Choosing a Provider: What Factors Matter Most to Consumers and Patients?
By Andrzej Kozikowski, PhD, Dawn Morton-Rias, EdD, PA-C,and Grady Barnhill, MEd
Sage Journals
Abstract
Enhancing consumer and patient choice has been proposed as a means to improve care quality and reduce health-related costs. Choosing a medical provider is one of the most critical and often complex decisions patients make about their health care. We investigated the perceived importance of factors patients may consider when selecting a practitioner and if rated importance of the factors varies with their characteristics and prior experiences with different types of clinicians (physicians, physician assistants, and nurse practitioners). Participants most often identified medical license, certification, and whether the provider accepts the patients’ health insurance as important, while provider type, others’ recommendations, and online reviews were among the least important. We found wide-ranging differences based on patient characteristics. Prior experience with providers was also a strong determinant of patterns of factors patients considered valuable. Policy-makers, health systems, insurers, and providers need to take into account that patients rely on a range of factors that vary based on their distinct needs, backgrounds, and previous experiences—requiring tailored information to make more informed decisions.
Introduction
In a progressively consumer-centric health care environment, patients are increasingly empowered to be active and informed decision-makers in their health care. Increasing patient choice has been proposed to improve care quality and reduce health-related costs through increased competition (1,2). One of the most significant decisions patients make occurs when selecting a provider for their medical needs (3,4). Many consider this choice to impact the course of their treatment, and ultimately, their health outcomes (3,4). Before deciding on a provider, patients can consider multiple factors and use various sources of information to inform their choice (5). Traditionally, patients relied on recommendations from family or friends (6,7); however, with the rapid proliferation of online resources, a plethora of provider information is readily available and accessible. Patients can verify whether providers have a medical license in their respective state, disciplinary actions (8), certification status (9,10), and if the provider participates in their health insurance plan (11,12). Patients can also view public reports of practitioner quality information (13) and learn from others’ experiences through numerous websites (e.g., yelp.com, ratemd.com, healthgrades.com) (14).
Prior literature exploring the importance of factors that patients use when choosing providers demonstrates that they consider qualifications such as certification (3,7,15–17), years of experience (3,12,17), and education (17). Patients also take into account logistical factors such as appointment wait times (17–19), office location (12,17,20), whether the provider accepts their health insurance (3,11,12,15,17), and out-of-pocket costs (17). More recently, there has been a proliferation of research on provider review websites (14,21,22). Approximately a quarter of patients use online reviews (12). However, a higher proportion relies on other factors such as whether the provider accepts their insurance, convenient location, and years of experience (12). Findings also show that the ratings are not associated with more objective care quality metrics (23), and that the number of reviews per provider is scarce (24).
Furthermore, patients typically have the option of selecting a physician, physician assistant (PA), or nurse practitioner (NP) for their medical needs (25). The PA and NP professions are rapidly growing, with 148,560 Certified PAs and 325,000 NPs in the US (26,27). At the same time, the Association of American Medical Colleges projects a shortage of up to 124,000 physicians by 2034 (28). Given the expanding PA and NP health workforces and estimated deficits in the number of physicians, it is critically important to assess patient perspectives toward PAs and NPs. It is essential that patients are willing to receive care from PAs and NPs for these providers to help alleviate existing and future care gaps. Research shows that patients are equally satisfied with the care received from physicians, PAs, and NPs (29). Consumers are also receptive to receiving care from PAs, especially if the wait time is shorter than seeing a physician (30,31). Leach et al. revealed that irrespective of whether patients preferred physicians or PAs/NPs, the most important factors in selecting a provider were qualifications such as medical knowledge, experience, and education (25). Notwithstanding the abovementioned studies, there is a dearth of research exploring how important clinician type (physician, PA or NP) is to patients when choosing—particularly compared to other factors previously shown in the literature to be of value.
