Physician Office vs Retail Clinic: Patient Preferences in Care Seeking for Minor Illnesses

INTRODUCTION

In 2005 there were approximately 1.2 billion ambulatory care visits in the United States—a 36% increase in 10 years.¹ One-half of these visits, representing 197 visits per 100 persons, were to primary care physicians in office-based practices. With older patients making more physician office visits, aging of the population has contributed to the increased volume^1,2 and is likely to further increase the demand for physician services. Although the likely impact of the increased demand on office visit attributes, such as time to appointment and waiting time, is unknown, delay of care is a persistent undesirable feature of the health care system.³ A niche market addressing these very attributes is rapidly developing in the United States. Recently there has been a phenomenal growth of walk-in clinics located in pharmacies, department stores, shopping malls, and even such unconventional locations as airports.^4,5 Generally staffed with nurse practitioners or physician assistants, retail clinics (also known as convenient care clinics or store-based health clinics) offer treatment for common acute illnesses, screening tests, and vaccinations to patients aged 18 months or older. Most clinics have referral or consultative arrangements with local physicians or clinics. Cost, time savings, and convenience are promoted as the advantages of seeking care at these clinics—patients do not need appointments to see a clinician, are usually attended to in a matter of minutes, and can fill prescriptions at on-site pharmacies, if necessary.

Currently these clinics are located mostly in major metropolitan areas. With many big-box retailers and pharmacy chains, such as Walgreens, joining the fray,^6–8 however, these clinics are likely to expand outside major metropolitan areas. As the coverage in mainstream media and business publications grows, retail industry analysts claim a significant increase in public awareness of in-store clinics.⁹ A recent national poll on children’s health found that 10% of children have used a retail clinic, and 70% of the parents of children who have visited a retail clinic are likely or very likely to take them back.¹⁰ In a 2005 Wall Street Journal online poll, 41% of adults indicated that they were somewhat or very likely to use a retail clinic for basic medical services.¹¹ Several major insurers have already started reimbursing for retail clinic services,^12,13 and with the increasing emphasis on consumer responsibility, more insurers are likely to cover such services.⁶ As of early 2009, approximately three-quarters of all retail clinics accept insurance payment.¹⁴

Individual physicians and physician organizations, including the American Academy of Family Physicians, have expressed concerns about the impact of retail clinics on quality, continuity of care, and medical home.^15–18 In some quarters, there is concern about increased prescription drug use because most retail clinics are located in pharmacies.¹⁹ Many of these concerns are also shared by the general public.¹¹ Even so, some of these concerns are yet to be substantiated, as most clinics have maintained good relationships with local primary care physicians and adhere closely to evidence-based protocols.²⁰ An analysis of patient records reported a very high rate of adherence to national clinical practice guidelines for acute pharyngitis by nurse practitioners and physician assistants in a retail clinic chain.²¹ Patient satisfaction is also very high among retail clinic users, and 89% of the children with retail clinic use have a usual source of care.^10,11 Various federal and state regulatory bodies have identified these clinics as a potential avenue for expanding access to health care, and many see it as a viable option for the uninsured.^22–24

It is too early to predict the overall impact of retail clinics on the US health care system and whether the scope of services in these clinics will remain the same.¹³ Even so, competition from retail clinics has prompted many physicians to make changes in their practices, including extending office hours to evenings and weekends and accommodating patients who do not have appointments.¹² The key attributes of retail clinics—time and cost savings—are also major factors in this competition and transformation. Waiting time has been well documented to be negatively correlated with patient satisfaction with physician visits, and the association is stronger among those who are not elderly compared with the elderly.^25–28 Similarly, appointment wait time is one of the strongest predictors of satisfaction with access to care.^29,30 The relative importance of time and cost attributes may vary depending on the type of illness. Researchers in the United Kingdom have found that people are willing to trade between different factors in choosing the method for managing minor illnesses, and sufficient reduction in wait time and cost may make a less-preferred management method more attractive.³¹

Discrete choice experiments (DCEs) have been used successfully to evaluate consumers’ decision making pertaining to valuation of health care services.³² DCEs have been shown to allow consumers to state preferences for choices when examining several options and to effectively estimate consumer utilities through willingness to pay for changes in the attribute.^33–35

In this article we report findings from a DCE that investigated the likely effects of cost of care, type of condition for which care is sought, type of care setting, and appointment wait time on care-seeking decisions at retail clinics or physicians’ offices.

METHODS

RESULTS

The 493 respondents in this study were predominantly white (73.6%) and female (68%). Mean age of the respondents was 49.47 years (SD = 15.38, median = 50); 38.9% had at least a bachelor’s degree, and 4.9% had less than 12 years of education. Total annual household income was less than $25,000 for 13.7% and $75,000 or more for 40.0% of the respondents. Most respondents (77.7%) lived in metropolitan statistical areas, with 49.7% respondents residing in the Atlanta metropolitan statistical area. Details of the demographic characteristics are displayed in Table 2⇓.

