2012 Survey of U.S. Health Care Consumers: Five-Year Look Back Key findings, strategic implications

Foreword

Consumers are the foundation of the United States’ economy: 70 percent of our Gross Domestic Product (GDP) is dependent upon personal consumption;¹ their needs and wants drive innovation in every domain of daily life except, perhaps, health care.

Recently, health policy experts and economists have challenged the health care industry’s approach to consumerism; many reason that costs would be lower, service better, and quality substantially improved if the industry repositioned itself as a consumer market. Among consumers, there is a widening gap between their unmet needs and the system’s performance. Still, many stakeholders doubt that the health care industry could function in a consumer economy, reasoning that health care can be too complicated for the “average Joe” to engage with it knowledgeably and appropriately. Consumers’ decisions to purchase or utilize health care services and products often rely upon expert recommendations from medical professionals. In addition, many consumers’ choices are affected by health insurance, which can distort the true cost of health care services and products. Increasingly, consumers are bearing the costs of health care; expenditures for personal consumption of health care are the second-highest household expense after housing/utilities.² Although the idiosyncrasies of the health care system are likely to characterize the market for a long time to come, there are signs that consumers are ready to become more active, informed decision-makers.

2012 marks the fifth year for the Deloitte Center for Health Solutions’ survey of U.S. adult health care consumers about their interest in and ability to operate in a consumer health care market.³ These annual online surveys have queried up to 4,000 adults per year in various age, health status, income, and insurance groups to identify the degree to which consumers are prepared to engage with the health care system. Five years ago, findings from Deloitte’s first consumer survey (2008) revealed that users of the health care system are “neither patient nor patients. They are consumers,” and this remains true in 2012. The distinctions between the two are stark; the implications are transformative—not only to the health care industry but to every U.S. household, company, and government agency.

This report provides data-driven insights gleaned from the Deloitte 2012 Survey of U.S. Health Care Consumers as well as a look back at five years of findings that point to untapped potential for increased health care industry engagement with consumers and, with that, new challenges and opportunities for providers, health plans, employers, and government.

Introduction

Health care consumerism: Conceptual framework for this study

Conducted annually since 2008, Deloitte’s longitudinal study of heath care consumers seeks to provide a comprehensive view of health care consumerism, a view that goes beyond the conventional boundaries of what health and health care are commonly thought to encompass.

In addition to the traditional services that doctors and hospitals provide, the study’s framework takes into account the expanding spectrum of treatment alternatives, delivery settings, information sources, and programs that are coming into existence to promote wellness and self-care, address health needs, and finance health care.

Now in its fifth year, the 2012 survey continues to build on previous years’ surveys by exploring consumers’ behaviors, attitudes, and unmet needs in six domains (figure 1):

• Wellness and healthy living
• Information resources
• Traditional health services
• Alternative health services
• Health insurance
• Health policy

Figure 1: Zones of health care consumer activity

Survey Methodology

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 February 2012, a nationally representative sample of 4,012 U.S. adults, aged 18 and older, was surveyed, using a web-based 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).⁴This 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.

The margin of error is +/- 1.6 percent at the .95 confidence level. The online 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 health-related characteristics. English and Spanish versions were available. Participants were asked about behaviors before attitudes within each topic area to reduce response bias.

2012 brings a five-year milestone in the consumer survey (figure 2) and, where possible, comparisons are made to the surveys conducted in 2008, 2009, 2010, and 2011. Differences in question wording and response scales—used in an effort to improve the survey instrument—preclude direct comparison in some cases. Core questions from the previous years are repeated periodically to assess how health care consumerism is evolving in the United States. Data presented in this report will note if a question was not asked in a specific year and all data refers to the 2012 consumer survey unless specifically stated otherwise.

Perspective: The U.S. health care system

In 2010, health care consumed 17.9 percent of the U.S. GDP, or $2.6 trillion in health care expenditures.⁵ As widely noted, the United States consistently spends more on health care per capita than do all other developed countries.⁶ Health care costs hover around $8,500 per capita⁷ and are expected to increase at an average annual growth rate of 5.8 percent for the next decade.⁸This annual growth is anticipated to exceed that of the economy by 1.1 percentage points; by 2020, national health spending is expected to reach 19.8 percent of GDP, at $4.6 trillion in health care expenditures.⁹

Figure 2: Total respondents: 2008–2012

An estimated 32 million currently uninsured individuals will be required to hold a minimum level of health insurance beginning January 1, 2014, a direct outcome of the Affordable Care Act (ACA). Implementation of the provisions of the ACA as it currently stands are in the near term (commencing 2013) and are to some extent subject to how the broader economic and political environments play out. Nonetheless, the Deloitte model, The Impact of Health Reform on Health Insurance Coverage: Projection Scenarios Over 10 Years,¹⁰ assesses the effects of key economic, behavioral, political, and strategic variables on insurance coverage under the ACA, and produces a 10-year annual projection of market configuration in terms of number of insured and uninsured providing considerable insights into how the health care system may change based upon courses of action that may be undertaken by states, employers, and ultimately health care consumers.

