Determinants of Patient Satisfaction: A Comparison Between Hungary, Austria & Denmark

This paper captures our research regarding factors that impact patient satisfaction. Our fieldwork project allowed us to investigate and analyze medical institutions in Hungary, Austria and Denmark.

By: Cassidy Swartz, Leah Shabo, Tianna Sheih and Ben Todd

Abstract:

This paper investigates major internal and external factors that directly and indirectly influence patient-doctor satisfaction in Hungary, Austria, and Denmark. A number of external factors directly affect the patient-doctor relationship and can impact patient satisfaction. Many factors affect how patients feel about the care they are receiving. These factors include the patient-doctor interaction, the length of waiting lists for equipment and facilities, and the potential burden of payment. Ultimately, the type of care received in any of these countries is contingent upon access to care, medical technology, and doctor and patient financial responsibility.

Introduction:

When discussing patient-doctor interactions, it is important to consider what factors will influence patient satisfaction and how a doctor or an institution can work towards meeting a patient’s expectations regarding his or her health care. Thus, this paper investigates the major internal and external factors that will both directly and indirectly influence the patient-doctor interaction.

Several external factors directly affect the nature of the patient-doctor interaction and can have profound effects on patient satisfaction. Of these factors, the length of waiting lists for equipment and facilities and the potential burden of payment are among the most influential. However, another incredibly important factor is job satisfaction since it will directly affect a doctor’s attitude during interactions with patients. The patient-doctor interplay and its effect on patient satisfaction is directly influenced by the actions of the doctor but also indirectly impacted by external factors; namely the length of waiting lists, method of payment, and patient autonomy.

Observations:

The hospital visits in Denmark, Austria, and Hungary gave insight on patient-doctor interaction and what factors contributed to overall patient satisfaction.

Hungary: In Hungary, the most noticeable effects on patient-doctor interactions were those that were caused by economic and financial need from both the larger institutions and the people involved. In fact, a doctor from Semmelweis University Health Center stated that the lack of funds was the institution’s biggest limiting factor in providing quality healthcare to the patient population. These economic struggles manifest in several different ways. First, diagnostic equipment and tests have long wait lists and the hospital is unable to afford updating equipment. Patients often complain of lengthy waiting lists and studies have shown that waiting for treatment directly decreases patients’ satisfaction with the health care they receive (Thompson 661).

Additionally, many doctors struggle working with the limited equipment as well. A similar situation was experienced at the Buda Health Center and National Center for Spinal Disorders. Dr. Jakab Gabor, the Chief Physician and Director of Education, explained that their center actually experienced higher rates of infection due to the layout of the hospital, where scrub in rooms were not located adjacent to the operating room and sterile environments were hard to maintain. He also briefly discussed how a large portion of the hospital’s money went into keeping the old structures properly heated or air-conditioned and that, at some point, they will have to knock everything down in order to build a more efficient space. However, despite these problems, patients at this center still report relatively high rates of patient satisfaction, a phenomenon that Dr. Gabor explains with a quote: “In the land of the blind, the one-eyed man is king.” Essentially, patients are satisfied with the level of care they receive at this center due to even lower standards of care in other institutions.

Another way the economy impacts the Hungarian health care system is the financial strain on doctors. Many Hungarian doctors, approximately thirty percent of the graduates from medical schools, will leave the country after receiving free education from the state because the salary in Hungary is simply too low. The average Hungarian doctor earns about 700 euros a month while the average for Denmark is 11.150 euros (Reginato 2). This constant drain of doctors causes the remaining doctors to work harder and to keep longer hours, often up to sixty hours a week, to compensate for the shortage of healthcare workers. Even Hungarian nurses feel overworked because some hospitals can have one nurse working with up to twenty patients and with no certified nursing assistant (CNA) to help. Consequently, many Hungarian doctors actually “burn out” in their forties because of the constant stress and demands of the job. However, the few doctors who do remain in Hungary and work within the public healthcare system are supposedly the ones who are willing to sacrifice for their patients.

