Abstract
Purpose: Ongoing changes in the operations and constraints of the health care system are likely affecting how patients make decisions about care seeking. Therefore, we analyzed data from a national survey asking people where they would seek care if they had no limits.
Methods: We conducted surveys of patient experiences and perceptions regarding primary care delivery and access during the pandemic, one of which conducted during November 15 to 23, 2021 included a question asking: “If you had no limits (such as insurance coverage, or what you could afford), what would be your first choice for handling most of your health concerns?” A multidisciplinary team analyzed responses using a 3-step process: identified categories using a grounded approach, tallied category frequencies using a template-based coding approach, and involved an auditor to search for confirming/disconfirming data.
Main Findings: Among 1,211 respondents with usable answers, the most frequent first preference for handling most health concerns was primary care (49.1%). Other common responses were hospital or health system (11.9%), a convenient/easily accessible source (11.6%), the current source of care (8.3%), a source that would provide quality care (8.2%), or a specialist (8.0%). Less common preferences include urgent care, clinicians with whom the respondent had a relationship, a specific procedure or treatment, self-care, alternative medicine, mental/behavioral health care, holistic/wellness/preventive medicine, or pharmacy.
Conclusion: A majority of respondents among a large national sample of patients preferred primary care for handling most health concerns. Given the known benefits of primary care, systems should support, rather than constrain, that preference.
- Community-Based Participatory Research
- Delivery of Health Care
- Health Behavior
- Health Care Surveys
- Health Services
- Health Services Research
- Pandemics
- Patient Satisfaction
- Primary Health Care
- Quality of Care
- Surveys and Questionnaires
Introduction
A patient’s decision to seek care is a vital first step that sets up or impedes all subsequent health care. Delays in health care seeking lead to more extensive and expensive health care services1 and worse health outcomes.2
Prior studies of patients’ health care seeking behavior have focused on utilization, delays, and avoidance, as well as factors that contribute to these behaviors, such as trust and collaborative relationship with their physician,3–5 communication between clinicians,4,5 cost and insurance coverage,4–7 time constraints, convenience,5,6 quality of care, health care system context, a variety of attitudes, expectations and cultural beliefs,5 as well as the effect of the COVID-19 pandemic.9
Recent societal and health care system changes and constraints are likely affecting how patients make decisions about care seeking. Understanding how patients would seek care in the absence of constraints would be helpful in understanding patients’ true desires, and as an aid to designing systems that meet patients’ needs and expectations. Therefore, this study was undertaken to understand patient perceptions by analyzing answers from a US national survey that asked people, “If you had no limits (such as insurance coverage, or what you could afford), what would be your first choice for handling most of your health concerns? Where or to whom would you want to go?”
Methods
The Larry A. Green Center for the Advancement of Primary Health Care for the Public Good conducted a set of 14 surveys among cross-sectional convenience samples of primary care patients from May 2020 through December 2022. Each survey focused on patient experience of primary care delivery, using both structured and open-ended questions. Structured questions focused on access to care, experience of care delivery, experience of telehealth, perceptions and beliefs around COVID-19 and vaccines, and challenges faced for meeting their health care needs. Patient samples were identified using the SurveyMonkey, Inc SurveyMonkey Audience (SM Audience) service. The SM Audience service is an effective means for matching researchers with members of the population willing to participate in survey-based studies, and has been successfully employed in past health services research.10–12 Through SM Audience, a random sample of participants was requested, with overall demographics to match the US census in terms of proportional distribution of age, gender, education, income, and geographic distribution within the US. A minimum sample of 1,100 was obtained for each survey. These surveys were part of a larger study on primary care capacity and response to the COVID-19 pandemic.13
Potential participants of patient surveys were eligible if they were able to read English, were 18 years of age or older, and responded yes to a screener question. These participants were first presented with a definition of primary care: Primary care is 1) a place and/or team that recognizes what is important to you, 2) makes sense of your health concerns in ways meaningful to you, and 3) is available to you when you need it in the ways you need it. Only those who then responded yes to the question “Have you been seen by primary care within the past 12 months” were then able to take the survey. This current article focuses on 1,276 respondents who participated in the survey fielded November 15 to 23, 2021, and answered the following open-ended question:
“If you had no limits (such as insurance coverage, or what you could afford), what would be your first choice for handling most of your health concerns? Where or to whom would you want to go?”
