From cost clarity to tech advances, we survey different generations to see where they stand on the changing dynamics of American healthcare.

State of Care

A lot has changed in healthcare over the last few decades.

Doctors can transmit test results from hospital to office in a matter of seconds. Medical records are stored in computers, not within manila file folders stacked on shelves upon shelves. Patients can book, move, or cancel appointments without picking up the phone.

Still, a lot hasn’t changed.

Medical billing is more complicated than ever. Lengthy waits still plague the system. And despite technology’s pervasive advance on many aspects of life, the healthcare industry still struggles to adapt the traditional doctor-patient relationship to a more 21st-century approach.

Healthcare in America stands at a precipice, an inflection point from which doctors, patients, and all other players in the healthcare industry can shape a future that is better for Americans and the American healthcare system.

For this report, Healthline set out to explore how patients interact with medical facilities, information, and providers, as well as discover how these providers have responded and are responding to changing demands. Such issues range from calls for more price transparency to the push for greater health technology integration.

To do this, Healthline interviewed several experts and conducted a new survey of 1,348 people. This is the Healthline State of Care Report 2017.

Key findings from the Healthline report are:

  • 80 percent of respondents rate themselves as “knowledgeable” on the subject of health.
  • Online research plays a large role in healthcare. 44 percent of respondents have Googled a health problem instead of going to a doctor, 83 percent research medications or treatments, and 82 percent research symptoms.
  • Cost and convenience are important factors in health decisions. 65 percent of respondents said their insurance network was the most important factor when selecting a healthcare provider. 42 percent said convenience was important.
  • 38 percent of respondents visited an urgent care center instead of a doctor in the last year. 55 percent said convenience was the driving reason.
  • Technology that facilitates healthcare isn’t widely used today, but growth is expected. Today, 5 percent of respondents have had a live online doctor consultation instead of in person, but 33 percent said they would do this in the future.

Findings are based on a national sample of 1,348 Americans, age 18+, recruited from SurveyMonkey’s Contribute panel. The survey was executed August 13 to August 21, 2017.

The changing dynamics of American healthcare

Healthcare in America is expensive, and it’s getting costlier with each passing year.

In 2015 (the last year records are available), the average American spent $10,345 annually on their healthcare, and as a nation, our healthcare costs climbed to $3.2 trillion. That’s 17.8 percent of the country’s gross domestic product (GDP). In other words, almost a sixth of the money spent in this country goes toward healthcare.

state of care

These numbers speak to one thing: Americans take their health seriously, and they’re engaged in taking care of themselves.

Perhaps that’s no surprise when we consider the age we live in. At no other time in human history have people been able to access the amount of health information that’s available to them today.

Internet searches, streaming videos, celebrity doctors — they all seek to bring complicated medical lingo and diagnoses into the realm of comprehension. Name a disease, and there’s likely to be myriad Instagram accounts, Facebook groups, and YouTube channels dedicated just to that issue.

This access translates to confidence about health knowledge — something 80 percent of people in the Healthline survey said they feel — and it points to dramatic changes in how patients are seeking interaction with medicine and providers.

According to our survey, millennials (people born between 1982 and 1999) are more likely to use technology and online resources throughout their medical experience. For example, millennials are two times more likely to Google a health problem versus going to a doctor.

Millennials are also three times more likely than baby boomers (born between 1946 and 1964) to ask for advice on a social platform or download a health-related app.

Despite the differences between millennials, boomers, and Gen Xers (people born between 1964 and 1982), the three generations all agree on two important aspects of healthcare that aren’t meeting their needs: cost and convenience.

Demands for a healthcare system that works on “my terms” instead of a doctor’s schedule has been one of the biggest driving forces for change in recent decades. For example, it brought about the rise of on-demand healthcare options like urgent care and health technology.

“Based on the 2016 Urgent Care Association of America (UCAOA) Benchmarking Survey, we’ve seen a 10 percent increase in the total number of urgent care centers nationally since 2015, up to 7,346 centers,” said Pamela Sullivan, MD, MBA, president of the UCAOA.

In fact, 41 percent of people questioned for the Healthline survey said they had been to an urgent care facility in the last year.

“Urgent care centers are designed with busy schedules and tight budgets in mind, making sure nonemergency health concerns are taken care of,” said Sullivan.

The growing appetite for more, newer, and better technology interfaces, from all generations of Americans, also provides an opportunity for companies to shift their mode of care and how they interact with their customers.

Better yet, it’s an opportunity for companies and healthcare offices of all sizes, like urgent care facilities, to listen to their patients — from the aging boomers and the youthful millennials to the Gen Xers in between — and develop options that speak to their biggest demands.

