INFObrief Deloitte 2012 Survey of U.S. Health Care Consumers Consumers utilization of the health care system Background This INFOBrief presents key findings about consumers utilization of the U.S. health care system in particular, their use of primary care and hospital services and consumers interest in and views of system of care innovations from the Deloitte 2012 Survey of U.S. Health Care Consumers. INFOBriefs also are available on the topics of consumers and health information technology; life sciences products and innovations; and consumers and health plans. For the full report: 2012 Survey of Health Care Consumers in the United States, 2012 Consumer Study Infographic, Five-Year Look Back, INFOBrief source questions and other INFOBrief reports, visit www.deloitte. com/us/consumerstudies. Highlights: Satisfied with care, but thirsty for information Most consumers have primary care providers, most people use them, and most people are satisfied with the medical services they provide. What they would like from doctors and hospitals is transparency about care quality and fees. In 2012, most consumers (84 percent) said they consider themselves to be in good health but more than half (52 percent) say they have been diagnosed with one or more chronic conditions. Half (51 percent) currently take prescription medications. Nearly 8 in 10 consumers report having a primary care provider (PCP) and three in four consumers say they sought medical care from a doctor during the last 12 months. More than 4 in 10 consumers say they received care in a hospital in the last year. Consumer use of emergency care is on the rise 13 percent went to an emergency room in 2009 and 19 percent did so in 2012. Satisfaction with primary care providers is consistently high and has increased steadily since 2008. Many consumers are satisfied with their hospital care: 65 percent of those who had used any type of hospital service in the past year including inpatient, outpatient, or emergency room services say they were satisfied with the care received. When people expressed dissatisfaction with hospital care, the reasons they cited were related to cost, customer-service, and the style or manner of service delivery.
Consumers want transparency regarding fees and quality. Three out of four consumers believe providers should publish quality of care information on the Internet; two out of three believe that hospitals should publish their prices on the Internet. Younger age groups are particularly active in seeking online quality and price information. Alternative avenues of non-urgent care, such as retail clinics, pharmacies, and shopping malls, appeal to consumers who were surveyed particularly if they could obtain care there more cheaply and quickly. Many are open to using nonphysician providers, such as nurse practitioners or physician assistants, as their primary care providers or as an option if a doctor is not available.
Key Findings: Use of the health care system Figure 1: Health care use 2008 to 2012 1 10 8 82% 83% In 2012, around 2 in 5 consumers say they received 78% care in a hospital in the last year, either as an 76% 61% outpatient (23 percent), emergency patient (19 percent), or inpatient (8 percent). In An 2012, increasing 76% of number consumers of report 65% respondents report using visiting emergency a doctor care, or rising other health from care 53% 13 percent in 2009 to 19 professional percent in in 2012. the past year, compared 51% with 83% in 2009. 41% In 2012, 2 38% in 3 say they had a wellness 39% check-up in the past 12 months and 2 31% in 5 say they had seen a doctor for an 26% illness or injury during that time. 23% 16% 19% 13% 8% 8% 2008 2009 2010 2011 2012 Percentage responding Yes * Hospital service figures for 2008 and 2009 are 1 year estimates calculated as half the reported 24-month rates Doctor visit (any purpose) Have primary care provider Doctor visit for well/check up Prescription medications Doctor visit for illness/injury Over-the-counter medications Hospital care (all types) * Outpatient care * Emergency care * Inpatient care *
Hospital care Use of emergency care is rising, while satisfaction with outpatient, inpatient, and emergency hospital care is decreasing. Quality and customer service issues are driving these attitudes more than cost. Figure 2: Hospital experience satisfaction 2 8 77% 71% Satisfaction with outpatient and inpatient care is high especially for those with insurance. 59% 55% 44% Satisfaction with emergency care is much lower, particularly for the uninsured. 41% Insured Uninsured Rating of 8, 9, or 10 on a 10-point scale where 10 is Completely satisfied Satisfied with outpatient hospital care (% of those who received) Satisfied with inpatient hospital care (% of those who received) Satisfied with emergency (ER) hospital care (% of those who received)