On the other hand, many doctors will actually supplement their income through alternative means. The most common method is through patient bribes. 44% percent of patients give their doctors a “gratitude payment” of an average of 131 euros (Study on Corruption in the Healthcare Sector 249). On the other hand, if a patient is unwilling to pay their “gratitude payment” the patient can be quickly lost in waiting lists and wait much longer than necessary for a particular diagnosis. This system of “Informal payments in medical service delivery” is viewed by the Hungarian public as a “very serious problem” (Study on Corruption in the Healthcare Sector 248). This problem results in a pervasive lack of trust in the medical system in which illicit payments can result in better care.

However, other doctors will choose to work part-time for private medical clinics such as FirstMed. By working with FirstMed, doctors and patients have access to more facilities and equipment, even an on-site laboratory, and the wait times are significantly decreased. This may be due in part to the fact that FirstMed is completely reliant on having higher patient satisfaction than public centers and they must maintain that competitive edge of providing faster services.

FirstMed also markets itself as a center that focuses on providing good customer service, something that most Hungarian public institutions do not have a financial luxury of providing to its patients. It should be noted that FirstMed patients are also of a different socio-economic background and the majority of them are expatriates from wealthier countries. Thus, FirstMed also aims to please its “customers” by providing services that are culturally and religiously sensitive. For example, FirstMed staff are required to know English and they even have a psychology department that helps expatriates deal with culture shock, such as changes in gender roles, or homesickness. Additionally, FirstMed offers significant bonuses to their employees and fosters a sense of community among the staff. Evidently, FirstMed aims to improve conditions both for the patient and their doctors, which in turn leads to more satisfactory patient-doctor interactions.

Overall, the Hungarian public healthcare system has several critical issues caused by their economy. This leads to decreased overall patient satisfaction due to the lowered quality of patient-doctor interactions.

Austria: Transitioning to Austria, the visit to the Orthopadisches Spital Speising GmbH and the Austrian Red Cross center showed that there were two main factors contributing to patient satisfaction: a strong economy and a positive attitude. When Austrian residents evaluated their healthcare system in 2008, they rated the quality of healthcare a 92/100, access a 92/100, and affordability a 79/100 compared to Denmark where the ratings in respective order were: 90/100, 68/100, and 86/100 (Jankauskiene and Jankauskaite). In another report in 2007, the proportion of citizens who found availability and access to hospitals “very easy and fairly easy” was 54% in Hungary, compared to 92% in Austria (European Commission 28). The visit to the Austrian healthcare facilities reflected these findings, as patients in the Austrian health care facilities appeared happier in general, and the facilities were not overcrowded as observed in Hungary. Accordingly, Dr. Saffarina from the Orthopedic center mentioned how he believed the short waiting times were what contributed most to patient satisfaction. Since the center is competitive with other hospitals, it focuses on reducing waiting times in order to attract more patients. The ratio of beds per inhabitants in Austrian hospitals is 6 beds per 1000 people, which is much higher than the European Union (EU) average of 4.2 beds per 1000 people (Hofmarcher and Rack 20).

As Dr. Saffarina noted, the center’s financial capital allowed the hospital to reduce these waiting times by introducing new and efficient technology. However, although the technology is a major component in reducing waiting times, Dr. Saffarina mentioned how there is such thing as too short of a waiting time for patients, and that it is important to have a perfect balance. For example, if a patient needed surgery, instead of rushing them to the operating room quickly, it is better to have them wait a little and adjust to the idea that they are getting surgery. Such an anecdote resembles the respect and commitment the hospital has towards the patients. The medical technologies available in the Austrian hospitals are vast. In 2008, the number of MRI units available per million population in Austria was 18.0, compared to the EU average of 9.5 units per capita, and in Denmark there are 15.4 units per capita. (OECD). Additionally, the number of CT scanners per million population in Austria was 29.9, compared to 19.2 scanners in the EU, and 21.5 scanners in Denmark (OECD). Clearly, Austrian hospitals have a vast availability of medical technology, which not only aid waiting times for patients, but also help attract patients and increase patient satisfaction.

