'Consumer' Approach Doesn't Work in Healthcare, Some Say

Marcia Frellick

March 11, 2019

With "consumer"-driven models in healthcare that are meant to lower costs and improve quality, it is assumed that patients will make choices the way they do when they purchase a car or reserve a hotel room.

However, several articles in the March issue of Health Affairs suggest patient-centric care and consumer-centric care are different, and the authors argue that conflating the two has given rise to strategies that won't work in an industry that is unlike any other. One author argues that using the two terms interchangeably can harm patients.

Why Healthcare Is Different

Hala Durrah, a patient and family engagement consultant and advocate in the Washington, DC, area, writes in a commentary that several things make healthcare unique. One is the presence of a "middleman" in healthcare — insurers.

Even when patients know the prices of care, it's not clear what insurance will cover, so direct comparisons are difficult, she writes. In addition, she notes, even if a patient knows that care may be cheaper with another provider, healthcare is built on relationships, and that is often valued above any other factor.

Durrah describes a doctor who has cared for her chronically ill daughter, Ayah, now aged 16, all her life. That doctor accompanied Durrah to an appointment with an oncologist when it was discovered that her daughter had cancer.

She writes, "During the meeting she did not utter a word. Instead, she just held my hand and squeezed it every time the oncologists discussed a distressing piece of news."

Durrah told Medscape Medical News, "Consumerism may empower me with tools such as price transparency and the ability to shop around for providers, but I would never trade that relationship with Ayah's provider for a better price or for a provider who may be rated more highly on a website."

Consumers Aren't Embracing Transparency Tools

Studies have shown that even when price comparisons are available, patients don't embrace the tools. For example, as reported previously, a study published last year in the New England Journal of Medicine showed that only 1% to 12% of patients who were offered Web-based or app-based transparency tools used them, and even fewer used them before they received care.

Patients also aren't motivated to shop around because they don't believe the benefits trickle down to them, Durrah said. In the auto industry, for instance, demand for certain models and dutiful research lead to savvy consumers and lower prices.

"We haven't seen that cost savings passed down in healthcare other than the systems or C-suites getting very large bonuses," she said.

She says a better approach is one centered on patient engagement, in which patients are truly partners and are helping make decisions and co-designing systems from their inception.

Consumerism Can Harm Patients

Michael K. Gusmano, PhD, an associate professor of health policy at Rutgers University, in Piscataway Township, New Jersey, and colleagues write in the same Health Affairs issue that focusing on consumerism can potentially harm patients and damage the physician-patient relationship.

"Patient-centered approaches aim to ensure clinical care that can meet patients' preferences and needs," the authors write. "That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society's cost-containment challenges."

Gusmano, who is also a research scholar at the Hastings Center in Garrison, New York, told Medscape Medical News that consumerism may work with respect to minor problems. Patients can appropriately compare prices and choose a provider to treat their routine carpal tunnel syndrome, for instance.

But asking sick, vulnerable people with major health problems to help rein in costs is "shifting the burden that ought to be placed on systems and on institutions onto individual patients, as if individual patients' choices are to blame as to why healthcare costs are so high in the US, which simply isn't the case," he said.

Good customer service should be a part of all care, he said. This includes respecting patients' time, communicating with them clearly, and asking them about their life goals and what they want from treatment.

But patient demands should not override physicians' experience and knowledge — for instance, a patient's demanding antibiotics for upper respiratory infections. In such situations, "the-customer-is-always-right" consumerism "is potentially unethical" and can both undermine the physician's professionalism and harm the patient, he said.

"I don't expect an oncologist to lay out an array of chemotherapies and suggest that I select among them once they describe the toolkit. I want to hear what he or she thinks," he said.

Physicians Must Recognize the Dual Roles

Sharon L. Levine, MD, a now-retired executive with the Permanente Medical Group in Northern California, told Medscape Medical News that "we are all consumers at some points and patients at other points" in our healthcare.

"In the exam room, at the bedside, none of us are consumers. We're patients," she said.

Consumer behavior is transactional in nature, and such models are not very useful in healthcare other than for choosing an insurance plan, she said.

It's important that the patient's experience not be confused with consumerism, she said. She noted that clinicians have an obligation to manage both parts.

"We have to understand as clinicians that our patients live in the real world, and outside the exam room, we're not there. They have to deal with the implications, including cost implications, of the decisions we make together," she said. "That doesn't mean physicians need to manage that part, but we have to be open to conversations about it."

Durrah, Gusmano, and Levine have disclosed no relevant financial relationships.

Health Aff. 2019;38:369-373, 502-505. Gusmano et al, Abstract; Durrah H, Abstract

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