Analysis of the open text comments involved a 3-step process. The first step used a grounded approach, as described in Glaser,14 to generate a codebook. Two coders (SHL & MMG) worked iteratively and inductively to develop the codebook. The second step used a template-based analysis process, as described by Crabtree & Miller,15 to use these codes to develop categories that grouped responses in ways that reflected their collective meaning. The primary analyst (SHL) then counted the frequency and percent of responses in each category. The third step involved an auditor (KCS), who independently reviewed the original codes and categories to assess for fidelity and bias in the application of the codebook and the template analysis process, with particular attention paid to both confirming and potentially disconfirming data.16
We summarize the findings in a table and provide category definitions, as well as example inclusions and/or exclusions for each category in the results section below.
Results
There were 2,000 overall responses to the overall survey, of which 1,276 included responses to the question we examine for this study. Of these 1,276 responses to our question of interest, 65 were excluded because their answers were either unable to be interpreted with any recognizable meaning, or were nonresponsive to the question (eg, random keystrokes), leaving 1,211 usable responses.
The types of care that respondents indicated as first choice for care and the frequency of their responses are shown in Table 1. Some responses fit into multiple types.
All Categories First Choice for Handling Most Health Concerns
The category “Primary Care” was defined by respondents mentioning primary care as their first choice. This was by far the most frequent reply, with 41.2% of responses (499 responses). Specific examples include “personal physician,” “family doctor,” and “I would go to my PCP Clinic.” More aspirational responses include “get a primary doctor,” and “I would see better primary care!”
The category “Hospital, Health System” was defined by respondents mentioning a hospital or health system as their first choice. This was the second more frequent category. Out of the 144 responses that were included in this code, nearly a third (45 responses) specifically mentioned Emergency Room/Department. The names of specific hospital systems, such as “Kaiser,” “Mayo Clinic,” and the “VA” were mentioned in 10 responses. While we understand that some hospital/health systems could be considered where a patient wants to go for their primary care needs, unless the patient specified a clear aspect of primary care in their response, these hospital system responses were not included in the “Primary Care” categories.
“Access to Care” was defined by respondents mentioning a desire for access to care or an ease of access to care, which was the third most frequent category with 11.6% (141 responses). Included in this code are comments related to proximity and easy commute (“to the clinic right down the street from my house”) with 24 responses, house calls (“A personal physician that makes house calls”) with 6 responses, good hours (“I would ask that I do not have to wait long hours for care or authorization of clinical examinations”) with 5 responses, faster service (“Whatever place could get me in, diagnose me and release me the fastest”) with 15 responses, all care in one place (“I’d want a supercenter that could meet all my needs no matter what was ailing me”) with 4 responses, wanting choice or the ability to choose where they seek their care (“Primary or specialist depending on the issue”) with 39 responses, concierge medicine with 6 responses, mentions of insurance or financial affordability (“free clinic”) with 31 responses, and frequency (“I would see the primary care doctor more”) with 3 responses. Mentions of the desire for telehealth (“I would do appointments over the phone,” “televisit,” “remotely”) were also included in this category with 14 responses.
“Current Source of Care” was defined by respondents mentioning they would continue with their current source of care, which was the fourth most frequent response category, at 103 responses (8.5% frequency). This included responses such as “[Healthcare entity name] by my home, they have all my history;” and also included responses such as “cost is generally not a factor;” “I already go to my first choice;” “I have no limits now.”
The category “Quality Care” was defined by respondents mentioning a desire for improved quality of care, which included comments expressing dissatisfaction with their current care or need for better source of care (“I would find a better doctor”) with 10 responses, and comments mentioning reputation, private practice, or experience (“top medical doctors in the world” “private practices with great doctors” “Oldest doctor still practicing”) with 70 responses. Total number of responses in “Quality Care” was 99 (8.2%).