The costs of health care are unsustainable. In 2011, Deloitte estimated that spending on health care outside of the National Health Expenditure Accounts (NHEA) for such items as supervisory care for others, complementary and alternative medicine, vitamins, supplements, and nutritional products would account for an additional $363 billion or 14.7 percent more than that reported in the NHEA accounts.¹¹

Subject to any future potential revisions, the ACA of 2010 proposes numerous ways to potentially extract greater value from and improve the quality of the U.S. health care system. Provisions of the act include a requirement that most individuals have health insurance and delivery system reforms that change the payment and service delivery systems. Challenged in the courts, on June 28, 2012, the Supreme Court of the United States in its rulings on the four legal challenges to the ACA provided a measure of certainty when it upheld the act’s constitutionality. But ongoing efforts in Congress to repeal and replace the law could create new challenges over the long term. Meanwhile, the Internal Revenue Service and other agencies are in the process of developing regulations to implement the law as enacted.

Highlights 2008–2012

Consumer engagement with the health care system is a work in progress

Tracking health care consumerism over five years 2008–2012, a period that saw major upheavals in the broader economy, reveals slow and incremental changes in how consumers’ attitudes and behaviors intersect with the health care system.

Favorable views of overall system performance appear to be increasing and yet the system is considered to be confusing, complex, and costly. Perceptions of wasted spending and the cost of the health care system continue to be unfavorable. Confidence about feeling prepared to deal with future health care expenses has declined over the five years—seniors feel more confident than younger generations, but their confidence is slipping as well. Furthermore, the cost of care leads many to delay or decide not to seek care, and, for some, to seek better value or cheaper alternatives by switching health plans, health care providers or treatment approaches, or foregoing the purchase of insurance.

Satisfaction with elements of the health care system varies with consumers consistently being satisfied with primary care services, less so for hospital care and for health plans. Utilization of the system is constant for seeking care from a primary care practitioner, although a decline in wellness/screening visits is noted; use of alternative therapies is low and constant. A recent increase in the use of the emergency room is also seen.

Key issues for consumers are access, cost, and value.

As health care consumerism grows, consumers are interested in more and better choices: in customizable health plans, in services such as retail clinics and non-physician primary care providers such as pharmacists, nurse practitioners, and physician assistants. Interest is shown in online tools that provide information on potential cost of care and insurance, quality, and performance information on both physicians and hospitals.

Many use online resources for information about treatments and medical conditions and growing numbers (younger generations in particular) look for technology-based solutions such as monitoring devices, apps, and information from social media.

Six segments of the health care consumer market

The health care consumer market is not homogenous­—Deloitte identified six unique consumer segments that navigate the system in very distinctive ways. Patterns in attitudes and behaviors—not demographics and socioeconomic characteristics—define these segments. Over the past five years, the most disengaged segment (Casual & Cautious) and one of the most active segments (Online & Onboard) have grown.

Figure 3: Health Care Consumer Segments

Views on U.S. health care system performance

Consumers relate to health care on a deeply personal basis. Their understanding of the “health care system” is based almost exclusively on their personal experiences. As a result, they hold strong opinions about its performance.

• Satisfaction is low in 2012 (22 percent), but it may be improving (up from 16 percent in the previous year) (not shown).
• Consumers’ views of overall health care system performance 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 (figure 4).
• 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). This finding is somewhat lower than in previous years, with 36 percent grading the system unfavorably in 2011, 35 percent in 2010, and 37 percent in 2009 (figure 4).

Figure 4: Using a typical report card scale with grades of A, B, C, D, and F, how would you grade the overall performance of the U.S. health care system?

• The system gets high marks for clinical innovation (61 percent give it an “A” or a “B”) and use of technology (56 percent give it an “A” or a “B”) (figure 5).
• Fewer consumers give the system high marks for value and responding to the needs of the uninsured (figure 5).
• The system is considered to fail (rating performance as a “D” or “F”) those without insurance (53 percent) and to offer poor value for money spent on health care (44 percent) (not shown).
• In 2012, only 25 percent feel that the best value is obtained for the money spent (figure 5).
• Increasing perceptions of waste and lack of value may be contributing to dissatisfaction with the system; in 2012, 62 percent believe that 50 percent or more of the dollars spent on health care are wasted—up from 51 percent in 2009, 49 percent in 2010, and 51 percent in 2011 (not shown).

