Participation in Healthcare Systems: Patients aren’t Customers

My favorite healthcare blog KevinMD posts every so often with an eloquent heartfelt piece on the problem of patients as customers. In This is Why Patients Cannot be Customers Dr. Tanya Feke points out that:

A study in the British Journal of General Practice showed how patient satisfaction surveys can be skewed. More than 980,000 patients were surveyed across 7,800 practices. Doctors who prescribed more antibiotics were perceived more favorably than family doctors who doled out fewer antibiotics. When you consider U.K.’s National Institute for Health and Care Excellence estimates more than 10 million antibiotic prescriptions are inappropriately prescribed every year (antibiotics do not treat colds and other viral infections), there is a serious disconnect.

We continue to borrow from inappropriate language constructs to make arguments about desired outcomes without thinking through the anticipatory ancillary effects. If we propose that patients are persons, as Tanya does, that’s a start. Individuals have unique needs and when we treat them as patients, we are authorized to treat them within the context of an institutional role.  However, patients are not customers, and if we treat them as such, we risk converting healthcare into a neoliberal market system. Customers have vastly different expectations and roles in a systems that recognizes the customer-supplier relationship. Rather than elevating “patient experience” this role transformation risks the destruction of human caring in the organization and the larger social system.

Theories of service define value as co-created in the exchange value of an offer, in the delivery and active acceptance of expected service. However, in health care, the direct service of clinical treatment is only the potential value. The realized value of care is in full relief or the outcome of treatment. If the health service provided is a simple intervention such as a wart removal, value realization may be immediate. If the service is iterative for a complex diagnosis, value realization may be diffused, it may arrive in stages. While people may inherently understand this to be the case, the responsibility of the patient to co-create “realized value” of their health is not typically acknowledged. In Design for Care five contexts of participation are identified:

  • The patient as health seeker, a self-directed agent responsible for his or her own health and well-being
  • The patient as a participant in the healthcare system and subject to the rules and roles this entails
  • The patient as a customer of a service, who seeks and pays for treatment directly
  • The health seeker or patient as a subject of user research for innovation
  • The patient as a person under care, located in a community in a particular society and culture.

If we adopt a view of the health seeker, we start treating persons as active agents in charge of recovering their health, relying on and partnering with the care resources of their providers, in their community, and in digital services.

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