Mentions of concierge medicine (eg, “A concierge service with a doctor I can call anytime if I needed to”) were included in the counts of both the “Access to Care” and “Quality Care” categories.
The category “Specialist” with 97 responses (8.0%) was defined by respondents mentioning a specialist or specialty as their first choice. Some examples include: “I will go to whichever doctor I feel I need to see, that is, dermatologist or cardiologist”; “Directly to a specialist to save time/steps”; “I would have All the dental work I need done.” We also included specialties that may be considered primary care to some, such as OB/GYN, nutrition, weight management, oncology, if the response did not explicitly mention “primary” care. We also excluded mentions of alternative medicine modalities (such as naturopathic medicine, Eastern medicine, spiritual medicine) and coded that separately under “Alternative Medicine.”
“No Change – Primary Care” was defined by respondents who specifically mention preferring to continue with an already established primary care clinician; these responses were excluded from both “Primary Care” and “Current Source of Care” categories. “No Change – Primary Care” had a frequency of 7.8% (95 responses). Examples include “I still would go to my primary doctor;” “I will stick with my primary doctor because he gives top care;” and “No change. Would go to family doctor.”
The category “Relationship” was defined by respondents who expressed a desire or prioritization of the relationship with the clinician, which had 53 responses (4.4%). Mentions of trust, respect, compassion, previous history, and experience were included in this category. Some examples include “I would want to go to a private kind doctor who I’d known for years who I respected and trusted…,” “Until someone finally listened,” “I would continue to go to my primary physician because it is hard to find someone you can feel safe with,” and “my spouse.” Some of these responses had overlaps with categories such as “Primary Care” and “Current Source of Care.”
The category “Urgent Care” with 40 responses (3.3%) was defined by respondents mentioning an urgent care or walk-in clinic as their first choice.
“Procedure, Treatment, Etc.” with 21 responses (1.7%) was defined by respondents seeking additional or specific procedures or treatments (labs, screening, rehab, etc.) Examples include “bariatric surgery,” “Full body scan,” “I would go get more checkups with the OB/GYN and mammograms,” and “I would want to see a cardiologist every 60 days to monitor my blood pressure pattern and cholesterol level.”
Definitions for categories which received less than 20 responses are included in the Appendix.
There were a notable number of responses (5.5%, 66 responses) that were too vague and/or brief to be analyzed properly, and these were put in their own category “Too Vague to Categorize.” Examples include one-word responses of “doctor,” “clinic,” or other unelaborated responses such as “I would pick medical” or “regular doctor.”
Discussion
Findings from this study shed light on the preferences of individuals regarding their primary choice for managing their health concerns when unbounded by factors they may normally have to consider such as insurance coverage or financial constraints. As a broad frame for interpreting these findings, the well-known study of the Ecology of Medical Care found that 25% of patients who experience symptoms seek care at a physician’s office, with 14% going specifically to a PCP office.17
In contrast, this survey has shown that over 41% would go to a primary care physician if they were able to go without limitations. When combining this survey’s responses of those who mentioned primary care as a first choice and those who would like to stay with their current primary care clinician, primary care as a first choice increases to almost 50% of respondents. Only 1.3% of the responses mentioned that they would simply take care of their health themselves even without limitations. This seems to point to a discrepancy between patient’s desires for their health, and their health care seeking behavior due to potential barriers in access since the data suggest that only around 40% of patients who experience symptoms seek any type of medical care.17
This study finding advances on prior research by assessing patients’ unconstrained desires for care. For example, patients may be using certain services (ie, emergency departments) over others (ie, primary care office) simply because it is more accessible, but not necessarily because that is their top choice in health care. Only analyzing behavioral data may mistakenly lead to the conclusion that patients prefer emergency departments over primary care. The existence of these constraints may also limit the ability to think of better possibilities and advocate for health care that suitably addresses all a patient’s health needs. Unlike a patient survey with constraints of discrete options to choose from, both the question posed and the free response format of our survey allowed respondents to answer with as little or as much as they would like, which allows room for more creative and deeper responses, but also vague, difficult-to-interpret responses as well. Future research could attempt to address the distinction between desires and behavioral outcomes in health care more deeply than the short-form responses provided in this study.