Research has also demonstrated that patients’ care experience is one of the most central sources of information (25,32–35). Leach et al. found that prior experience with either a physician, PA, or NP was an essential determinant for patient preferences (25). For example, having a positive experience with a PA made patients more receptive to receiving care from PAs in the future (25). Conversely, a negative experience led patients to prefer another provider type for their medical needs (25). However, except for one previous effort, most research focused on the impact of patients’ prior experience on the choice of hospitals rather than health practitioners (34,36,37). Additionally, the literature is relatively silent on how previous quality of experience with each provider type is associated with the factors patients find valuable when selecting a provider.
Given the existing literature gaps, we investigated 1) which of eleven factors related to provider qualifications, logistical aspects, and others’ perspectives are deemed most important for patients when choosing a provider; and 2) the relative strength of association of participant characteristics and prior experiences with physicians, PAs, and NPs on importance of the factors patients attach importance to when choosing.
Methods
After institutional review board (Sterling IRB# 7122) determined our study to be not-human-subjects research, we conducted a cross-sectional online survey with participants (N = 1,388) recruited from a Qualtrics online panel. Eligibility criteria required individuals to have seen a medical provider or decided about one for a dependent in the past two years. Participants were excluded if they or any family member was a medical provider. We utilized quota sampling to approximate the proportions in key demographics of the US population. Data collection occurred during November/December 2018. An attention check question was embedded to ensure quality responses (38).
The survey was developed based on a comprehensive literature review and adapted from our previously conducted study (39). The overall survey assessed three primary areas: public knowledge and beliefs regarding licensure, certification and medical education of PAs (40), care quality and satisfaction with PAs (41), and factors important in selecting a provider—the focus of the current analysis. The following question was asked: “What factors are important to you when selecting a health care provider for yourself or a family member?”. Participants were presented with 11 factors related to provider qualifications (medical license, certification, amount of education, years of experience), clinician type (physician, PA, NP), logistical factors (whether provider participates in insurance plan, cost, how quickly they could be seen, office location), and sources of information regarding potential provider (recommendations from others, online reviews). Rather than asking to check all that apply for the above factors, we used a forced-choice format. Participants were presented after each factor with the following response scale: “important,” “not important” or “not sure.” Prior research shows that this format encourages deeper item processing (42). We counterbalanced the factors to eliminate response order effects (43). The survey instrument also included socio-demographic questions relating to gender, age, race/ethnicity, education, rural-urban setting, self-reported health, and health insurance type. Lastly, three questions assessed experience with physicians, PAs, and NPs in the last 12 months: “Thinking about the experiences you have had in the last 12 months with various health care providers, please indicate the quality of your experience”. The response scale was “no experience with this type of provider,” “positive experience,” “mixed experiences with providers of this type,” and “negative experience.”
The outcome variables were the 11 abovementioned factors in selecting a provider. The three-category response scale of “important,” “not important,” and “not sure” was collapsed into two “important” and “not important/not sure.” To model participant selection of “important” for each factor, separate multivariate logistic regressions were conducted (using not important/not sure as the reference category). The predictor variables were socio-demographics and quality of experience with physicians, PAs and NPs in the last 12 months. All analyses were conducted using R version 3.63 (R Foundation).
Results
There were slightly more females, and 51.1% were between 35 and 64 (Table 1). The majority were white (72.4%), followed by African American (13.3%), other race (8.4%), and Asian (5.9%); 15.9% were of Hispanic/Latino ethnicity. Regarding education, 38.5% had a high school degree or less, while 34.3% had a bachelor's degree or higher. Almost half (47.0%) reported to reside in suburban areas while 27.9% were in rural and 25.1% in urban. The majority (69.7%) reported being in either excellent or good health. The highest proportion had private insurance only (38.9%). When asked about quality of experience with physicians, PAs, and NPs in the last 12 months, the majority indicated having a positive quality experience with each provider (79.9%, 62.5%, 65.2%, respectively); however, a higher percentage of respondents reported having no experience with PAs (23.8%) and NPs (20.3%) compared to physicians (3.2%) during this time.
