INTRODUCTION

Patients have several choices besides physicians’ offices or emergency rooms (ERs) when seeking care for minor illnesses, including urgent care, retail clinics, and virtual physicians. The limited literature assessing costs and quality offered in these settings has mixed findings, concluding that they are attractive to patients when costs are lower while quality may not be comparable.1,2,3 Our goal is to provide the patient’s perspective, missing from the extant literature.

METHODS

We surveyed all employees of the University of California, Irvine (UCI), which resembles a “mini-city” because of its diverse spectrum of employment types and socio-economic strata.

In addition to questions about demographics, education, income, insurance, and health status, we asked questions about actual experience with care in physicians’ offices, ERs, urgent care, retail clinics, and virtual physicians. Respondents were asked about their expectations and satisfaction with each of four attributes: out-of-pocket costs, wait time, quality, and overall experience. The expectation questions were “How was the [attribute, e.g. wait time] at the [setting] compared to what you expected it to be?” “Answers were on a 1–9 Likert scale with 1 = “Much worse than I expected,” 5 = “Neither worse nor better than I expected,” and 9 = “Much better than I expected.” The satisfaction questions were “How satisfied were you with your [attribute] at the [setting]?” Answers were on a 1–9 Likert scale with 1 = “Very dissatisfied,” 5 = “Neither dissatisfied nor satisfied,” and 9 = “Very satisfied.”

We calculated average expectation and satisfaction scores by setting and compared them to physicians’ offices using t tests.

To understand what predicts patients’ satisfaction, we estimated separate linear regression models for each setting and attribute. Dependent variables were the satisfaction scores. We added groups of independent variables successively in the following order: expectation scores for all settings, patient demographics, health status, family composition, socio-economics, and health insurance. We measured the increase in variation explained as variable groups were added by the incremental adjusted R2.

RESULTS

Of the 21,037 employees surveyed, 5451 responded (26%). Respondent characteristics are in Table 1. Most (81.6%) had at least one medical encounter. Among those seen at least once in each setting, the average number of visits in the previous 12 months were physician’s office, 4.1 visits; ER, 1.4; urgent care, 1.8; retail clinic, 2.0; and virtual physician, 1.6.

Table 1 Descriptive Statistics (Percent of Respondents in Parentheses)
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Patient expectations were least likely to be met for costs and most likely to be met for quality and overall experience (Fig. 1a). Patients were most disappointed with respect to physicians’ offices’ (score of 4.95) and ERs’ (4.60) costs. Virtual physicians exceeded expectations (score of 6.10) and had the best scores in all categories, tying with physicians’ offices (p > 0.05) for quality and overall experience.

Figure 1
figure 1

Expectation and satisfaction scores (* = not significantly different from physician’s office p > 0.05). a Expectation scores by care setting b Satisfaction scores by care setting.

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Patients were satisfied with care in all settings and for all attributes (Fig. 1b). They were least satisfied with ER costs and wait time (scored at 5.5). When compared within attributes, ERs also had the lowest scores, at 6.5 for quality and 6.3 for overall experience. As with expectations, patients reported the most satisfaction with virtual physicians in all attributes, and they tied with physicians’ offices in quality and overall experience (p > 0.05).

In our multivariable models, the first model (including only expectations for out-of-pocket cost, quality of care, wait time, and overall experience) had the largest predictive power of variation (largest incremental R2). Other models, successively adding demographics, health status, number of medical conditions and encounters, family composition, socio-economics, and health insurance, added very little to our model’s predictive power.

DISCUSSION

Virtual physicians performed best in our study in meeting patients’ expectations and satisfaction. This is a relatively new modality. It has been growing fast but is yet to reach parity among consumers, as the relatively small number of encounters among our responders suggests. Other studies suggest that even substantially lower prices may not be sufficient to convince patients to change decades’ long healthcare seeking habits.4 Substantial price differential2, 3 coupled with higher satisfaction might make for faster adoption.

Our other interesting finding suggests that the most important thing providers can do to increase patient satisfaction, irrespective of the patient population they serve and the type of setting they manage, is to meet their patients’ expectations, similar to prior findings.5, 6