence the cost component are other hospital equivalent rates, insurance / JKN guaranteed fees, transparent fees and free services available.

d. Comparison of components of the marketing mix that choose and do not choose RSJ Prof. Dr. Soerojo Magelang
A comparison of the components of the marketing mix of respondents who chose and did not choose RSJ Prof. Dr. Soerojo Magelang was shown in the following data:

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A comparative analysis of the components of the marketing mix of respondents who chose and did not choose RSJ Prof. Dr. Soerojo Magelang obtained the results that there were significant differences in the components of doctors/staff, promotions and 7 components of the marketing mix.

Discussion
Data from the Central Statistics Agency states that the population of Magelang Regency aged 20-59 years is 697.450 people while the total population of Magelang City aged 20-59 years is 70,265 people (15.16).Based on the origin of the respondents, the distribution of respondents is quite representative of the distribution of the population between the city and Magelang Regency.The distribution of respondents has also met the comparison according to the proportion of patients visiting RSJ Prof. Dr. Soerojo Magelang from Magelang City and Regency, namely 1: 2. While the characteristics of respondents are seen from age, the majority have an age between 24-55 years where the age of 24-39 years is included in the millennial gene category and 40-55 is in the X gene category.(16).The proportion of respondents does not match the majority of jobs owned by the people of Magelang Regency where the majority of the population has jobs as farmers / planters followed by private employees.Meanwhile, the majority of the residents of Magelang City work in the trade and processing industry sectors.(15,17).This is also inconsistent with the majority of the work of patients visiting at RSJ Prof. Dr. Soerojo Magelang which is dominated by private employees by 31 percent.In addition to the inclusion criteria required by researchers is a per capita expenditure of at least 1.5 million rupiah, this is likely to be the cause of the respondent's work being dominated by civil servants / TNI / POLRI / government.Based on employment, the distribution of respondents is not enough to represent the proportion of work of the people of Magelang City and Regency.The education is quite representative of the level of education of the people of Magelang Regency which in the second place has the most high school education and the majority of the residents of Magelang City have high school education (17,18).This is in accordance with the level of education of patients who visit at RSJ Prof. Dr. Soerojo Magelang where 34 percent have a high school education.Based on education, the distribution of respondents can represent the proportion of education of the people of Magelang City and Regency.While the ownership of BPJS/JKN respondents was 92.5 percent, this was in accordance with the coverage of national BPJS participants which reached 82.3%.(19).As many as 7.5 percent of respondents do not have a BPJS card.This data is also in accordance with the distribution of respondents' jobs, the majority of which are civil servants / TNI / POLRI / government who are BPJS card owners.Based on BPJS ownership, the distribution of respondents is quite representative of the proportion of BPJS ownership in the community.
The public transportation system in Magelang city and regency does not support the ease of transportation access to RSJ Prof. Dr. Soerojo Magelang.To reach RSJ Prof. Dr. Soerojo Magelang requires several changes to public transportation routes and public transportation operating hours are less reliable.The average operating hours of public transportation are from 08.00 to 16.00, so if they need transportation outside of these hours, people experience difficulties or worry if public transportation is not available.This is different from Tidar Hospital which is located in the middle of Magelang city so that the affordability of public transportation is easier.This is not in accordance with Raadabadi's research in Iran which states that location factors are the least important factor that influences the patient's decision to choose a hospital (20).
Process factors are customer orientation that must be met with excellent service from hospital staff.Respondents to this study are very concerned about the quality of interaction between customers and service providers in terms of the factors of advice, detailed explanations and disciplined and careful service delivery.This is in accordance with the definition of a process that contains interactions between customers and service providers to meet the needs and satisfy customers (21,22).Even in online reviews, the quality of interaction between customers and service providers is most often shown by reviewers.It is also possible that hospital customers give recommendations to family / relatives / friends to choose or not to choose a hospital based on the experience of service interactions they have.As for the factor of service speed in the process component, it is a paradigm shift for hospital customers.In the past patients would faithfully wait for the presence of doctors and even wait for the hospital to open in line.Currently, patient behavior has changed, people demand that hospitals be able to provide fast services from registration to drug collection.If the hospital is unable to provide fast services then the level of complaints both orally and in writing will be high.This is in accordance with the research of Moscelli et al., that patients are becoming more likely to prefer longer distances to choose hospitals with better quality or shorter waiting times (23).
Although the composition of respondents to this study is the majority (92.5%) who own BPJS / JKN cards, it turns out that the cost factor is very influential.Some of the outpatient hospital services available are not all guaranteed by insurance / JKN, for example medical check-up services (MCU), aesthetic services, traditional services ( acupuncture and acupressure) as well as preventive services such as vaccination.Not to mention that there is an element of cost in BPJS insurance that rises in class with rates that vary between hospitals is the reason the cost component is important.In addition to this, several hospitals in the city of Magelang currently provide free services such as patient pick-up and drop-off for certain clinics.This is an important concern for hospital customers and is one of the considerations that influence people's decision to choose a hospital.
The above further strengthens the cost component as an important thing that customers assess in choosing a hospital.Another study that mentions the cost factor as an important factor is the research of Abedi and Abedini mentioned that the cost factor is the most important factor in the marketing mix that influences the tendency of patients to choose public hospitals.As for private hospitals, the cost factor is the least important factor (12).This is also in accordance withresearch in Oman which shows that there is a relationship between hospital selection and hospital services and the cost of services offered (10).This is also in accordance with Malik and Varma's research in India where cost and product factors are important factors that influence people to choose hospitals (24).Likewise, Shrimali's research mentions that promotion, insurance financing and big name factors of hospitals are the most important factors in hospital selection (25).
This study is in accordance with Ravangard's research in Iran comparing government and private hospitals where significant differences in promotion, cost and process components were found in the two groups (9).The results of the study are also in accordance with the research of Al Balushi and Khan in Oman which stated that the different factors that affect the choice of government and private hospitals are the factors of the friendliness of doctors and other officers, the cost and ease of access to services.(10).The quality of service providers including good and competent doctors, pleasant staff and adequacy of officers is considered better than other hospitals.Likewise, promotional components such as banners, websites, brochures, routine reporting and promotions via television / telephone are considered better than other hospitals.
Product components, location, process, cost and physical environment were assessed by respondents as no difference between the group that chose and did not choose RSJ Prof. Dr. Soerojo Magelang (p value >0.05).This means that the product components, location, process, cost and physical environment at RSJ Prof. Dr. Soerojo Magelang are considered the same or only slightly different when compared to other hospitals.Although the percentage of respondents who chose RSJ Prof. Dr. Soerojo Magelang was only around 20 percent, the assessment of the most dominant component, namely location, was considered the same.Even on the components of the product that were rated the lowest by the respondents, the same assessment was given.This is likely because the type of services owned is almost the same between RSJ Prof. Dr. Soerojo Magelang and other hospitals.
The decision of respondents who chose RSJ Prof. Dr. Soerojo Magelang gave a higher assessment of the 7 components of the marketing mix than respondents who chose other hospitals.This is likely to be because respondents who chose RSJ Prof. Dr. Soerojo Magelang had a better understanding of the factors of the hospital's marketing mix.This is in accordance with the theory that consumers who have better information, then can choose alternatives and make buying decisions more rational and not based on intuition or impulse.(8,26).In this study, no data were obtained related to the possibility of choosing a hospital decision caused by impulse / intuition or recommendations from trusted people.Overall, there is an influence of the 7 components of the marketing mix on the decision to choose a hospital.This is also in accordance with Setyowati and Soekotjo's research at one of the Mojokerto hospitals which states that the marketing mix influences the decision to choose a hospital (27).

