Comment
Our study revealed that patients spend a substantial amount of time and money attending dermatology clinic appointments. Round-trip travel time exceeded 2 hours for 20% of patients and accounted for the majority of the total time attributed to the visit. Patients who were employed typically requested an average of 4 hours off from work, resulting in a mean (SD) opportunity cost of $144.30 (93.6) due to lost wages. Direct costs such as co-pays, deductibles, travel expenses, and child care accounted for a smaller proportion of total costs. The study assumed a wage of $0 for unemployed patients, thus underestimating the true costs of the visit for these patients whose time may otherwise have been spent on leisure, education, volunteerism, or other activities that contribute to individual and societal productivity. The total costs for unemployed patients reflected only direct costs, and thus were notably lower than those for employed patients.
Direct out-of-pocket costs and travel time negatively impacted provider preference. Patients with out-of-pocket costs were much less likely to stay with their current care provider (OR, 0.27; 95% CI, 0.10-0.71), preferring to seek care closer to home/work or teledermatology services. Similarly, for each minute that travel time increased, preference for current care provider decreased by 2%. Those who traveled 60 minutes or more were 71% less likely than those who traveled less than 60 minutes to stay with their current provider when given other options for care. Opportunity costs did not affect provider preference, even though they far exceeded direct costs for employed patients. Perhaps opportunity costs are not as immediately apparent to patients as out-of-pocket costs and travel time, and thus they do not factor as heavily in provider preference.
Despite high time and monetary costs, the majority of patients (60%) still preferred their current care provider, especially those with 4-year university degrees or higher education level (OR, 3.29; 95% CI, 1.23-5.26) and those presenting for skin checks (OR, 9.01; 95% CI, 2.28-35.59). Patients with higher levels of education likely have higher incomes and thus may not be as adversely affected by direct and/or indirect visit costs. Patients presenting for skin checks may value continuity and prefer providers with whom they already have an established therapeutic relationship. Future studies are needed to analyze the impact of these nonmonetary factors on provider preference.
Seeking Alternative Care
Tufts Medical Center does not have satellite dermatology clinics, making it the only option for patients who wish to receive care within the Tufts hospital network. However, patients do have the option of visiting non–Tufts-affiliated dermatology clinics outside of the city. To our knowledge, no formal studies have been performed comparing wait times for dermatology appointments in suburban versus urban Boston areas; however, it has been reported that rural practitioners have longer wait times than urban dermatologists, possibly due to the fact that physicians tend to aggregate in metropolitan areas.2 Thus, the potential for shorter wait times in the Boston metropolitan area may make it a more desirable location to receive care compared to more suburban or even rural areas of Massachusetts, but additional data are needed to substantiate this hypothesis. Additionally, health insurance restrictions, refractory or complex dermatologic conditions, and referring providers’ preference may affect patients’ decisions to seek care at a particular clinic. However, these factors do not alter our finding that those who travel long distances to our dermatology clinic are less likely to stay with their current provider if given the choice to seek care closer to home/work or utilize teledermatology services.
Prior studies have demonstrated patient preference and willingness to accept alternative modes of care delivery to reduce time and monetary costs associated with in-person medical visits.7,8 Dermatology patients at a clinic in Ontario, Canada, considered the time they spent attending the clinic to be even more burdensome than the monetary cost.7 Patients with nondermatologic chronic diseases and high out-of-pocket costs would prefer email rather than a clinic visit as the first method of contact with care providers.8 The explosive growth of direct-to-consumer (DTC) teledermatology services in the last 10 years speaks to patient demand for alternative care delivery that saves time and money. Although telemedicine has been implemented in various specialties, including ophthalmology and neurology, one of the most common applications is teledermatology. With DTC teledermatology, patients can take photographs or videos using personal smartphones and communicate directly with care providers using mobile or online applications. More recent review articles have identified 22 to 29 DTC mobile and web-based teledermatology services, with costs varying from $0 to $250.9-11 The median consultation fee of $59 for DTC teledermatology services is substantially less than total visit costs for employed patients in our study.9 Teledermatology has become an accessible and affordable modality of care, though perhaps not yet fully optimized for quality of care.
With increasingly higher co-pays and high-deductible insurance plans, time and monetary factors play increasingly important roles in patient preference for specialty care providers,12 as demonstrated by our study. Dermatologists can work with patients to reduce the costs of medical visits. Perhaps monitoring of chronic but stable conditions can be accomplished through telecommunication to reduce the number of follow-up visits. For instance, psoriasis patients enrolled in telemonitoring perceived savings of time and expenses through reduction of clinic visits, resulting in high patient satisfaction levels.13 Telephone calls and secure email messaging are other feasible alternatives shown to aid in clinical management and decrease the need for in-person care.8,14 Fewer unnecessary follow-up visits also means more availability for new patients and those with acute needs.
Barriers to obtaining care are not limited to dermatology and are pervasive across most medical specialties. Issues of patient time burden and out-of-pocket expenses are reflected in recent reports focused on quantifying these costs throughout ambulatory care visits and services such as colorectal, cervical, and breast cancer screenings.1,15-18 Similar to our findings, many of these studies also show high time and opportunity costs from the patient perspective. Expansion of telemedicine to reduce patient costs is becoming a viable option for many specialists, though low reimbursement rates restrict its widespread application.9,19 However, this obstacle is not impossible to surmount. One study found that offering teledermatology to Medicaid patients through their primary care providers significantly improved access, allowing for a 63.8% increase in the number of patients visiting a dermatologist (P<.01).20 Currently, a total of 48 state Medicaid programs now cover telemedicine, and a growing number of states are requiring private insurers to cover telehealth services.21 As more dermatologists adopt telemedicine practices, it may allow for better access as well as expanded insurance coverage.
Limitations
The results of our study are limited by the single-institution survey design. Patients were asked to complete the survey while still at the clinic visit to minimize recall bias. Because these patients actually attended their appointments, they might perceive the time and monetary costs associated with the visit to be less problematic than those who canceled their appointments or transferred care elsewhere; however, we were still able to detect a significant impact of time and monetary costs on provider preference in this cohort (P<.05). Larger studies in different geographic settings and other specialty clinics are needed to confirm our findings and to determine if nonmonetary factors such as specific diagnoses, length of time with a certain care provider, or patient socioeconomic status can modulate the impact of time and monetary costs on provider preference.
Conclusion
This study showed that patients expend a substantial amount of time and monetary costs to attend dermatology clinic visits. Data from the current and prior studies suggest that these costs affect patient provider preference for dermatologic care and may pose barriers to necessary medical care. Recognizing direct and indirect patient costs may drive critical changes in health care delivery, such as increased telecommunication utilization, the more cost-saving alternative. Telemedicine, when integrated appropriately, can help minimize expenses for patients while continuing to maintain a high level of care.
