Are Patients Customers?

Our guest blogger this week is Andrew S. Gallan, PhD who is an Assistant Professor, Department of Marketing, Driehaus College of Business, DePaul University, Chicago, IL, and faculty research fellow at the Center for Services Leadership at Arizona State University.

A particularly heated discussion recently among health care practitioners and leaders has been over the question of whether or not patients should be considered customers. The very notion that clinicians should acquiesce to the demand of consumerists that patients be treated as customers is against their training, intuitions, and preferences. Why has this trend emerged? And how can patients’ roles be better understood in an attempt to reconcile the various sides of this discussion?

First, risk-shifting has been occurring for years, and has heaped loads of decisions, financial costs, and levels of involvement onto providers and patients (for more, see: http://healthaffairs.org/blog/2011/08/24/risk-shifting-in-health-care-and-its-implications-part-one/). Because of reform ideas and movements, government payers have decided to hold providers and patients accountable for recognizing and controlling costs. Additionally, health care organizations have begun to appreciate the business case for focusing on patient experience. For these reasons and others, patients are now squeezed into roles that many are simply unprepared to handle. Patients are now asking more questions about costs, increasingly demanding timely answers, and feeling more empowered. Unfortunately, the availability of data that may assist patients in making informed choices is way behind the decisions that patients face.

Nonetheless, for various reasons, patients are now interacting with physicians and other health care providers in very different ways. As a result, there exists a very different environment in the examination room. This trend also has seemingly provided permission for business perspectives to be introduced more explicitly into health care. As a result, some advocate for an overt change of title for those being cared for from “patient” to “customer” (for more, see http://www.bloomberg.com/news/2013-01-03/to-fix-health-care-turn-patients-into-customers.html). Others strongly disagree, advocating for the specialized knowledge that only a highly-trained provider possesses (see http://www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=0). My take is that there is more complexity to the situation than can be captured by two simple alternatives and that people take on many roles when they engage in a health care system. (I also don’t use the term “consumer” because patients don’t consume, or use up, anything. They co-create value in the form of improved health by engaging in the system).

One potentially enlightening framework may be found in thinking about the various roles that patients may play when they engage in health care: User, Buyer, and Payer (see Michel, Brown, & Gallan (2008). “An Expanded and Strategic View of Discontinuous Innovations: Deploying a Service-Dominant Logic.” Journal of the Academy of Marketing Science, 36(1): 54-66). A patient enacts all three roles when she alone decides which physician to see, pays entirely out of pocket, and engages in the health care experience. This may be seen, for instance, when a person shops for, buys, and obtains cosmetic surgery.

However, most of health care divides the three roles among various actors in a service network. Most likely, an insurance company (or the government) has a significant effect on which provider a patient might see, or even the system that is most cost-effective based on coverage. In this case, a third-party is the payer, and has some influence on buying. Additionally, a primary-care physician may refer a patient for specialized care, and alone decides the best provider for a particular patient. In this case, the physician is the buyer. But, ultimately, the user is the patient, and has to manage his care despite, or as a result, of all the decisions made on his behalf.

But we all know that health care is more complex than that simple example. Increasingly, insurance companies (and even the government) are not paying for everything, which shifts risk to patients. Thus, the patient is thrust into the payer role, and has good reason to behave in ways that may appear to be an (overly) empowered consumer. Moreover, patients demand that they see specific providers (a primary provider that they’ve seen for years), forcing them to find ways to “work the system” to cover as much out-of-pocket costs as possible. And, physicians are strongly considering things like communication skills and “bedside manner” when considering referrals to specialists, an indication of the channel power of the patient.

The point is that a patient who progresses through a series of health care encounters for a specific condition finds himself engaging in various roles at various times – such as when he sets an appointment, checks-in, is present for the consultation, etc. The parking lot attendant and billing clerk most likely think of him as a customer. The nurse, physician, and most other clinical personnel think of him as a patient. And when he is in front of each of these people, he is acting most like the title they assign him.