Figure 5: Using a typical report card scale with grades of A, B, C, D, and F, how would you grade the U.S. health care system on the following dimensions?

• In 2012, causes of waste were considered to be fraud and abuse in payment systems (69 percent), consumer behavior such as unhealthy lifestyles (49 percent), and duplication of tests and procedures (38 percent) (figure 6).

Figure 6: Which of the following do you think cause the most money to be wasted?

Impact of unfavorable economic conditions and rising health care costs

The cost of health care, coupled with the state of the economy, is of concern to consumers, prompting many to alter household spending, delay care, and worry about their ability to pay for future health care costs.

• 2 of 3 consumers say the recent economic slowdown has caused them to be more cautious or to cut back on what they spend on health care products and services, a drop from the 3 in 4 who said they were cautious with health care spending in 2011 (figure 7).
• However, there was a slight increase between 2011 and 2012 (rising from 13 percent to 15 percent) of those who say the economic conditions have had a highly significant impact on household health care spending (figure 7).

Figure 7: What impact has the recent economic slowdown had on your household’s health care spending?

• In 2012, around 2 in 5 say the proportion of total annual household income spent on health care stayed about the same as the previous year (figure 8).
• Around 3 in 10 say their spending increased and 2 in 10 say spending decreased (figure 8).
• The proportion of household expenditures directed toward health care in the past year decreased among considerably more of the uninsured and unemployed than among other consumers (figure 8).

Figure 8: Would you say that the proportion of your total household consumption spent on health care has increased, decreased, or stayed about the same when compared to the previous 12 months?

• There is a decline across all generations between 2011 and 2012 in consumer confidence about feeling prepared to handle future health care costs (figure 9).
• Of all the generations, Seniors feel the most secure financially; however, only 1 in 3 Seniors are confident about dealing with future health care costs (figure 9).
• Over the years, very few of those without insurance say they feel prepared to meet future health care costs.
• Between 2011 and 2012, the insured report a decreasing sense of confidence in meeting future health care costs (26 percent in 2011 and 20 percent in 2012) (figure 9).

Figure 9: To what extent do you feel your household is financially prepared to handle future health care costs?

• In 2012, 1 in 4 consumers (27 percent) (1 in 3 (34 percent) among the uninsured) say they decided not to see a doctor when sick or injured in the last 12 months. 1 in 9 (12 percent) decided to delay or skip treatment recommended by a doctor.
• Among those who didn’t seek medical attention, the percentage citing cost as the reason decreased between 2011 and 2012 (from 53 percent to 46 percent) but remained higher than in 2010 (39 percent) and 2009 (38 percent). Those who say they delayed or skipped treatment for cost reasons rose from 52 percent in 2011 to 58 percent in 2012 (not shown), continuing an upward trend from previous years (40 percent in 2009, 42 percent in 2010).

Zone one: Wellness and healthy living

Consumers augment health care with wellness checks, use of vitamins and healthier food choices, and some self-care programs—but overall engagement in wellness and preventive actions is low.

• Most consumers in 2012 believe themselves to be in good health (84 percent), slightly fewer than in 2011 (91 percent), but more than half (52 percent) have been diagnosed with one or more chronic conditions (similar to 2009, 2010, and 2011). In 2012, around half (49 percent) of consumers with chronic conditions say that these have “little” to “no” impact (between zero and 33 percent impact) on their activities of daily living (not shown).
• 2 in 3 (65 percent) say they had a wellness check-up in the past 12 months, a decrease from 2011 (76 percent), 2010 (68 percent), and 2009 (73 percent) (figure 10). The uninsured are half as likely as the insured to report seeing a doctor for a well visit or routine check-up (36 percent vs. 72 percent). This is similar to previous years (not shown).

Figure 10: Which of the following have you done in the last 12 months?

• Participation in healthy living/wellness programs offered by employers, health plans, and other organizations declined between 2011 (25 percent) and 2012 (10 percent) (figure 10).  Both insured and uninsured consumers reported lower rates of participation in 2012 compared to previous years (not shown).
• Use of vitamins, minerals, and herbal supplements is relatively high. 60 percent report taking vitamins/minerals (68 percent in 2011) on a regular basis for health purposes; 18 percent take herbal supplements (not shown).
• 44 percent say they deliberately purchased food such as probiotic yogurts or cholesterol-reducing spreads for its perceived health benefits (figure 10).
• 37 percent of consumers say they received an influenza shot during the past year, compared with 43 percent in 2011 (figure 10).
• Around half (49 percent) of consumers who engage in tobacco use and one-quarter (24 percent) who drink alcohol say they are trying to reduce intake (figure 11).

