Original Research

Direct and Indirect Patient Costs of Dermatology Clinic Visits and Their Impact on Access to Care and Provider Preference

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Demographic data for respondents are outlined in Table 1. Of 145 patients who completed the survey, the majority had already seen a dermatologist for their presenting condition (87.4%), and were English speaking (96.5%), white (76.6%), employed (59.4%), and male (50.3%), with a mean age (SD) of 52.3 (18.1) years and education level of 4-year university or higher (64.7%). The most common reasons for dermatology clinic attendance were general skin checks (30.8%) and psoriasis (26.6%). A smaller proportion of patients (16.1%) presented for surgical visits. Other less common conditions that brought patients into the clinic included acne (6.3%), eczema (4.9%), and skin rash (2.8%).

The mean (SD) reported hourly wage of employed patients was $36.60 (15.8). The most common reasons for unemployment were retirement (65.5% [38/58]), disability (10.3% [6/58]), and schooling (10.3% [6/58]).

Time Attributed to Attending Dermatology Clinic Visits
Time costs are reported in Table 2. Patients traveled to the clinic mainly by car (56.5% [78/138]) or train/subway (25.3% [35/138]). One in approximately 5 patients (21.3%) spent more than 1 hour traveling one-way to the clinic. Most patients waited less than 20 minutes to see their care providers. Face-to-face time with providers (ie, residents and attending physicians) ranged from less than 21 minutes to more than 1 hour, with a mean (SD) time of 36.8 (18.9) minutes.

Of the employed respondents, 76.5% (65/85) took off time from work for the appointment. Patients took a mean (SD) of 4.1 (2.4) hours off from work, which was considered sick pay (35%), paid time off (36.6%), or unpaid time (28.3%). The total mean (SD) time dedicated to attending the clinic appointment averaged 144.8 (60.47) minutes. On average, the time spent traveling for the clinic visit was double the amount of time spent with the care provider (77.4 vs 36.8 minutes).

Monetary and Opportunity Costs
The mean (SD) monetary cost associated with clinic attendance for employed patients who reported their wages was $187.50 (103.2)(range, $37.50–$489), most of which was opportunity cost from loss of potential work income (mean [SD], $144.30 [93.6]; range, $27–$432)(Table 3). Similar total and opportunity costs were found for employed patients using the imputed average wage. The mean (SD) total cost per visit for unemployed patients or those who did not report employment status was $38.65 (103.6)(range, $0–$800), which was 4-times less than the cost per visit for employed patients. Mean (SD) and median one-way travel expenses were $16.60 (40.5) and $10, respectively. Mean (SD) and median reported costs for deductibles/co-pays were $44.20 (66.1) and $25, respectively. Only 2 patients reported child care costs, which were valued at $65 and $75.

Patient Provider Preference
The majority (59.3% [67/113]) of patients preferred their current care providers, whereas 33.6% (38/113) preferred providers closer to work, home, or in a different unspecified setting. Only 7.0% (8/113) of patients who answered this survey question would choose teledermatology over their current providers.

On multivariate logistic regression (Table 4), patients who had additional out-of-pocket costs were significantly less likely to prefer their current care provider compared to patients with no out-of-pocket costs (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.10-0.71; P<.05). Opportunity costs were not a significant predictor of provider preference. For every minute the travel time increased, the likelihood of preference for the current care provider decreased by 2% (OR, 0.98; 95% CI, 0.95–0.99), and patients who traveled 60 minutes or more round-trip were 71% less likely to choose current provider care than those who traveled less than 60 minutes (OR, 0.29; 95% CI, 0.09-0.96; P<.05). Patients with higher education (≥4 years of college) were 3.29-times more likely to stay with their current care provider than those with lower education (≤2 years of college). Those presenting for skin checks also preferred the current provider more than those with noninflammatory skin conditions such as alopecia and warts (OR, 9.01; 95% CI, 2.28-35.59). Age and gender were not statistically significant predictors of patient provider preference.

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