The desire for primary care is further supported by categories of relationship, alternative medicine, holistic medicine, wellness, and preventive medicine that were brought up by participants throughout the survey. When Nápoles-Springer et al. asked participants from 3 different ethnic groups what cultural factors influencing the quality of medical encounters, the highest percentage of participants reported “sensitivity to complementary/alternative medicine (17%)”, while others reported “physicians’ acceptance of the role of spirituality and of family.”18 When considering that their study specifically asked for cultural factors in medicine while our question was broadly asking for first choice in medical care, it is notable that our survey still elicited alternative medicine in 16% of our respondents.
The desire for convenience in access could potentially explain patients’ desire to have access to a hospital or health system (with many stating ED specifically) as their first choice. At an emergency department, a patient can often get a variety of diagnostic testing within the same day and rule out feared emergencies. Hospital systems provide the convenience of an integrated portal system and potential for easier referrals. While we did not include mentions of a hospital or health system within our Primary Care category if the response did not explicitly mention primary care, it could be argued that some respondents may have meant having preference of primary care from these systems, along with the convenience of an integrated referral system, so primary care cannot be confidently excluded in the mention of this specified desire.
While primary care was the most frequently mentioned in the responses, 99 respondents pointed to specialty services and 21 pointed to additional procedures. Specialty services are still very highly desired, especially when the patient knows what type of specialty they require for their health; however, this also points to a potential access issue: patients may not be getting the coordinated care they need, or the coverage for their specific individualized needs, especially in a timely manner.
One limitation with analysis of this type of survey data are the brevity of some responses that do not give enough information to differentiate the respondent’s first choice within the health care infrastructure. One potential interpretation of some of these vague responses could be that the respondents simply want accessible health care, regardless of financial status. But even this is difficult to ascertain with the responses’ brevity, and thus these responses were put into their own category of “Too Vague to Categorize.”
One such reoccurring response that mentioned “regular doctor” or “my regular doctor” (14 responses, 1.2%). Depending on context, this could mean a doctor that a generic patient sees on a regular basis, which is often a primary care physician, but understandably could also be a specialist the particular respondent sees regularly for a special need. It could also be referring to a doctor who is able to take care of “regular” or broad-based needs that PCPs would normally take care of, or the respondent is referring to a desire for consistent follow ups. These different interpretations could put these responses into categories such as Primary Care, Access to Care, Current Source of Care, Relationship, or depending on the specific respondent, Specialist. Due to this ambiguity, we placed these responses in the “Too Vague to Categorize” category.
An interesting recurring response included some version of “I am not sure,” “I haven’t thought about that,” “I do not know, I haven’t been in this situation,” and “I do not know, never enough energy to dwell on what will never happen.” There were also other responses that did not address the part of the question that states “if there were no limits,” including ones that comment on health insurance (ex. “the insurance coverage from Medicare and VA Tricare will cover all bills if not enough then I get a bill”). These, along with the recurrent “I do not know” responses, may indicate a difficulty in thinking of what ideal health care could look like given that constraints within our health care system are prevalent and frequently encountered, but there are not enough data to conclude this.
As mentioned in Methods, we primed the survey with a definition of primary care: “1) a place and/or team that recognizes what is important to you, 2) makes sense of your health concerns in ways meaningful to you, and 3) is available to you when you need it in the ways you need it.” This prefacing, as well as in only allowing respondents who had recent experience with primary care to answer the open-ended question analyzed (63.8% of the total respondents to the rest of the survey), is another potential limitation. We also did not provide definitions of other type of care to the respondents. In future studies with similar surveys, it would be important to understand patients’ reasons for not having recent primary care experience, and whether or not their reasoning influences their response to the type of health care they would choose without facing limitations.