Figure 11: Which of the following, if any, have you done in the last 12 months?

Incentives and better health

Few are willing to pay for supports such as health coaches or yearly health screenings; half the consumers are open to incentives to change behaviors.

• Few consumers are willing to pay for health coaches (5 percent) or yearly health screenings (8 percent) if they have to pay for the full cost of the program (figure 12).
• If the program was offered for no out-of-pocket cost, over one-half (57 percent) say they would be willing to use a health coach and two-thirds (66 percent) would undergo an annual screening exam (figure 12).

Figure 12: How willing would you be to meet with a “health coach”/complete yearly health screenings and follow through with recommended actions and activities?

• Incentives would motivate around half of consumers to use a health coach (48 percent) or complete an annual health screening (55 percent) (figure 12).

Zone two: Information resources

Many want access to tools or websites that enable them to gauge quality and cost. Fewer are currently interested in technologies that support self-monitoring and health improvement.

• In 2012, 45 percent of consumers report looking online for information about treatment options—similar to those who did so in 2011 (43 percent) but lower than the 55 percent in 2010 and 57 percent in 2009 (not shown).
• 7 percent say in the past year, they have searched online for information to help decide which hospital to visit and 10 percent say they looked online for information to help select a health insurance policy (not shown).
• Around half the consumers say they would like access to tools or websites that enable them to estimate the cost of care, evaluate quality and satisfaction with specific providers and hospitals, and benefit from user reviews (figure 13).

Figure 13: How likely would you be to use websites that offer the following?

• Interest in using self-monitoring devices has decreased from 2008 to 2012 (figure 14).
• In 2012, half of all consumers say they would prefer to communicate with their doctor in person or by phone instead of using a self-monitoring device (figure 14).
• 56 percent say they would be willing to use videoconferencing for sick visits; 67 percent would do so for follow-up visits (not shown).

Figure 14: If you developed an ongoing health condition that needed to be checked or treated regularly, how interested would you be in using the following tools or supports on a regular basis if the technology became available to you?

• Around 4 in 10 consumers say they are interested in using apps that provide medication reminders, and that help set and track health improvement goals (not shown).
• Although the number of people who keep a personal health record (PHR) of some kind has nearly doubled over the past five years (25 percent in 2008 to 46 percent in 2012), few maintain an electronic personal record (figure 15).
• 35 percent overall say they are concerned about privacy and security of personal information if they were to use an electronic health record (figure 15).

Figure 15: Do you currently maintain a paper-based and/or electronic-based personal health/medical record? / How concerned are you that the privacy and security of your personal health/medical information might be at risk if you were to use a computer software program or website to maintain a personal health record that allowed you to share information with your doctor through an Internet connection?

• Preferred channels to receive health information (e.g., treatment plans, reminders) vary, with older generations preferring telephone- and paper-based approaches; younger generations prefer emails, phone calls, and text messages (figure 16).

Figure 16: If your health plan or doctor’s office could help you look after your health by reminding you to take medicines, perform routine self-exams, and schedule clinical exams, how interested would you be in receiving the following types of reminders?

Social media

Using social media for health care appeals to younger generations; older generations use it sparingly; all find that user-generated health information via social media needs additional verification.

Figure 17: In the last 12 months, have you used social media (e.g., an online community support site, chat room, or social networking site) to do any of the following?

• 26 percent of total respondents say they used social media for health-related purposes in the past year—use is highest among Millennials (40 percent) and Gen X (29 percent) (figure 17).
• Consumers primarily use social media for learning more about a specific illness/health problem/injury (figure 17).
• As trusted sources of information about the effectiveness and safety of specific treatments, consumers—especially Seniors (not shown)—prefer to rely on the medical community more than other sources (figure 18).
• Independent health-related websites (24 percent) garner nearly as much trust as pharmacies (27 percent) and slightly more trust than the U.S. Food and Drug Administration (22 percent) (figure 18).
• Health plans, general Internet search engines, bio-pharma/medical device companies, employers, and social media are least preferred as trusted sources of information (figure 18).
• Reasons for lower levels of trust in manufacturers include concern about full disclosure about products (60 percent), a preference to receive this type of information from a medical professional (54 percent), and a belief that more objective sources may be available (43 percent) (all not shown).

Figure 18: If you wanted information about the most effective and safe treatment(s) for a certain health condition, how much trust would you have in the following “third-party” sources to provide reliable information?

Zone three: Traditional health services utilization

The majority of consumers report accessing primary care—either for routine check-ups or injury/illness. Use of the emergency room is rising but satisfaction with this service is dropping.