Hospital care Use of emergency care is rising, while satisfaction with outpatient, inpatient, and emergency hospital care is decreasing. Quality and customer service issues are driving these attitudes more than cost. Among consumers who say they were dissatisfied with the experiences they had in a hospital setting, dissatisfaction is driven more by quality and services factors (2 out of 3 consumers) than by cost (40 percent). Figure 3: Dissatisfaction with recent hospital care 3 Cost 41% Customer service Access/availability Coordination/follow-up 16% 24% 28% 32% 37% 42% 2 out of 3 consumers who were dissatisfied with their recent hospital care cited service related reasons (66% ER and 62% inpatient care) Treatment process 36% 39% Style/manner Skills/specialization 26% 35% 35% 2 out of 3 consumers who were dissatisfied with their recent hospital care cited quality related reasons (63% ER and 67% inpatient care) Infrastructure 17% 19% 8 Of those who were dissatsified with their hospital care experience Emergency Care Inpatient Care
Primary care A growing number of consumers are using nurse practitioners (NPs) or physician assistants (PAs) for primary care. Those who switch care providers do so for service, quality, or cost reasons. One in four Medicare enrollees and one in three consumers with commercial coverage experience issues with access. For the uninsured, access is a substantially greater problem. Figure 4: Perceived availability of primary care, by insurance source 4 8 59% 64% 7 64% Perceptions of availability and quality vary considerably by insurance status and source. For those without insurance, access is perceived to be substantially more difficult than for the insured. 69% 58% 58% 58% 61% 72% 39% 38% 46% 48% Medicare enrollees perceive greater access and shorter 48% waiting times for appointments than other 41% groups. 42% 37% 44% 39% 46% 27% 25% 26% Availability of doctors who are likely to accept my insurance Length of time have to wait to get appointment with primary care doctor Availability of places for care after normal business hours Quality of care provided by hospitals Quality of care provided by doctors Rating of 8, 9, or 19 on a 10-point scale where 10 is completely adequate Uninsured Medicaid Direct purchase Employer-sponsored Medicare
Primary care A growing number of consumers are using nurse practitioners (NPs) or physician assistants (PAs) for primary care. Those who switch care providers do so for service, quality, or cost reasons. One in four Medicare enrollees and one in three consumers with commercial coverage experience issues with access. For the uninsured, access is a substantially greater problem. Few switched primary care providers (8 percent) in 2012, a decline from 17 percent in 2008 (not shown). Figure 5: Primary care providers, 2008-2012 5 Figure 6: Switching primary care provider 6 10 8 86% 85% 86% 87% 82% 81% 81% 82% 58% 49% Nearly 4 out of 5 consumers report having a PCP. 43% 46% Among the uninsured, the percentage having a PCP has dropped from 58 percent in 2008 to 46 percent in 2012. 87% 78% 46% Poor style/manner (e.g. lack of courtesy/respect, didn't spend enough time during exam) Personal circumstances (e.g. I moved) Lack of skill/knowledge/expertise High out-of-pocket cost (e.g. fees too high, provider no longer accepted insurance) Poor access/availability (e.g. couldn t get an appointment when needed, long wait times) 25% In 2012, 1 in 5 switched due to a perceived lack of skill or knowledge on the part of the provider or due to high out-of-pocket Of those who did change providers costs borne by the consumer. 24% in 2012, 1 in 4 consumers switched due to the poor style/manner of the care the provider delivered. 18% 18% 17% 2008 2009 2010 2011 2012 Poor customer service 17% Poor treatment process 15% Insured Total Uninsured Lack of integrated alternative treatment approaches or natural therapies Poor coordination, communication or follow-up. 12% 11% Poor infrastructure (e.g. unclean exam rooms, lacking technology) 6% 1 3 Those who switched doctors/medical professionals in the past year
Primary care A growing number of consumers are using nurse practitioners (NPs) or physician assistants (PAs) for primary care. Those who switch care providers do so for service, quality, or cost reasons. One in four Medicare enrollees and one in three consumers with commercial coverage experience issues with access. For the uninsured, access is a substantially greater problem. Figure 7: Type of provider,among consumers who have a PCP 7 10 8 95% 87% Consumers with a medical doctor (MD) as a PCP have declined over the past five years. During the same time period, use of a nurse practitioner (NP) or physician assistant (PA) as a PCP has increased from 4 percent to 10 percent. 1 4% 1% 1% MD NP/PA Other 2008 2012