Some other limitations are related to the style of the study: open forum surveys like this that carry risks to external validity. Though the response sample was modeled to reflect basic demographic categories proportional to how they seem in the US census, they still may not necessarily be representative of the US. However, considering that participants filled this survey out during the COVID-19 pandemic, the findings in this study provide valuable data from a unique time period where many were faced with issues to access to health care and were subsequently compelled to contemplate more deeply on their health care needs and desires.
The Affordable Care Act has increased access to care for patients using community health centers, and for some, have reduced barriers to insurance. However studies have still shown that patients with high deductibles may delay seeking health care until their condition worsens, leading to more severe health outcomes.7,8 Patients from low-income backgrounds may delay seeking health care services due to financial constraints, lack of health insurance, and transportation problems.19 Therefore, to meet patients’ desires for health care, primary care needs to be more accessible. Alternative payment structures and delivery methods such as value-based care, home-based treatments, and direct primary care address issues in quality and access of primary care for patients. Emphases on preventive medicine and relationship building in these systems could also make primary care a more enticing option for future clinicians by providing a fulfilling and more financially sustainable career than the current fee-for-service spaces.
In conclusion, this study provides valuable insights into patients’ preferences regarding health care utilization, emphasizing the importance of primary care, continuity of care, access, and quality. By understanding these preferences, health care stakeholders can develop targeted strategies to improve health care delivery, enhance patient experiences, and ultimately promote better health outcomes. The predominant preference for primary care justifies efforts to increase its availability to all Americans.
Acknowledgments
The authors are grateful to the survey respondents and our funders. We appreciate initial literature review help from Raghavee Neupane.
Appendix
Codebook Definitions and Examples for Categories with Less than 20 Responses
“Self-care” was defined by respondents mentioning they would choose to take care of their own health without seeking a clinician, which included responses such as “do it myself if possible,” “Google.com,” “CVS and buy a Nyquil.”. These encompassed 16 of the responses (1.3%).
“Alternative Medicine” was defined by respondents mentioning a desire for alternative medicine, with inclusions such as “Eastern medicine,” “natural homeopathic doctor several hours away,” “spiritual advisor,” and “Ayurvedic healer.” This category had 16 responses (1.3%)
The category “Mental Health/Behavioral Health” was defined by respondents mentioning they would seek care for mental health, behavioral health, or substance abuse. This category had 15 responses (1.2%), which include “I would find the best psychiatrist in town,” “therapist,” “psychologist,” “If I could afford to, I would check into an inpatient care facility to help with my mental health, but it costs too much.”
Closely related to alternative medicine, “Holistic, Wellness and Preventive Medicine” was defined by responses mentioning a scope of care with holistic, wellness, preventive, or comprehensive care components. This category had 14 responses (1.2%). Examples from this category include “a whole-body doctor,” “Holistic health care that address my entire person with a focus on wellness, longevity and disease prevention – diet/nutrition/exercise/stress management/physical therapy,” and “I still need to keep myself healthy. Part of what I like with my health provider is their Wellness program.”
Mentions of either “integrative medicine” or “functional medicine,” due to the nature of both of those modalities, were coded for both “Alternative Medicine” and “Holistic, Wellness and Preventive Medicine” categories.
“Pharmacy” was defined by responses that only mentioned pharmacy or medications as their first choice, which had 4 responses (0.4%). Examples include “CVS pharmacy,” “I would have the medications,” and “…check with pharmacist…”
Notes
This article was externally peer reviewed.
Funding: The data collected and analyzed for this study were funded by a grant by Agency for Healthcare Research and Quality (1R01HS028253-1), the Corey and Andrew Morris-Singer Foundation, and the Samueli Foundation. Drs. Etz and Stange are supported by Distinguished Scholar Fellowships from the American Board of Family Medicine Foundation and by a grant from the University Suburban Health Center Foundation for the Wisdom of Practice Initiative.
Conflict of interest: We have no conflict of interests to disclose.
Acknowledgments: The authors are grateful to the survey respondents and our funders. We appreciate initial literature review help from Raghavee Neupane.
- Received for publication November 3, 2024.
- Revision received March 24, 2025.
- Accepted for publication April 7, 2025.
