Monday, April 25, 2011

Are Patients Consumers? Yes and No

"When I use a word," Humpty Dumpty said in rather a scornful tone, "it means just what I choose it to mean -- neither more nor less." - Lewis Carrol, Alice in Wonderland
This is not a standards related post, but it is a healthcare related one.

Paul Krugman wrote for the New York Times recently wrote about patients not being consumers. His article comments on the Republican backlash against the Independent Payment Advisory Board.  I agree with a good number of his points (I'm pretty much a liberal independent), but the title: "Patients are not Consumers" misses the mark.  Others have written on the same topic.  Jackie Fox wrote on patients not being consumers on KevinMD nearly a year ago, and Dr. JC writes something similar in 2007 on Brain Blogger.

Lets look at a few definitions.
  1. A person who purchases goods and services for personal use. -- Google
  2. Consumer is a broad label for any individuals or households that use goods and services generated within the economy. -- Wikipedia
  3. An individual who buys products or services for personal use and not for manufacture or resale.  -- Investor Words
  4. One that utilizes economic goods -- Merriam Webster
  5. A person or thing that consumes -- Websters New World College Dictionary
And then there is the origin of the term "Consumer", whose earlier sense comes from "squanderer".

All of the definitions pretty much agree on "use" or "consumption", and most agree that it applies to individuals.  Economic definitions seem to distinguish between use and "purchase".

So, am I a consumer of healthcare?  Under my current (high deductable) plan, I do pay for the first few thousand dollars of it to providers of healthcare goods and services.  I  fit into any of the definitions above.  When I was covered under a different plan, I only paid for a small part of my care (at each even).  I'm not really sure I qualified as being a consumer then.  So, I am now, but not everyone is.

Is the Federal Government a consumer of healthcare?  It pays for it.  It receives some benefit from it, although not direct.  By some definitions it could be argued to be one, by others not.  Given that we fund the Federal government, we also are beneficiaries of these services but not really consumers.

Is my employer a consumer of healthcare?  It picks up the tab for a significant chunk after my deductible, although I'm still on the hook for some of it.  They receive some benefit from the expense (a happier, healthier, less distracted employee).  If the government is a consumer, employers are as well.

Is my payer a consumer?  Not in my case, but likely in many others where the payer is providing the "insurance".  My payer isn't spending their own money in any way, but those that take on risk (e.g., my employer) do.  They accept risk on behalf of their "customers".  Payers also negotiate the best deals they can on to benefit their stakeholders (which is not necessarily the same as their consumers).

From a different viewpoint; As a consumer of a TV set, an airline ticket, a car, or a good dinner, I have quite a bit of choice.  There is also a great deal of information that I can use to help me make my decision.  I can pick an airline based on where they go, their schedule, price and services.  I can easily compare one airline to another.  I can check out the quality of a TV or automobile, check prices, determine features, et cetera.  I can also check out the quality of a dealer or distributor, et cetera. I can check the ratings on service, food quality and price on just about any restaurant from numerous sources. As a consumer, I can choose to check out manufacturers and their distributors, or I can just buy what looks good to me.  My dollar, and my choice.

As a patient, I don't really have those choices.  I cannot easily check the quality of a surgeon or other specialist against any readily understandable benchmark (there are ways to do it in my state, but they aren't easy to find out, and the ratings aren't as easy to understand as something I would find in Consumer Reports).  I cannot figure out how much care is going to cost me from provider A or provider B for a specific condition.  Recently I spoke with a healthcare provider about what a visit would cost.  Nobody in the office could even give me a ballpark figure for what a visit would cost me.  I needed to speak to a specialist in billing to get that information.  My doctors don't have a good idea of what the costs of care are.  They cannot tell me the difference in costs between two tests that would give them additional information.  Some can probably tell me the difference in result quality, but even that is arguable given some of the reports of innumeracy.  My payer cannot even help.  They have a website that can tell me costs from certain providers for certain conditions and treatments, but to use it, I need to know both my diagnosis and what services they are going to bill me for.  And I won't know that until after I see them.  So even though I have been given a list of five specialists by my doctor in a recent visit, I cannot readily compare costs.

When I deal with a plumber or roofing contractor, I can talk to them about my options: quality, features and cost being the operative components.  When I deal with my doctor, I cannot easily have the same kinds of conversations, even though I try to do so more often now.  My healthcare dollar is important.  I want to get the best value I can for it overall, not just for a single problem, but for my entire health.
From this perspective, patients are not consumers.  We don't have the information that a consumer would have, and I'd sure like to have that now.  The argument that vouchers will change that doesn't hold water for me.  High deductible plans were supposed to have a similar effect, but they've made it no easier for patients to figure out how to best spend their healthcare dollar.


  1. Keith,
    I think you lay out the argument for and against well. Yes, we're all consumers of healthcare goods and services, but there's not a direct buyer-seller relationship in healthcare. And, as you say in your words in the final 2 paragraphs, as consumers we aren't given sufficient information to make informed choices as we do in typical markets. I wrote something quite similar on the blog:

  2. Other consumer purchases that we have minimal control over include the unit costs of household utilities, energy used in commuting, and postal services. Along with medicine, health care, the costs are determined by factors that are largely insensitive to end-user (consumer) preferences, knowledge, or ability to pay. Instead, they answer to regulatory mandates and bulk-purchase agreements. They are largely monopolistic or oligopolistic, so it is unclear if an efficient information-rich market can influence the consumer economics much.

    I suspect that, at least in the short run, the cost of developing better information for consumers will not result in better population health, improved care outcomes, or availability of health services. But that's not how the results are being measured or rewarded in any case.

  3. I agree with your points.

    I will point out that the reason behind someone wanting to use the word 'consumer' is complex. The term 'consumer' has been brought into Privacy discussions about 4-5 years ago. At that time it had nothing to do with the use of the word 'consumer' that you focused on. It was to differentiate the human that is actively receiving care inside of an healthcare delivery organization - a Patient - from all of the other use-cases where a human might seek advice or information about their own health condition. At the time some were using patient as constrained only to the treatment, and not post-treatment or pre-treatment. So rather than re-define patient to be inclusive, some chose to use 'consumer'. Now that term has taken on a new meaning and thus is not living up to expectations.

  4. Agree, Keith. I think both "using" and "paying for" count. After all, children consume thousands of dollars of food, electricity, and water without paying a penny! It's just that the balance between payers and users is very skewed in HC. I still believe we are all consumers of HC nonetheless.

    Remember AHIC's "Consumer Empowerment" use case in 2006? I think the word consumer was an aspiration rather than a statement of reality. That led to the early incarnations of HITSP IS03 and IS05 and C32 CCD, which supposedly empower consumers by giving them access to their clinical information, which they could then share with other providers ("clipboard replacement"), import into PHRs, and use to make better informed decisions. Today's "blue button" has similar "consumer-empowering" goals. But without the other items you mentioned (transparency in pricing, ability to comparison-shop) HC will be a long way from consumer-centric. Still, despite all these factors that limit us to baby steps, I think baby steps towards greater aspirations are worth taking.