The new and available medical technology in the Austrian centers help attract patients and make them feel that they are getting good quality care. In the orthopedic center, they had technology to measure gait, balance, and posture. The doctors at the center noted how such technology appealed to athletic patients. Though this access and availability to technology is likely due to Austria’s stable economy, it is not the only factor that contributes to Austria’s high patient satisfaction reports.

“To improve the lives of vulnerable people by mobilizing the power of humanity” is the mission statement of the Austrian Red Cross. The Austrian Red Cross and Austrian hospitals are committed to helping their patients. The value of health care in Austria is so respected that volunteering at the Red Cross fulfills the military service required for young, male citizens. Similarly, at the private, Catholic Orthopedic center, the hospital does not refuse medical treatment for those who need it, regardless of one’s faith. The patients in the Austrian center looked in general happier compared to the patients in Hungary, and would smile and wave during the visit. At the Red Cross, one blood donor even took the time to tell his story to the group on why he donates blood; the fact that he could open up to strangers on his own personal story was a good indicator of patient satisfaction.

Similarly, the doctors in the Austrian centers appeared to be more enthusiastic and content with their work. The average general practitioner in Austria makes 101241,62 euros a year, which is about 3.2 times higher than the average wage in Austria (Picard). In general, the Austrian healthcare system supports patient satisfaction by providing doctors with good working conditions (hours and salaries), and by providing financially stable funds to the healthcare sector.

Denmark: In Denmark, patient-doctor satisfaction rates are fairly high because of the way the health care system is structured. General practitioners are the trusted point of contact for the majority of health care needs. The GP handles 90 percent of all patients, therefore fewer patients are sent to the hospital, overtreatment is not an issue, and the cost is not a burden to the patient. GPs have their own practice, and there is typically one GP per thousand patients; however, since GPs see most of their patients for many years, there is still a maintained relationship between the doctor and the patient. Patients usually stay with one general practitioner; sometimes multiple members of a single family share one GP. This aids in a better patient-doctor connection, providing the patient with a sense of comfort and familiarity, and in addition it allows GPs to maintain a complete and accurate record of their patients’ medical history. Studies have show that continuous care not only increases patient satisfaction, but also allows the doctor to accumulate knowledge that saves time; patients were shown to value their relationship with their doctor more and felt they had more control over their health (Sudhakar-Krishnan 382).

In further investigation of the patient satisfaction rates, a study was conducted which asked patients from ten different European countries about their opinions on the access and quality of care within their country. Danish and Austrian citizens “evaluated their health systems positively in their countries and nearly half of the respondents think their system is better than in other countries (Denmark has 42% of such respondents, Austria- 64%)” (Jankauskiene and Jankauskaite).

When looking at doctor satisfaction rates, Denmark has a greater doctor satisfaction rate in comparison to Hungary. Danish doctors have little to no malpractice, do not obtain any debt from education costs, are well paid, and can maintain a good work-life balance, by working less than 37 hours per week. In return, Danish citizens are quite satisfied with their overall quality of health care. According to the OECD, patient satisfaction rates in Denmark are higher than the European average (Colombo 16). Patients have the freedom to choose their GPs and healthcare providers, the system is decentralized, and they often feel a sense of identity when they visit their GP. However, there are some factors that contribute negatively to the doctor-patient satisfaction rate. The ratio of patients per bed in Denmark is 3.2 beds per 1000 people, which is slightly below the EU average of 4.2 per 1000 inhabitants (Hofmarcher and Rack 20). In addition, there are long waiting lists in Denmark, but fortunately the waiting lists are getting shorter.