• 76 percent of consumers (85 percent in 2011) say they visited a physician or other health care professional in the past year for some purpose (figure 19).
• 65 percent visited for a routine check-up (76 percent in 2011) and 39 percent for an injury or illness (54 percent in 2011) (figure 19).
• Around 2 in 5 consumers say they received care in a hospital in the last year, either as an outpatient (23 percent), emergency patient (19 percent), or inpatient (8 percent); use of  emergency care is rising (from 13 percent in 2009 to 19 percent in 2012) (figure 19).

Figure 19: Which of the following have you done in the past 12 months?

• Half of all consumers (51 percent) in 2012 say they currently take prescription medications: of those taking medication, 23 percent take one medication, 38 percent take two or three, and 35 percent take over four prescription medications (not shown).

Primary care

More consumers are using nurse practitioners (NP) or physician assistants (PA) for primary care.

• Nearly 4 out of 5 consumers report having a PCP (figure 20).

Figure 20: Do you currently have a doctor, nurse practitioner, physician assistant, or other health care professional you consider to be your primary care provider? 

• Satisfaction with their PCP is high and rising—76 percent of consumers are satisfied with their PCP in 2012, compared with 73 percent in 2011, 71 percent in 2010, 72 percent in 2009, and 66 percent in 2008 (shown in figure 23).
• Among the uninsured, the percentage having a PCP has dropped from 58 percent in 2008 to 46 percent in 2012 (figure 20).
• Of the uninsured, reasons for not having a PCP include being unable to afford care (64 percent), no insurance (49 percent) or feeling as if they don’t need a PCP (15 percent) (not shown).
• Poor quality of both care and service prompt people to switch physicians and 8 percent say they switched their PCP in the past year. Of these, 25 percent say they did so for reasons associated with the PCP’s “style/manner” (such as not showing courtesy or respect or not spending sufficient time); 18 percent did so for cost reasons (such as out-of-pocket costs or physician no longer accepting insurance); and 17 percent switched for access and customer-service reasons (such as difficulties in getting a timely appointment or long wait times) (not shown).
• Consumers with a medical doctor (MD) as a PCP have declined over the past five years (figure 21).
• 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 (figure 21).
• 13 percent say they used a pharmacist for treatment or advice for themselves or a family member rather than consulting a doctor in 2012. Millennials seek out pharmacists more than older generations: 1 in 5 (22 percent) of Millennials (1982-1994) say they used pharmacists in this manner compared with 14 percent of Generation X (1965-1981), 10 percent of Baby Boomers (1946-1964), and 6 percent of Seniors (1900-1945) (figure 22).
• 1 in 4 Millennials believes that pharmacists could provide many primary care services similarly to a physician (figure 22).

Figure 21: What type of health care professional do you consider to be your primary health care provider?

Figure 22: Please indicate your level of agreement with the following statements / Which of the following, if any, have you experienced yourself in the last 12 months? / How likely would you be to do the following if these options were available to you?

Perceptions of availability and quality of hospitals and physicians vary substantially by insurance status and source.

• Medicare enrollees perceive greater access, better after-hours availability, and shorter waiting times for appointments (figure 23).
• For those without insurance, access is perceived to be substantially more difficult than for the insured (figure 23).

Figure 23: Thinking about what is available within a reasonable driving distance from your home or through public transportation, how would you rate the adequacy of the following?

Hospital care

Use of emergency care is rising; satisfaction with hospital care (outpatient, inpatient, and emergency care) is decreasing slightly, being driven more by quality and customer-service issues than by cost.

• 2 in 5 (41 percent) say they used a hospital service in the past year (shown in Figure 19). 65 percent of recent hospital users (any hospital service) are satisfied with the care they received (77 percent in 2011, 75 percent in 2010, and 74 percent in 2009) (not shown).
• Satisfaction with primary care providers is consistently high and has increased since 2008, while satisfaction with other system elements (hospital care and health plans) appears to be declining (figure 24).
• Over time, satisfaction with inpatient and emergency hospital care appears to be decreasing considerably (figure 24).

Figure 24: Overall, how satisfied are you….?
Among consumers who say they were dissatisfied with the experiences they had in a hospital setting, dissatisfaction is driven more by quality and services (2 out of 3 consumers) than by cost (40 percent) (figure 25).

Figure 25: Why are you less than completely satisfied with your most recent experience as an overnight patient/outpatient?

Retail clinics

Consumers are receptive to using retail clinics for minor medical problems—their value, convenience, and access are attractive.