Retail clinics Consumers are receptive to using retail clinics for minor medical problems. Why? Value, convenience, and access. Figure 8: Reasons for using retail clinics 8 8 58% 5 5 Among retail clinic users: Almost 2 out 3 (61 percent) are satisfied with the care they or Dissatisfaction 14 percent with of retail consumers clinic 25 percent experiences report say their they they family used are a member willing received at relate to retail quality clinic (37 in percent), the past to cost visit 12 months, (34 a retail percent), a retail clinic down clinic if from a physician visit (not shown). and an unmet 19 percent need in (292011, percent) is but not (not similar available shown). Around to 15 (not percent half shown). choosee retail clinics in 2010 and 13 percent in 2009) because (not shown). of convenience and/or speed of getting an appointment. 41% 26% 6% Convenience: clinic location Speed of appointment Access/availability after normal business hours Cost: Visit at the clinic cost less than a doctor s visit Quality Other Reasons for use of retail clinic for self and/or family (those who used in past year)
Views on health care system performance Consumers views are mixed on the performance of the health system but hold its clinical capabilities in higher regard. Figure 9: System report card, 2009 to 2012 9 43% 41% 42% 39% 2% 4% 3% In contrast, in 2012 39 percent give the U.S. health care system an average report card grade of C, or a failing grade of D (16 percent) or F (8 percent).* The 26% percent who graded the system unfavorably (rating of D or F ) in 2012 (24 percent) is somewhat lower than in previous 18% 19% years, with 36 percent grading the system unfavorably in 2011; 35 percent in 2010; and 37 percent in 2009. 8% Consumers views of overall health care system performance are low, but may be improving 1 in 3 gives it a favorable report card grade of A or B in 2012 compared to 1 in 5 four years ago. 25% 23% 24% 16% 13% 12% 12% 8% A B C D F Report card grade of A, B, C, D, and F where A is excellent and F is failing In 2012, 3% say don t know/uncertain (not shown) 2009 2010 2011 2012
Views on health care system performance Consumers views are mixed on the performance of the health system but hold its clinical capabilities in higher regard. Figure 10: Satisfaction with health care providers, products, services, or care settings 10 10 8 8 81% 79% 74% 76% 81% 72% 71% 73% 68% 7 7 Satisfaction with primary care 52% Satisfaction with 57% the performance has increased from 72 percent of the overall system grew from 52% in 2009 to 76 percent in 2012. 16 percent to 22 percent between Satisfaction 2011 and 2012. with hospital care declined Fewer between consumers 2011 give and the 2012 for inpatient system The system gets high marks and high emergency marks for room value services, as did and for clinical innovation and use satisfaction responding with to the health needs plans between 16% of of the technology (not shown). 2010 uninsured and 2012. (not shown). 76% 74% 67% 55% 44% 22% 2009 2010 2011 2012 Rating of 8, 9, or 10 on a 10-point scale where 10 is completely satisfied Satisfied with outpatient hospital care (% of users) Satisfied with inpatient hospital care (% of users) Satisfied with primary care provider (% of those with a PCP) Satisfied with emergency hospital care (% of users) Satisfied with health plan (% of insured) Satisfied with overall system performance
System of care innovations Consumers are open to using non-md providers for primary care. Many of them say using NPs and PAs more than MDs can increase the overall value they receive for the money spent on health care system as a whole. Figure 11: Use of non-mds for primary care 11 8 ** A Primary pharmacist care doctors could should Half provide be of paid consumers many more than of the nurse agree same practitioners that services an or NP physician that a primary care assistants provider because (e.g., they doctor, have or PA more can nurse training provide practitioner, and expertise. primary or care physician that assistant) offers. ** A nurse practitioner comparable or physician in assistant quality to can care provide provided primary care that is comparable in quality by an to MD the (Figure care provided 11), and by a also primary agree care doctor. *** Primary care doctors should be paid more than nurse practitioners or that overall health care spending could physician assistants because they have more training and expertise. be reduced by using NPs and PAs more than doctors to provide primary care Strongly agree (shown or agree in Figure 15). Neutral 28% 3 in 5 consumers agree that people 25% who keep up with routine preventive Np s/pa s 21% Around 4 in 10 consumers 5 say they are 28% 21% care, and seek care from primary care interested in using apps that provide providers before seeing specialists, medication reminders; and that help set should pay less for health insurance and track health improvement goals (not 8% than people who do not. shown). MD s Pharmacists * 68% NPs/PAs ** 21% MDs *** 8% Strongly disagree or disagree Strongly agree or agree * A pharmacist could provide many of the same services that a primary care provider (e.g., doctor, nurse practitioner, or physician assistant) offers. Neutral 56 percent say they would be willing to use videoconferencing for sick visits; 67 comparable in quality to care provided Pharmacist 21% 25% 51% percent 51% would do so for 5 follow-up visits by an MD. (not shown). * A nurse practitioner or physician assistant can provide primary care that is comparable in quality to the