The results of the random-effects logistic regression and the corresponding odds ratios (OR) are displayed in Table 3⇓. The constant term in the regression model estimated the respondents’ preference for doing something rather than nothing to address the symptoms. The positive and significant value of the constant term (5.698; 95% CI, 4.726 to 6.671; P <.001) indicates that the respondents preferred to seek medical care for both conditions. Respondents were slightly less likely to seek care for UTI than to seek care for influenza (β = −0.149, 95% CI, −0.259 to −0.038, OR = 0.882; P = .008) and preferred to spend less (β = −0.034, 95% CI, −0.041 to −0.027; P <.001). All things equal, the respondents preferred to seek care from a physician at a private office than a nurse practitioner at a retail clinic (β = 1.067, 95% CI, 0.923 to 1.212, OR = 2.365; P <.001) and preferred not to wait 1 day or more for receiving care (β = −2.789, 95% CI, −2.944 to −2.635, OR = 0.107; P <.001). There was no statistically significant association between the respondents’ decision to seek care and age, race, sex, education, income, home ownership, marital status, or residence in a metropolitan statistical area.

Willingness-to-pay estimates suggest that, all else being equal, a cost savings of $31.42 would be required for the respondents to seek care from a nurse practitioner at a retail clinic. Similarly, a cost savings of $82.12 would be required for them to choose to wait 1 day or more. Overall, a savings of $167.77 would be required for the respondents not to seek medical care for their symptoms (ie, they would seek care if the cost is less than $167.77). Table 4⇓ displays the details of willingness-to-pay calculations.

DISCUSSION

This study provides the first estimates of the consumer utility related to common attributes of the recently emerging retail clinics in the United States. We found that the respondents preferred to seek medical care under both clinical scenarios. Additionally, they preferred to receive care from a physician at a private office, pay less, and receive care on the same day. Given sufficient cost savings, changes in each attribute may also be acceptable to consumers in our sample.

Although these findings are what we expected and consistent with the findings of recent surveys of consumer preferences of retail clinic use,^11,40 this study is the first in the United States to quantify the relative importance of and the utility associated with the main attributes of retail clinics. Particularly important to note is that the coefficients in the regression model and the corresponding estimates of willingness to pay indicate that the appointment wait period is likely to be the largest determining factor in an individual’s choice. Furthermore, the utility (willingness to pay) associated with receiving same-day care is more than twice the utility associated with receiving care from a physician. Primary care physician practices, especially in competitive markets, are therefore likely to derive greater competitive advantage by addressing patient convenience features (such as same-day scheduling, walk-in hours, and extended hours) than by reducing fees.

These findings will be valuable to both primary care practices and retail clinics in service planning and rate setting as the emerging retail clinic market crystallizes. It cannot be determined from our study, however, whether the relative importance of the time and cost attributes would remain the same when the choice is between seeking care from a nurse practitioner or physician assistant in a physician-led primary care practice and seeking care from a nurse practitioner or physician assistant at a retail clinic.

It is also not possible to predict from our data the impact of retail clinics on overall utilization of outpatient primary care services or on the primary care physician practices. A study in Scotland found a relatively low impact of pharmacy-based minor ailment service on general practitioner workload.⁴¹ On the other hand, early evidence suggests that some primary care practices in the United States are making changes in their scheduling system to accommodate same-day care, extending their hours, and publicizing fees for routine procedures on their Web sites.⁴² In the same vein, our study does not lend itself to the determination of the impact of retail clinics on access to and overall cost of care. Although proponents see retail clinics as a vehicle for expanding access to care, most retail clinics are currently located in large metropolitan areas and offer a limited set of services. The literature is sparse on what proportion of clients do not have access to care from other sources; however, 27% to 30% of the retail clinic users are uninsured.^14,40 Even though some insurance companies see retail clinics as potential cost-saving vehicles and have started reimbursing for the services, there is concern in some quarters that retail clinics may drive up prescription drug spending.¹⁹

Another potential limitation of our study is that it was limited to 1 state, although Georgia, particularly the Atlanta metropolitan area, is one of the early markets with a substantial retail clinic presence, and the residents were likely to be more attuned to the characteristics of retail clinics than residents of other areas. The study sample had slightly higher educational attainment and income compared with the state averages and thus may have affected the estimates.

A response (cooperation) rate higher than the rate achieved in this study (33.1%) would certainly have yielded more robust estimates of the utilities. As suggested by Kemp and Remington in their review of current challenges for telephone survey research, however, the response rates in random-digit-dial telephone surveys have declined in recent years for various reasons, yet telephone surveys continue to play a vital role in public health research and practice.⁴³ Our study identified few important factors affecting patient preferences. Further in-depth studies of patient preferences and care-seeking decision making that incorporate additional patient, clinician, and market characteristics and disease scenarios are necessary to refine the estimates of consumer utilities associated with retail clinic use and fully understand the potential impact and long-term future of retail clinics in the US health care system.