So, after all, I don’t think it really matters what we call “patients.” Let’s let each member of the service network decide for him- or herself. But let’s recognize that patients are multidimensional people – the very people we created a health system to serve. And the complexity of that system is placing increasing demands on people to perform well in all their various roles. The most important thing is that we do our best to support patients in all of their roles as they do their best to navigate a relatively unfamiliar and multifaceted system.

I welcome your comments and insights.



Categories: Patient reported experience, Uncategorized

Tags: , , ,

7 replies

  1. I think people are becoming savy to getting the best medical
    treatment that meets their needs. Education is the key.

  2. As a heart patient and a women’s health activist (but also as a person who spent over three decades in the public relations field), I’ve given this topic a lot of thought.

    A few months ago, I wrote “Why The Harvard Business Review Was Wrong About Patients” – http://myheartsisters.org/2013/01/27/why-the-harvard-business-review-is-wrong-about-patients/ – in which I quoted Dr. Atul Gawande’s New Yorker piece. He summarized why patients must in fact revisit their willingness to put up with what we would NOT tolerate if we thought of ourselves as health care consumers (a word I have no problem using, by the way, since the “product” I’m consuming is indeed health care). Dr. Gawande explained why:

    “Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.”

    If health care was working fine, we wouldn’t eve be having this discussion about what to call PATIENTS. But it’s not. Some pretty compelling examples:

    – medical errors perpetrated on PATIENTS (the Institute of Medicine, for example, tells us that as many as 98,000 Americans die each year as a direct result of medical errors – the approximate equivalent of a very large airplane crashing every day and killing every person onboard)

    – the growing incidence of hospital-acquired infections in PATIENTS

    – the pervasive influence of the pharmaceutical industry on what’s now called “marketing-based medicine“ for PATIENTS

    – stent-happy cardiologists who are implanting unnecessary coronary stents while fraudulently altering the medical records of PATIENTS

    – the meek expectation that there’s nothing we can do about intolerable health care wait times or downright rude behaviour because we’re just PATIENTS

    Take all these (and more) into consideration, and you have on your hands a crisis in consumer protection.

  3. Patients have certainly moved into more of a consumer mode. They have so many ways to interact with each other and contrast and compare the “products”. Even though, they are subject to “third party” payers, they are engaged in high level decision making for themselves. They are in many cases the “experts” on their own bodies and treatments.
    It is wonderful this is finally being recognized. It is exciting to see how it plays out. Thanks for the topic!

    • I feel it is insulting to refer to me as a “customer” instead of a patient. During the times I have spent in a hospital, I felt vulnerable, scared, and at the mercy of the professional staff….not at all like a “customer”. I am also scared to death of the costs surrounding my hospital and doctor visits because I have no control over how much I will be left to pay after copays, deductibles, cost shares, etc. How this makes me more like a “customer” instead of a “patient” is beyond my scope of understanding. FYI..I worked as an administrator in a hospital for over 20 years and not once did I consider patients to be customers. Anyone who thinks this is acceptable to refer to patients as a “customer” is not seeing the patients as human beings, but merely a means to provide revenue which is a travesty for the health care system in general.

  4. Barbara – Amen! Thanks so much for your heartfelt remarks. That’s what separates health care from every other service – that we are so vulnerable, in so many ways, and sometimes lose sight of our own humanity in the process. Perhaps my original post could have more explicitly stated my personal beliefs in the power of human dignity, and the role it must play in order to improve health care in the future. However, there is no denying that there are forces afoot that are attempting to “consumerize” health care, and have patients shop around when finding a primary care provider, choosing elective procedures, getting second opinions, etc. An empowered patient, in my view, looks out for his/her well-being and considers cost as part of the equation, depending on a lot of circumstances (personal wealth, coverage, severity of disease, etc.). The overall objective of health care is to provide for a patient’s health and well-being, and that needs to remain the #1 focus and priority of everyone involved. Thanks so much for your passionate perspective!

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