care provided by a primary care doctor. In 2012, 56 nearly Around percent half 4 say (47 in they 10 percent) consumers would of be consumers say willing they to are say they use would interested videoconferencing be willing in using to see apps for a sick NP that or visits; provide 67 PA at the percent doctor s medication would office reminders do if so a for doctor follow-up and was that help visits set and not immediately (not track shown). health available improvement (not shown). goals (not shown). Strongly 68% disagree or disagree Half of consumers agree that an NP or PA can provide primary care that is Figure 12: Reward for preventive activities 12 People who deliberately try to improve their health or show measurable improvement should pay less for health insurance than people who do not 59 % 61 % Insured All Respondents 51 % Uninsured Respondents Response of Strongly Agree or Agree Respondents
System of care innovations Consumers are open to using non-md providers for primary care. Many of them say using NPs and PAs more than MDs can increase the overall value they receive for the money spent on health care system as a whole. Figure 13: Transparency of hospital and physician pricing and quality 13 Figure 14: Value of primary care 14 8 75% 66% 54% 64% 62 % Overall healthcare spending could be reduced if primary care is used early. early. Hospitals/Physicians should publish their prices/fees onthe Internet. Strongly agree and agree Hospitals Physicians Information about the quality of care provided by hospitals/physicians should be published on the Internet. 61 % primary care early in an episode of care. Better value for money could be achieved if primary care is used early. early. 56 % Half of all consumers say that current incentives do not encourage people to Better health outcomes could be use primary care to either prevent or treat achieved if primary care is used early. early. emerging health care needs early on. 49 % Incentives currently do not encourage use of primary care to prevent and address needs early. early. 36 % Around 3 in 5 feel that health care costs can be lowered and better value gained by using Incentives in the system currently encourage greater use of specialty care than primary care. Around 2 in 5 consumers believe that incentives currently tend to encourage greater use of specialty care over primary care.
System of care innovations Consumers are open to using non-md providers for primary care. Many of them say using NPs and PAs more than MDs can increase the overall value they receive for the money spent on health care system as a whole. Figure 15: Views on system changes 15 52% 46% 49% 48% 44% Respondents say integrated delivery systems have potential to reduce costs (52 percent), provide better quality outcomes (46 percent), and offer better value (49 percent) when compared to systems where hospitals and doctors practice independently. 5 5 43% Close to half of consumers agree that overall health care spending could be reduced by using NPs and PAs more than MDs to provide primary care. Using integrated delivery systems instead of operating independently * Using performance/ outcomes-based payment vs. fee-for-service payment * Using nurse practitioners and physician assistants more than MDs for primary care ** * Response of Strongly Agree or Agree ** Response of believes has the greatest potential to Could reduce overall spending Could achieve comparable/better quality or outcomes Could achieve increased value
Stakeholder considerations Consumers are eager for meaningful and satisfying health care experiences. Consumers are satisfied with their primary care providers. They re mostly satisfied with outpatient and inpatient hospital services, although this appears to be decreasing over time. And they feel a growing dissatisfaction with the emergency room which may be a reflection of increased ER use and a corresponding increase in waiting times and frustration. Nevertheless, the pattern is surprising. Satisfaction with individual elements of the health care system appears to be dropping, while a slight uptick is evident in satisfaction with the system overall. Understanding health care consumer satisfaction is important. The way that consumers view the system directly affects the way they use providers and seek care. System-level performance improvement initiatives such as evidence-based care and efficient delivery and administration of care are not on consumers radar except in the sense that they would like the health care system to offer better value for money spent, improved quality, and better access. Consumers would like quality of care ratings and price transparency to be readily available online. The consumer s experience is personal. People don t want to wait for care. They want a good experience with their provider and an affordable one. Consumers are increasingly willing to use other avenues for care if they more convenient or faster, and consumers are open to new service delivery models such as the use of non- MD professionals for primary care and retail clinics.