One of the most important things a doctor can do for a patient is simply to engage in active listening. Not only is this crucial for gathering the appropriate amount of information in order to make a diagnosis, but also serves as a therapeutic process for the patient and fosters improvements in the doctor-patient relationship (Jagosh 371). Dr. Jørn Jepsen, from the Vascular Department of Surgery in Kolding Sygehus incorporates a unique principle, “Train How to Love,” into his surgery department, which focuses on the importance of creating both a good doctor-patient relationship and a good clinical team relationship. In order to uphold this strong connection there should be communication, intimacy, and awareness. He emphasizes that it is important for doctors to be “human first, then professional,” and to “make patients feel important by remembering small important facts, giving them a sense of identity.” This particular surgery department focuses on patient-centeredness, is based on quality not quantity of care, and pays its doctors extra based on the level of quality care they provide to their patients. All in all, the patient-doctor satisfaction rate in Denmark is high due to the quality of care provided, the patient-centeredness aspect, the doctor’s good quality of life, and the overall functional healthcare system.

Discussion and Learning Outcomes:

Prior to visiting these countries and learning more in depth about the fundamental aspects of their health care system, it was expected that the patient satisfaction between Denmark and Austria would be similar. In contrast, the patient satisfaction in Hungary would be vastly different and much lower because Hungary is a much poorer country. Many people may think that patient satisfaction depends solely on the initial patient-doctor interaction; however, this does not appear to be the case.

Other external factors that showed to influence this rating were: access to medical technology, length of waiting times, and doctor job satisfaction. First, with healthcare access, all three countries virtually had universal health care systems yet realistic access to the health system was not the same between the countries. Noted in the observations, it was seen that Austria’s health care system was easily accessible to patients, followed by Denmark, and then Hungary. A second factor that influenced patient satisfaction was access to medical technology. Both Austria and Denmark had more access to medical technology than Hungary. For example, both countries had more MRI and CT units available per capita than even the EU average. One last factor shown to influence patient satisfaction was how much doctors were satisfied with their work; this was measured by doctor’s salaries, attitudes, and work hours in which Hungary appeared to have the lowest doctor satisfaction. The observations therefore showed the importance of social factors such and economy in determining patient satisfaction.

With a stable and relatively wealthy economy, countries such as Denmark and Austria are able to provide medical services and technology which directly and indirectly influence patient satisfaction by both attracting patients to the hospital and by reducing waiting times and increasing efficiency. Social factors seemed to stem from the doctor’s satisfaction ratings. Perhaps if doctors were satisfied with their job by having a good salary and work hours they would be able to improve the way they interact with their patients to promote higher patient satisfaction.

Limitation of Research Findings:

Although comparisons can be made between larger institutions and hospitals in each of the three countries, there were no visits to general practitioners in Austria or Hungary and thus there are no similar comparisons made for that portion of the healthcare system. This paper would have benefited from a more comprehensive view of all aspects of the different healthcare systems that allowed for investigations of each level of patient-doctor interaction.

Furthermore, some of the research that went into the paper was based on studies that were slightly older. For example, the figures for doctor salaries were taken from a study conducted in 2011. Although significant differences should not be expected between these reported numbers and current numbers, it would have been more significant if a more recent study could have been cited. Additionally, some of the information that was gathered was on sensitive topics, such as bribes, and the authenticity of these values would be hard to prove.

Conclusion:

The importance of patient satisfaction is hard to overstate. Higher patient satisfaction is an indication of a better functioning medical system. Thus its important that patient satisfaction is increased. The true challenge is how medical systems can do this. This is difficult since much of the factors contributing to patient satisfaction such as access to equipment, doctor satisfaction, freedom of choice and short waiting lists are all primarily reliant on the financial means of the medical system. For example, Hungary has many problems which yield low patient satisfaction, such as low doctor satisfaction due to low salary, and the corresponding system of bribery which goes along with financially desperate doctors. The primary way to address this problem is to put more money into the system in either doctor salary or enforcement. With tight government budgets, little money will be added to the medical systems budgets. Thus it is vital that hospitals improve efficiency to make the most out of the little they have. While increased efficiency may not directly increase patient satisfaction, the money freed up could be used to buy new equipment, hire doctors, decreasing waiting times and increasing quality of care. It is difficult to change ingrained medical systems, but they must if the patient is to get the best care.

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