How the generations differ in healthcare relationships

Americans might spend a lot of money on healthcare each year, and the high number might suggest they run to an office with each sniffle or sneeze. Indeed, 84 percent of people surveyed said they had been to a doctor in the last year. Still, the Healthline survey found a lot of people hesitate to make an appointment in the first place.

Thirty-four percent of millennials, 40 percent of Gen Xers, and 57 percent of baby boomers said they sought medical attention when they had symptoms, but one-fourth of people in the survey said they are as likely to ignore or minimize symptoms.

One unique generational dynamic has made getting some younger people into the door a bit harder than people a generation or two older.

That dynamic? Millennials don’t emphasize the doctor-patient relationship the same way their parents or grandparents might. Instead, they prefer their own knowledge, or at least what they can find on the internet.

“Baby boomers generally rely more heavily on the advice and leadership of their doctors. They respect the patient-doctor relationship and will generally follow their advice while millennials will question and challenge,” said Grant Geiger, CEO of EIR Healthcare, a healthcare technology and innovation group.

“This has created a new opportunity in the market. The millennial generation does not believe in a ‘single source.’ That goes for not just healthcare but car shopping, clothes, TVs, and even vacations.”

Geiger sees these generational shifts as room for improvement and growth. Millennials are seeking out more information and clarity when it comes to their health and their care. Doctors can fulfill that by providing their expertise with a side of empowerment.

When a diagnosis is handed down, doctors can offer supplementary information for further research. The Healthline survey results show people are looking and researching. The two younger generations often use Google or the internet as a first-step stop when symptoms arise. Doctors can help make sure the information they find is reputable, honest, and trustworthy.

“Ultimately, this will only improve healthcare outcomes as both patients and clinicians will ultimately have better dialogue, and in the interim, this newest generation participating in our healthcare system has found a way to improve it and push it further,” Geiger said.

healthcare across generations

The new health paradigm: Convenience and cost are imperative

The traditional doctors’ office experience has an infamous reputation. Whether it’s mostly anecdotal or truly the vast majority of experiences, the sit-and-wait ordeal of the modern-day doctors’ office visit has driven many people of all generations to demand something different.

“The workflow in medicine isn’t geared toward the patient experience. Whereas in other industries, if you’re talking hospitality, if you’re talking the restaurant industry, if you’re talking shopping, it’s all about what’s best for the consumer. We want them to have a good experience,” said Shoshana Ungerleider, MD, an internist in San Francisco.

“Medicine is set up for billing and for doctors and nurses. Honestly, doctors don’t even think twice about making their patients wait 45 minutes, which I think is atrocious. I think we’re finally at a place where consumers are kind of pushing this forward and saying, ‘Listen, that’s not acceptable for me to sit in your office and wait. I have many other important things to be doing.’ I actually agree with the patients on this.”

For many people, that broken experience has driven them to visit urgent care facilities. In the Healthline survey, 4 in 10 people used an urgent care facility in the last year because they didn’t want to wait for an appointment, or they said they’d be too inconvenienced by a long wait time.

“Most urgent care centers provide a wait time of 30 minutes or less to see a provider and 60 minutes or less for an entire patient visit,” Sullivan said. “Ninety-six percent of urgent care centers are even open seven days per week and at least four hours per day, according to the UCAOA 2015 and 2016 Benchmarking Surveys.”

And people of all generations have responded — especially the younger sets.

In the Healthline survey, millennials and Gen Xers were more likely to use urgent care (42 percent and 43 percent, respectively) than baby boomers. Only 30 percent of this older generation said they’ve used these on-demand healthcare facilities.

“In a UCAOA consumer survey we conducted in 2016, we found that millennials most highly prioritize convenience and cost-savings when seeking healthcare options,” Sullivan said. “So we definitely think that younger patients are more likely to use urgent care.”

For David Cutler, MD, a family medicine physician at Providence Saint John’s Health Center in Santa Monica, California, the growth of urgent care facilities makes sense considering the harried pace of many peoples’ lives — but those visits may eventually come at a cost.

“Urgent care can almost always be used, but it’s often not optimal,” Cutler said “One thing it does is it interrupts the continuity of care with the primary care physician. That’s the physician that knows that patient best and can perhaps diagnose more efficiently a complex medical problem. We’re probably no better at diagnosing the cold or the bladder infection or the limited illness that’s going to get better in a few days regardless, but if they have chest pain or abdominal pain with a lot of diagnostic considerations, then you’re probably better off seeing your primary care doctor.”