• 14 percent of consumers report they used a retail clinic in the past 12 months (down from 19 percent in 2011, but similar to 15 percent in 2010 and 13 percent in 2009) (not shown).
• 25 percent say they are willing to visit a retail clinic if their physician is not available (not shown).
• Among retail clinic users:
  • Almost 2 out of 3 (61 percent) are satisfied with the care they or their family member received during a retail clinic visit (not shown).
  • Half choose retail clinics because of convenience and/or speed of getting an appointment (figure 26).
• Dissatisfaction with retail clinic experiences relate to quality (37 percent), cost (34 percent), and an unmet need (29 percent) (not shown).

Figure 26: Which of the following factors led you to choose to go to the retail walk-in clinic?

Prescription medications and over-the-counter health care products

Consumer confidence with prescription medications is high but cost concerns lead many toward generic alternatives, as well as to use home remedies and over-the-counter products.

• Prescription drug use has declined in recent years, including among those with chronic conditions and among both the insured and uninsured (figure 27).
• 40 percent of all consumers say they used home remedies or over-the-counter medicines instead of going to see a doctor/medical professional because it was cheaper (not shown).
• In 2012, 37 percent say they purchased a generic drug rather than a prescribed “brand” drug based on advice received at the pharmacy counter (not shown).

Figure 27: Are you currently taking any of the following products to treat a health condition/problem or improve your health?

• Close to 9 in 10 prescription medication users are highly confident about their medications, saying they understand how the medications work, understand risk and side effects, and believe in the efficacy of the medications (figure 28).
• In 2012, 1 in 10 reports they stopped taking their medication early or changed dose/frequency without speaking with their doctor (figure 29).
• Fewer prescription medication users report switching medications than in previous years—14 percent in 2012 compared with 29 percent in 2009 (figure 29).
• Few consumers switch medications, but those who do, switch in search of better effectiveness (42 percent), fewer side effects (30 percent), and medicines that are easier to take (12 percent). 34 percent say they switched to a generic to save money and 16 percent say they switched for insurance-related reasons (not shown).

Figure 28: Thinking about the prescription medication you are currently taking, please indicate your level of agreement with the following statements:

Figure 29: Which of the following, if any, have you done in the last 12 months?

Zone four: Alternative health services

1 in 10 consumers integrates alternative therapies with traditional care.

• Nearly 1 in 10 respondents in 2012 says they treated a health problem with alternative treatment approaches and natural remedies compared with around 1 in 5 who did so during 2008–2011 (figure 30).
• Few use alternative or natural therapies either in substitution for or in addition to prescription medications and use appears to be declining over the years (figure 30).
• 12 percent say they prefer doctors who take an alternative/holistic approach to treating health problems, down slightly from 15 percent in 2008.  Over the same period, the percentage stating a clear preference for doctors who take a standard medical approach grew from 42 percent to 47 percent.
• To treat minor illnesses, 17 percent say they prefer to take natural remedies like herbal medicines rather than medicines prescribed in standard medical care. This has not changed in recent years, but is higher among the younger generations (22 percent of Millennials, 19 percent of Gen X) than the older generations (14 percent of Boomers, 11 percent of Seniors), suggesting use of natural remedies may increase in coming years.

Figure 30: Which of the following, if any, have you done in the last 12 months?

Zone Five: Health insurance

Fewer than half the consumers are satisfied with health plans—in particular, a shift from feeling “well-insured” to feeling either “adequately insured” or “under-insured” is evident.

• 80 percent of consumers in 2012 report having some kind of health insurance through a commercial plan or government-sponsored program (figure 31).*
• Most consumers have insurance from employers (47 percent), through government programs (27 percent) or purchased directly (6 percent) (figure 31).*
• Satisfaction with health plans has declined in recent years, from 52 percent in 2009 saying they are satisfied to 57 percent in 2010, 52 percent in 2011, and 44 percent in 2012 (shown in figure 24).
• 16 percent of the insured report switching health plans in 2012 (11 percent did so in 2008, 17 percent in 2009, 20 percent in 2010, 11 percent in 2011). Many consumers are switching plans for cost-related reasons: 47 percent of those who switched in 2012 say they did so for cost-related reasons, including seeking to pay less, get better value, or reduce out-of-pocket costs; or an inability to afford premiums (not shown).

Figure 31: Which of the following best describes your health insurance status during the past 12 months?*

• Coverage-related reasons for switching insurance, such as seeking better coverage or accessing different benefits or providers, also appear to be increasing, rising from 22 percent among reasons for switching plans in 2009 to 29 percent in 2012 (not shown).
• The number of those feeling well-covered has declined with sentiment shifting to feeling “adequately” or “under-insured” (figure 32).

