There is broad support for building healthcare systems that
are patient-centred, seen as a means of improving health outcomes and as
morally worthy in itself. But the concept of patient-centred care has
increasingly merged with the concept of patients as consumers, which “is
conceptually confused and potentially harmful,” write Michael K. Gusmano,
a Hastings Center research scholar and an associate professor at Rutgers
University and colleagues in an article in the March 2019 issue
of Health Affairs.
The metaphor of patients as consumers, long used by
advocates of patient-centred care, has recently been co-opted by critics of
government health care regulation and advocates of market solutions to healthcare
According to the authors, patients can be construed as
consumers only if they are operating within a market. But there are several key
differences between healthcare and typical commercial markets. Patients often
lack the information and time to select the best healthcare on the basis of
quality and price. Even if healthcare were to be made more like a conventional
market – for example, by increasing the number of competitive health care
choices – patients still could not act like consumers because they would often
lack the time and knowledge to “shop” for different options.
Some commentators believe that healthcare costs are high
because patients overuse healthcare, and that one way to reduce costs is to
make patients pay more out of pocket. Though requiring patients to pay more for
their care has been shown to reduce overall healthcare spending, this tactic
also reduces patient usage of appropriate or essential medical care. What does
drive up healthcare costs, the authors write, is the common practice of
compensating physicians for each service they provide and the U.S. government’s
failure to sufficiently negotiate prices of hospital, physician, and other
In conventional markets, knowing the price of different
items might help customers make informed choices about what to purchase. While
it is helpful for patients to consider the costs of different treatments as
part of deciding the best course of action with their provider, there is little
evidence that price transparency reduces healthcare spending. Patients may have
little time or insufficient knowledge to shop around for healthcare options
that provide treatments at the best value.
Physicians rely on their knowledge, skill, and obligations
to patients’ well-being to recommend the best course of treatment. But if “the
customer is always right,” physicians might feel compelled to defer to what
patients ask them to do, for example, when patients insist on unproven,
ineffective, or even harmful treatments, such as cardiopulmonary resuscitation
for terminally ill patients. Avoiding or devaluing physician expertise in
healthcare decision-making would erode medical professionalism and could result
in poorer patient outcomes.
The concept of patients as consumers does not bolster
patient-centred care but instead places undue burdens on patients to reduce
healthcare costs and erodes medical professionalism, the authors write.
“Pursuing the sensible goal of creating a patient-centred health system will be
undermined if consumer metaphors prevail,” they conclude.
Gusmano MK, et al. Patient-Centered Care, Yes; Patients As Consumers, No.
Health Affairs. March 2019