The results, however, are mixed when it comes to the experiences at these urgent care offices. The trade-off between a doctor who has a more established relationship with their patient and a doctor who can treat quickly creates a gap in satisfaction that was evident in our survey.

For example, only 59 percent of people in the survey rated their urgent care experience “good.” Millennials offered the lowest praise, with 55 percent of that age group in the survey saying their experience was good. Of the other two groups, 57 percent of Gen Xers and 63 percent of baby boomers gave the fast medical offices a thumbs-up.

“I think urgent care, when it’s used for what it’s actually there for, in like an urgent situation or after hours, that’s a great time to use urgent care,” Ungerleider said.

“I think that using urgent care for primary care is a really bad idea. The whole point of having a primary care doctor is so that the person knows you. You build a relationship over time, and that doesn’t happen when you walk into an urgent care clinic. You’re going to see whatever random provider is on call. They’ll do their best to take care of you, but I think there’s value in sticking with one doctor and one doctor’s office that really knows you over time. Mistakes can happen, and things can get overlooked when you go to urgent care for regular primary care.”

Calls for cost clarity grow louder

What makes most doctor visits even more frustrating is the lack of transparency when it comes to pricing, survey participants told Healthline.

At a restaurant, the customer selects an entrée from a wide variety of options, the prices of which are clearly displayed on the menu. When the bill arrives, there should be no surprises.

The same can’t be said for healthcare. Often, the total of the visit isn’t known until the appointment is finished, or sometimes even later.

That means patients are put in a situation where they have to make choices based on their expected costs, not their expected outcomes. For example, 65 percent of people in the survey said the most important factor when they select a healthcare provider is that the person or facility is in their insurance network.

Out-of-network providers cost more money, so while reputation or a recommendation might be tempting, the expected costs — and the share an insurance company has in paying them — is the single greatest determining factor for the majority of people in our survey.

Just behind insurance networks on the list of important factors for picking a healthcare provider are reputation (55 percent) and convenience (42 percent).

One-third of people in the survey said they’ve canceled or postponed seeing a doctor because of expected costs. Seeing urgent care practices as a cheaper option, 29 percent said they have used one of these offices in the last year specifically because they expected the cost to be lower.

“Interestingly in healthcare, there’s very little price transparency. That’s a big frustration for me as a provider, for our front desk staff, for patients, in that we don’t always know. We can’t always give an estimate,” Ungerleider said.

Game-changer: Access to online health research has greatly empowered and educated consumers — with some perils

America, Dr. Google will see you now.

The majority (82 percent) of people in Healthline’s survey said they typically research a symptom before seeking out a healthcare professional.

Indeed, the survey reveals most health decisions are fueled by research at an increasing rate — from the first sign of symptoms, to deciding to fill a prescription, to checking the reputation of a doctor or hospital before booking an appointment or procedure.

Almost 7 in 10 survey participants (69 percent) said they research a doctor’s reputation before making an appointment. After the appointment, 83 percent said they use the internet to research a medication or treatment their doctor prescribed.

“In the past 20 years, we’ve seen fairly dramatic shifts in how people find healthcare information and make healthcare decisions,” said Arun Mohan, MD, MBA, practicing internist in the Atlanta area, CEO of Radix Health, and medical advisor for CareDash.com.

“My oldest patients tend to place a lot of faith in what doctors recommend. Younger generations, on the other hand, have spent much of their lives in a world that is awash with information. As a result, there’s a natural skepticism toward authority and the desire to ‘trust but verify.’”

The problem with using the internet for medical research and diagnosis, Cutler said, is that a computer algorithm can’t distinguish between the likelihood of certain diagnoses. For example, search results for a headache could turn up a sinus headache, a migraine headache, a ruptured aneurysm in the brain, or even a brain tumor. The likelihood of each of these decreases decidedly as one sorts through the signs and symptoms, but a computer search can’t always tell.

“When it’s simple enough that you can make a computer algorithm out of it, it might work,” said Cutler. “But when it’s complex and there are so many choices, you need a human brain to sort through those choices.”

“If anything, Gen Xers are more comfortable going online for health information because they have to be. Not only do they have a greater number of chronic health conditions, but they care for older relatives and make healthcare decisions much more routinely than younger generations,” Mohan said.

Technology in the delivery of care is not ready for primetime yet — but gaining momentum

If the hassle of going to a doctor’s office is too much of a burden — or if the doctor is hundreds of miles away and patients don’t have a way to get there — technology can bring the doctor to them electronically.