Figure 32: Thinking about the amount and types of health insurance coverage you currently have, do you consider yourself to be?

• Those feeling under-insured grew between 2011 and 2012 (8 percent to 14 percent) (figure 32).
• 2 of 3 consumers who are uninsured have been without health insurance for at least 12 months. 1 in 5 has been without insurance for part of the past year (figure 33).
• Cost (61 percent), changing or losing employment (26 percent), and employer not offering insurance (19 percent) are key reasons for not currently having insurance (not shown).

Figure 33: Which of the following best describes your health insurance status during the past 12 months?

Consumers want choice and customization when purchasing health insurance.

Many consumers are interested in taking a more active role when selecting and purchasing their health care coverage. Younger generations, in particular, show interest in customizing plans and having a choice of plan styles and options.

• Only 6 percent currently have insurance that they bought directly; however, 33 percent say they would prefer to obtain insurance that way (figures 34 and 35).
• Consumers show some interest in alternative ways of obtaining insurance: interest is split between a preference for personally shopping for insurance and for taking advantage of employer offerings (figure 35).
• If given the choice, close to 3 in 5 consumers say they would prefer to customize their health plan rather than select from predefined options (figure 36).
• Interest in customizing is highest among the youngest generations: 64 percent of Millennials and 62 percent of Gen X say they are interested, whereas 41 percent of Seniors say they are interested (figure 36).

Figure 34: Thinking about your primary health insurance coverage (meaning the health insurance policy/health plan that currently provides the most coverage for medical care), how did you get this coverage?

Figure 35: There are many potential ways to obtain a health plan. If you were given the choice, which approach would you prefer?

Figure 36: There are different ways to design a health plan such as the mix of benefits, features, and costs that might make up a particular health plan. If you were given the choice, which kind of health plan would you prefer?

Zone six: Health policy views on health care reform

A “good start” or a “step in the wrong direction”?

• Overall, consumer support for health care reform slipped from 2011: half felt positively about health care reform in 2011 (49 percent) versus 38 percent in 2012 (figure 37). The strongest positive inclinations about the health care reform law are held by the Millennial generation (1982-1994) (41 percent in 2012).
• Uncertainty about reform increased, with 34 percent in 2012 either not knowing or expressing no opinion versus 21 percent in 2011 (figure 37).
• Seniors are more negative about reform than others: the percentage of consumers of all generations thinking that health care reform is a “step in the wrong direction” has remained relatively constant; however, positive views of reform have declined substantially in all generational groups, shifting toward “don’t know/no opinion.”

Figure 37: Based on what you know or have heard about the health care reform law, is it a good start or a step in the wrong direction?

What might be achieved by health care reform?

Consumers are unclear about the likely results of the Affordable Care Act (ACA): the majority is not sure it will increase access, reduce costs, or improve quality.

• Views of health care reform’s likely success in achieving its stated goals are mixed. Around one-fourth (27 percent) of consumers feel that health care reform will successfully increase access to health insurance coverage and around one-fifth (20 percent) believe that reform is likely to be successful in increasing the quality of care, motivating individuals to improve their health (20 percent), better coordinating care (20 percent), and ensuring access to the latest technologies (21 percent) (figure 38).
• Only 16 percent feel that health reform will successfully decrease health care costs overall, with 32 percent believing the contrary (figure 38).

Figure 38: Based on what you know or have heard about the health reform law, how successful is the health reform law likely to be at accomplishing the following?

Key findings

The six major takeaways are:

1. Evident over the five years of this study, U.S. consumers recognize that the health care system is costly, confusing, and is perceived to deliver suboptimal service and value.
2. Most consumers have a touch point with the health care system through their primary care practitioner, and satisfaction with this service is high. Consumers increasingly are open to primary care being delivered by a range of professionals including physicians, nurse practitioners, physician assistants, and pharmacists—and see potential for primary care to lower costs and improve quality of the health care system overall.
3. Consumer confidence in dealing with future health care costs is declining—anxiety and concern about future health care costs are prevalent. The cost of care coupled with the unfavorable economic conditions of the past few years are prompting consumers to scale back out-of-pocket spending, delay or skip care, and consider using non-conventional options.
4. A solid base of “e-health consumers” is slowly growing: over the past few years, comparatively low numbers of consumers have turned to online resources for health care when compared with use of online resources in other industries. Generational differences in the use of technology for health care purposes are critical insights: the younger, healthy generations are the most interested and open to using technology but have the least need to do so. However, with the passage of time, utilization of health care by these groups will increase—either for themselves or as carers for family members and this group will expect smart-tools, ready access, and immediacy with respect to health care information and communications with providers and insurers.
5. Insurance is key to accessing the system, with disparities between those with and those without insurance clearly evident over the past five years. Insured consumers’ feelings of being adequately covered are declining.
6. Despite the fact that about half of consumers recognize that unhealthy lifestyles are a substantial cost driver of the system, a low level of engagement is evident in consumers’ pursuit of healthy behaviors, use of preventive care, and health maintenance activities. The reasons for this are unclear—they may be due, in part, to consumers’ cost-sensitivities but this highlights the need for a greater focus on wellness in the system.