Stakeholder considerations Among important considerations: 1. Convenience and satisfaction drive the consumer experience. Optimal consumer experiences will help drive and consolidate patient loyalty. Four pressure points are shaping the current provider landscape: operating margins, clinical transformation, consumer expectations, and market rationalization. Likely outcomes include acceleration of consolidation, unprecedented alignment of hospitals, physicians and allied health, and substantial disruption in the delivery system. Health care providers confront a raft of opportunities and challenges consumer-oriented service strategies to position to drive patient loyalty and create an optimal consumer experience are of essence. 2. Capitalize on consumer interest in new and non-traditional delivery channels and service models particularly in primary care. High-quality care, convenience, ready access, and affordability all work to consolidate consumer interest and potentially, ongoing loyalty. New service delivery models draw upon a different mix of provider and organizational skills and competencies which have implications for staff recruitment and ongoing training as well as for organization s product and service mix. 3. An engaged health care consumer is central to successful strategies to re-focus the current health care system. Carrots and sticks to motivate and incentivize consumers to manage their own health will be necessary and organizations such as providers, health plans, and bio-pharma will need to devise and implement effective consumer engagement strategies. Specifically, tools and systems to encourage consumer engagement, patient self-management, and patient activation, and facilitate personal responsibility for managing health. In particular, devising strategies to take advantage of new technologies such as distance medicine and telemedicine, self-care, bio-monitoring, and e-visits that reduce demand for in-person visits to physicians, allied health clinics, and other ambulatory facilities.
About this research Wellness & healthy living Since 2008, the Deloitte Center for Health Solutions has annually polled a nationally representative sample of the U.S. adult population (up to 4,000 U.S. consumers) about their experiences and attitudes related to six domains. These online surveys have queried adults in varied health status, income, and insurance cohorts to gauge the degree to which individuals are engaging with the health care system as patients or consumers. In 2012, a nationally representative sample of 4,012 U.S. adults, aged 18 and older, was surveyed in February, using a webbased questionnaire. The sampling frame was based upon quotas reflective of the 2010 U.S. Census to ensure proportional representation of the nation s adult population with respect to age, gender, race/ethnicity, income, geography, insurance status (insured or uninsured), and primary insurance source (employer, direct purchase, Medicare, Medicaid, and other).* This marks a change from 2008-2011, when fewer quotas were used and supplemented by cell weighting to achieve a representative sample. In those earlier years, the survey results were weighted with respect to basic demographics (age, gender, race/ethnicity, and income), but not additional variables such as insurance status and source. To achieve even closer sample alignment with insurance status and source distributions in the U.S. population, a more extensive set of quotas was used in 2012 and additional weighting was not necessary to achieve a representative sample. Differences reported in insurance status and source between 2008-2011 and 2012 are due largely to this adjustment in sampling. Health policy Consumer Survey: six domains of health care Health insurance Alternative health services The margin of error is +/- 1.6% at the.95 confidence level. The survey consisted of 65 questions addressing specific behaviors and attitudes, with 39 potential follow-up questions and an additional 20 questions asking about demographic and healthrelated characteristics. English and Spanish versions were available. Participants were asked about behaviors before attitudes within each topic area to reduce response bias. Information resources Traditional health services * Source: Quotas for insurance status and insurance source distributions were based on KCMU/Urban Institute analysis of the 2011 ASEC Supplement to the CPS, presented in slides published by the Kaiser Family Foundation (http://slides.kff.org).
Contacts Paul H. Keckley, PhD Executive Director Deloitte Center for Health Solutions Deloitte LLP pkeckley@deloitte.com Sheryl Coughlin, PhD, MHA Head of Research Deloitte Center for Health Solutions Deloitte LLP scoughlin@deloitte.com Deloitte Center for Health Solutions This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this publication. Contact Information Deloitte Center for Health Solutions 1001 G Street N.W. Suite 1200 Washington, DC 20001 Phone 202-220-2177 Fax 202-220-2178 Email healthsolutions@deloitte.com Web www.deloitte.com/centerforhealthsolutions Follow @DeloitteHealth at www.twitter.com Acknowledgements We would also like to thank Laura Eselius, Leslie Korenda, Elizabeth Stanley, Jennifer Bohn, Katrina Drake Hudson, Claire Boozer, and the many others who contributed to the preparation of this report. About Deloitte Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee, and its network of member firms, each of which is a legally separate and independent entity. Please see www.deloitte.com/about for a detailed description of the legal structure of Deloitte Touche Tohmatsu Limited and its member firms. Please see www.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting. About the Center The Deloitte Center for Health Solutions (DCHS) is the health services research arm of Deloitte LLP. Our goal is to inform all stakeholders in the health care system about emerging trends, challenges and opportunities using rigorous research. Through our research, roundtables and other forms of engagement, we seek to be a trusted source for relevant, timely and reliable insights. To learn more about the DCHS, its research projects and events, please visit: www.deloitte.com/centerforhealthsolutions. Copyright 2012 Deloitte Development LLC. All rights reserved. Member of Deloitte Touche Tohmatsu Limited