At least, that’s the working structure of the Department of Telehealth at the University of Alabama at Birmingham. The university’s decision to invest in this area of healthcare technology is a recognition of the shift that is coming in healthcare engagements. Eric Wallace, MD, is the director of this recently opened department.

“It increases access to care and has been shown to decrease the utilization of the emergency room for low acuity problems, thus saving the patient and the healthcare system money,” Wallace said.

Wallace, who visits with patients from around Alabama via internet connection, sees the future of this program as a win-win for patients and the healthcare industry as a whole.

Though many of Wallace’s appointments happen to be with older kidney or dialysis patients in rural Alabama (Wallace is also an assistant professor in the Division of Nephrology and director of the UAB Peritoneal Dialysis Program), he knows the future for the program goes beyond the scope in which he operates right now. In fact, Wallace said, the goal for engaging anyone in health technology shouldn’t hinge on age. It should, he said, hinge on getting people into a tech experience that feels right for them, whether that’s talking to someone on the phone, video chat, or in person.

“This model can also be used for behavioral health, and, in many ways, is better than our traditional model. Patients may be more likely to do a visit with a behavioral health provider in the privacy of their home, as opposed to going and waiting in a public waiting room for one of those providers,” he said.

Health technology in action

In our survey, only 5 percent of people reported having had a live doctor consultation via a form of online healthcare technology. Millennials, with 8 percent saying they’ve done this, lead the pack. Only 3 percent of boomers have used technology to meet with their doctor online.

Baby boomers actually beat out both millennials and Gen Xers when it came to using a patient portal to ask a doctor a question. One-third of boomers used this technology, whereas less than one-fourth of the two younger generations had.

While the use of technology today hasn’t been widely adopted, the number of people who said they expect to use health technology in the next few years shows there is growing demand.

One-third said they would use health technology to have a live online doctor appointment or consultation. More than half (53 percent) said they would use a patient portal to ask a doctor a question or get advice from medical staff. Lastly, 6 in 10 (61 percent) said they’d use a patient portal to make a doctor’s appointment.

“If the issue is the flu that you need a Z-Pak for, a telemedicine consult is not only faster, but more cost effective, too,” said Meg Murphy, communications manager for HealthJoy, an employer-based tool that can help engage employees with smarter healthcare decisions that cost less and save time. “People aren’t necessarily used to solving medical issues over the phone or video chat, but the value proposition of talking to a doctor in two minutes and having a prescription delivered an hour later, without ever getting out of bed because you feel crummy with the flu, is hard to deny.”

“The problem with a lot of technology today is that people don’t know what they have access to, because access to these technologies is hidden in enrollment packets, or buried in a carrier web site,” said Murphy. “So even if you have access to these tools, you don’t think about them when you need them, and you default to whatever you’ve always known.”

Technology that circumvents traditional healthcare pathways

With the advent of the smartphone and smartwatch, Americans have increasingly become a tracker nation. That is, we’re strapped with phones and wearable technology that can count and track our every step or minute of sitting.

For many people, this information never leaves their phone. It’s a thing of natural curiosity, but doctors lag behind in adapting these health monitors into their overall care plan.

One group that hasn’t lagged behind in the spacious potential between technology and health is app developers. The booming growth of apps like HealthTap, HealthJoy, and Woebot allow people to get a “diagnosis” or “treatment” for just a few dollars or no dollars at all. These apps are designed to provide the user a level of treatment that might not match that of an in-office appointment but suffices to the extent they need it.

Greater understanding of these apps, as well as further adaptation of them into the healthcare setting, may provide doctors, patients, and healthcare staff another venue for communicating in a 21st-century mode.

The use of social media to source healthcare

Almost half of people in the recent Healthline survey (44 percent) said they used Google to research a symptom. Almost 7 in 10 (69 percent) said they searched the internet for a doctor’s reputation or reviews before making an appointment.

With numbers that high, it’s surprising that very few people actually reported they use social media to post about or ask questions for their healthcare needs. It seems for three generations of people who typically openly share on social media like Facebook and Instagram, healthcare is just too personal.

Fewer than 1 in 5 millennials, Gen Xers, and baby boomers reported in our survey that they have used social media to share or post about a good experience with a doctor. Another 9 percent of people said they have used social media to post about a health condition affecting a family member or themselves.

But that doesn’t mean Americans aren’t open to input from friends and family. Indeed, Americans rank reputation as their second most important factor when picking a doctor (55 percent), just behind insurance coverage.

“I think millennials rely on reviews and word of mouth to choose where they’re going to get their care,” Ungerleider said. “I do this myself. They look online for some sort of reviews like Yelp reviews or a review platform to make sure the healthcare provider they’re seeing or the hospital they’re using is well rated.”