Stakeholders in the U.S. health care system should consider the following implications, issues, and challenges:

• How best can stakeholders (particularly health plans, medical device and bio-pharma companies, and health care providers) optimize the “customer experience”? Effective customer-service strategies, including the relentless pursuit of quality, patient safety, and care coordination, will be required. Also, new and/or additional  resources and structures will be needed to provide consumers with advice and information to help them successfully navigate the system and better manage/coordinate their health. In addition, drug and device manufacturers will need to increasingly consider their end users when positioning their value proposition.
• An engaged health care consumer is central to successful strategies to re-focus the current health care system. What “carrots and sticks” are necessary to motivate and incentivize consumers to manage their own health, and how can stakeholder organizations (providers, health plans, bio-pharma companies) devise and implement effective consumer engagement strategies?  What tools and systems need to be in place to encourage consumer engagement? What part do new technologies such as distance medicine and telemedicine, self-care, bio-monitoring, and physician e-visits, as well as allied health clinics and other ambulatory facilities, play in achieving this?
• Commercial health insurance companies will need to consider how best to structure products and shopping experiences for consumers who have been without health insurance. An influx of newly insured will require business models that reinforce the need for real-time integration of clinical and claims data for better decision-making; payment systems that align with outcomes; a focus on enhanced clinical effectiveness; information and decision-support tools; consumer-oriented information, accountability, and incentives that align with care goals; integration of care pathways; and the use of tools and technologies such as monitoring devices.
• Multi-channel information strategies will be necessary to reach consumers in a marketplace that is fragmented with multiple opportunities, resources, and information streams for consumers to use to access information and facilitate decision-making about the health care they consume. Different media preferences and utilization behaviors are evident among generational age groups; services and channels should, therefore, be targeted to take these differences into account. Emerging media formats, tools, and apps offer consumers—particularly younger generational groups—considerable opportunities to use online resources and social media for motivation and health goal tracking, wellness, information gathering, support, and encouragement.
• Health care providers may need to position their core services, customer service strategies, and communications tools and techniques to take advantage of the myriad consumer-oriented, technologically based health care tools. Providers need to meet the challenge of providing real-time, understandable health information, test results, and other relevant data for consumers in easy-to-access formats. Not every one has, or wants, a smartphone or tablet—nor is all health care information suitable for such platforms—so, what are the solutions going forward?
• Providers, regulators, and insurers should be alert to the changing landscape of providing health care—particularly primary care. New non-traditional sites/service models that offer high-quality care, convenience, access, and affordability provide opportunities to capitalize on consumer interest. These new service delivery models will draw upon different skills and competencies, as well as changing incentives in payment systems and increasing consumer demand for health care services, and will require a new and different mix in the skilled health care workforce.

Closing thoughts

To U.S. consumers, health care is intensely personal—opinions about the system’s performance are based on individual, often local, sometimes painful and frustrating experiences. Nonetheless, there is considerable opportunity to engage consumers more effectively in decisions about their health and the care they utilize. For consumers, a less expensive and less complicated health care system, better coordinated services, improved delivery models (such as team-based care), and increased value are imperative.

For many industry stakeholders, consumerism in health care is problematic. Although inevitable, it is disruptive to “standard operating procedure”—in some cases, requiring a massive overhaul of business models and personnel. Deloitte believes this transformation is necessary and worth it.

As the health care marketplace moves toward one that is grounded in value-based competition, innovation, and consumer engagement, what has the industry learned about how consumers view their health and the health care system? More critically, what more do stakeholders need to know about health care consumers’ behaviors, expectations, and unmet needs? How best can consumers be reached? The challenge posed by decoding health care consumerism is to grasp where the end recipient fits into the “new normal” of health care and to identify what opportunities may be around the corner when consumerism is translated into a high-performing, consumer-centered system of care.

Companion reports to the Deloitte 2012 Survey of U.S. Health Care Consumers: Five Year Look Back include an INFOBriefs series that presents key findings about consumers and health information technology, social media and online resources; utilization of health care services; life sciences products and innovations; consumers and health plans. An additional report on health care consumer segments is also available.

For more information and additional reports, visit www.deloitte.com/centerforhealthsolutions