Conclusions
The location, process and cost components are the components of the marketing mix that most influence the decision to choose a hospital.RSJ Prof. Dr. Soerojo Magelang ranked second in respondents' choice in the decision to choose a hospital.
Demographic factors that influence the decision to choose a hospital are the respondents' age and occupation factors, where the respondents' age and type of work cause differences in the hospital of choice.Suggestions for improvements that can be made by RSJ Prof. Dr. Soerojo Magelang based on the results of this study include: a.For General Substance to evaluate the ease of transportation of patient care places in hospitals and provide free shuttle services to patients who have a community network with a certain radius.This is making good performance for location.b.For the substance of human resources to ensure the implementation of excellent service in service so that service interaction can run well.This is making good performance for process.
c.For Medical Check Up Installation to develop fast service with drive thru.This is making good performance for process.d.For the Tariff Team to design attractive rates and be able to compete with surrounding hospitals, especially for services that are out of pocket.This is making good performance for cost.e.For Promotional Installations in order to increase the promotional role of hospitals and select the right promotional media related to customer segmentation by age and occupation.For young people, promotion is through online media, while for old age promotion is through offline media.As for merchant and private groups, promotional media can be done through community groups in the community.This is in accordance with the theory that consumers who have better information will choose rationally.

Research Limitations
Some of the obstacles and limitations that can be found in this study are: a.The selection of respondents cannot be done with a proportional comparison between the City and Regency of Magelang because the survey is carried out online by distributing questionnaires to the public at large.b.The subjectivity factor of respondents' understanding of questionnaires cannot be controlled by researchers due to the absence of direct interaction between respondents and data collectors.

Table 1 . Demographics data
majority of respondents came from Magelang Regency by 62.6 percent, this is in accordance with the proportion of the total population of Magelang Regency which is more than the total population of Magelang City.The characteristics of respondents in terms of gender were 72.7% female.Based on age, the distribution of respondents is quite representative of the proportion of age in society.The respondent's work was dominated by civil servants / TNI / POLRI / government followed by private employees.The education of the majority of respondents is S1 / Diploma, because researchers apply the minimum educational inclusion criteria is high school.Majority of respondents have BPJS card as health insurance.