Planning for the future: Majority of Americans have future care needs in mind but others need to consider

No one plans for the health emergency they have. A cold seems to come at the busiest time at work. A broken leg complicates everything. A heart attack fits into no schedule. But one thing people can do now to prepare for the healthcare possibilities of the future is plan.

Most people in Healthline’s survey (67 percent) have a designated hospital in mind for their medical needs, but millennials are the least likely to have their hospital picked.

Almost half (46 percent) of millennials don’t have a hospital designated for medical treatment or future procedures. Of those 46 percent, more than half (52 percent) said they have never thought about which hospital they prefer.

People who don’t have a hospital selected cite several reasons why. They don’t believe they need a hospital because they’re healthy (21 percent), or they don’t know which hospital has the best reputation (15 percent).

People in the survey said the primary factor in picking a hospital is insurance network coverage. More than 60 percent of people surveyed ranked their insurance company’s network above other important factors like reputation, convenience, and cost.

These results spotlight the importance of helping patients prepare for future healthcare events that require a hospital’s services. The needs may be simple, like an X-ray for a fractured finger, Or the needs may be complicated, such as an MRI scan after feeling dizzy for several weeks. The decision should be made based on what is needed most, not on other stressors.

What’s missing in healthcare today: How providers can shape behaviors for the future

Americans have a healthy appetite for health guidance.

Indeed, 58 percent of people in the survey said they would like a guide to health tests and screenings by life stage. Addressing preventative needs can help people live longer, healthier lives and ultimately keep their lifetime healthcare costs down. Preventative measures can also help people with early stages of disease keep from getting sicker — and needing costlier care.

“In the era of value-based medicine, I think we are seeing a shift in cost, such that there is a willingness to increase telemedicine visits and coverage because of the promise that it will decrease unnecessary hospitalizations and re-hospitalizations, reduce emergency room visits, and overall improve health before the patient ever needs to utilize higher-cost health interventions,” Wallace said.

Another half of respondents (52 percent) would like patient tips for a specific medical procedure, surgery, or condition. After a new diagnosis or medication, 43 percent said they would like information they can read and comprehend, and 35 percent would like lifestyle tips for recuperating after surgery.

Hospitals can capitalize on these gaps with programs meant to incentivize compliance and cooperation with both pre- and post-surgery, procedure, or appointment guidance. This endears the providers to their patients, and also prevents costly follow-ups or complications.

Millennials and healthcare: What the future holds for the largest generation

Millennials grew up in the age of the internet. They’ve had great access to a wealth of information for their healthcare decisions almost their entire lives, but they were least likely to say they’re knowledgeable on the subject of health. Healthline’s survey showed that 71 percent of millennials ranked themselves high on the health knowledge scale, while 81 percent of Gen Xers and 87 percent of baby boomers did the same.

Millennials are also more likely to avoid healthcare interactions or postpone a doctor’s appointment. Why? Cost. Again, the lack of clarity in healthcare costs prevents this younger generation from seeking the healthcare they might suspect they need.

Millennials also reported they avoid doctor’s appointments for fear of what the diagnosis will be. In the survey, 27 percent of millennials said they are scared the doctor will deliver bad news, and for them, that was reason enough to avoid the doctor entirely. 26 percent of Gen Xers and only 11 percent of boomers avoided appointments because they were concerned about what the doctor might have to say.

Millennials are two times more likely than baby boomers to use Google to search a health problem and three times more likely to use social networks for advice. Our survey found that 59 percent of millennials have used or do use Google to search a health problem instead of going to a doctor. Only 47 percent of Gen Xers and 30 percent of baby boomers have done the same.

“Millennials are much more open to adapting new technologies, thinking holistically about their care, really focusing on the day-to-day of health maintenance, exercise, and wellness, versus just going to the doctor once every year or once every two years,” Ungerleider said. “They’re actually thinking about how technology can best support them to live a healthy life every day, which is wonderful. I think that also blurs into Gen X as well.”

Millennials have lead the charge in revolutionizing much of what we thought of as typical just a decade ago. Startups full of younger CEOs and engineers have turned many parts of accepted life on their end. Traditional transportation models like taxi services are now being scooted out by on-demand car services. Grocery shopping declines as doorstep-delivery companies grow. Dating has left the bar scene and moved to apps.

The same will likely happen for healthcare if care providers, hospitals, doctors, and patients are willing to work together, get over the notorious speedbumps of healthcare transformation, and develop a system that is more convenient and efficient, and has better outcomes.