"Customers" vs. Patients - Economics and Enabling

ER Nursey and WhiteCoat Rants, two of my favorite bloggers, had great posts earlier this month. With Migraine Rants, ER Nursey jumped on the great "users versus abusers" and "are they customers or are they patients" debate, while Dr. WhiteCoat provided a comprehensive view of our enabling culture here.

As both bloggers and medical professionals, a certain amount of weigh-in on the "patient" side is inevitable. However, I can't shake the feeling that our system has moved way past the point where most patients are merely, well, patients.

In allowing patients to choose their level of care and have relatively unrestricted access to services, we are indeed "enabling" (and yes, encouraging) them to become customers.

We are, either directly or indirectly (via HMOs and other coverage) consumers of healthcare, and this puts us solidly in the "customer/client/guest" realm.

However, just because we're now consumers doesn't mean we make "good" consumptive choices. Similar to the subprime lending fiasco and the mortgage crisis fallout currently smacking our economy in the face, this means some customers make "bad" or self-centered choices about how to individually access resources. We're not concerned with saving the system; we're concerned with saving ourselves.

Dr. WhiteCoat has selected a great example in the ambulance services market.

Anyone in this country may dial 911 (please note I don't use "can..." here - I'm not assuming everyone in the country is physically/mentally capable of dialing 911) and be transported to an emergency room for care. The minute these patients come through the front or back doors of your ED, they morph into customers.

The issue isn't really whether or not we consume H/HC but whether or not we are EFFICIENT consumers of healthcare. Having worked in an ED myself, the answer to that question is a booming NO, at least as it pertains to 'emergency' services.

Unless we are in no physical or mental condition to make choices, we select from a variety of treatment options when seeking 'emergency' medical care. Again, this makes the vast majority of us "customers."

How many "customers" come into the ED not for an emergent, life- or limb-threatening condition, but because they can't get in to see their PCP for a week? Because they're out of pain meds? Because they are scared, uninformed, and/or uninsured?

Unfortunately, many patients (and their worried families/friends) treat the ED as a 24 hour doc's office, rather than a place for emergency healthcare.

No doubt about it - at most hospitals the ED is a service line that bleeds cash rather than generates it.

There are, however, service lines that contribute regularly to a hospital's bottom line (with traditional, average profitability a paltry 4-6 percent) - these include Ambulatory (Elective) Surgery and OB/GYN.

The patients who select a hospital based on the perceived strengths of certain departments are certainly customers making conscious purchasing decisions. Shouldn't they be treated as such?

This is a dividing issue I haven't heard much chatter about in the blogosphere, much less the 'mainstream' industry media...I'm concerned about the internal fragmentation between medical staff who view patients as "patients" low on the traditional medical hierarchy and administrators who view patients as "customers" who need to be wooed with well-designed marketing campaigns.

The opposing views are generating plenty of conflict in individual departments. They're certainly contributing to employee churn and burnout, but the debate isn't surfacing at the system/management level where it may have some small hope of resolution (or at least facility-specific improvements).

Why am I so concerned with this dichotomy of perception...there are plenty of other things to worry about the the H/HC market right? Right.

However, the way varying members of the organization view the patients/customer population determines what services are provided. This can make or break a hospital in terms of revenue generated.

And let's face it; money is the bottom line - it keeps the doors open, the lights on, and the staff paid (hopefully) saving lives. Hospitals are businesses, and patients are customers. It's a noble business of course, but a business nonetheless.

We're really talking around the issue though - try to put aside ruthless, self-centered enabling and multiple abuses of hospital resources by frequent flyers, just for a moment.

Let's revisit the issue using economic terms: needs versus wants. Hospitals have two distinct population groups...those who NEED care and those who WANT care. Those who NEED care are patients; those who WANT care are customers.

Will the need-versus-want divide prove too large? Will the hospital/healthcare market eventually fragment according to the acuity of varying conditions?

Dr. WhiteCoat articulates the crux of the issue well...we suffer from a fragementation in access in addition to level of consumptive options - economically disadvantaged "customers" have disproportionate access to healthcare (especially preventative care). As the good doc puts it:

"The health care system in the US is broken for a lot of reasons.
One of the biggest reasons is that the costs of providing healthcare to this nation’s
citizens outpace the resources available to provide those services. Like it or not,
rationing already exists. And unfortunately, that rationing disproportionately
affects the poor."

After speaking with a psych nurse about the customer vs. patient issue, a scary vision of the future popped into mind.

If the schism in industry perceptions deepens and we refuse to reinforce the concept that the majority of our patients are customers, we may end up with an irrevocably divided care environment.

Imagine this environment (a few decades from now): Politikos have yielded to popular opinion that access to "lifesaving" care be added to the Bill of Rights. They establish federally funded, state administrated facilities similar to the hulking, inefficientVA system. These behemoths are ward-like emergency facilities that provide ONLY emergency care and then discharge patients.

Patients discharged would then morph into total H/HC consumers, selecting a specialized facility based on their own ability to pay, their personal preferences and the type of care needed.

Similar to other consumer markets, there would be great variability in the offerings; think of airlines, auto makers, and hotel chains. Some hospitals would be tailored towards bare-bones consumers, some would act as 'massclusivity' economy lines, and some would be luxury facilities.

We'd revert to a class/caste system of healthcare, where customers are the "haves" and patients are the "have nots..." and how is that so different from the broken system we have now?