A particularly heated discussion recently among health care practitioners and leaders has been over the question of whether or not patients should be considered customers. The very notion that clinicians should acquiesce to the demand of consumerists that patients be treated as customers is against their training, intuitions, and preferences. Why has this trend emerged? And how can patients’ roles be better understood in an attempt to reconcile the various sides of this discussion?

First, risk-shifting has been occurring for years, and has heaped loads of decisions, financial costs, and levels of involvement onto providers and patients (for more, see: http://healthaffairs.org/blog/2011/08/24/risk-shifting-in-health-care-and-its-implications-part-one/). Because of reform ideas and movements, government payers have decided to hold providers and patients accountable for recognizing and controlling costs. Additionally, health care organizations have begun to appreciate the business case for focusing on patient experience. For these reasons and others, patients are now squeezed into roles that many are simply unprepared to handle. Patients are now asking more questions about costs, increasingly demanding timely answers, and feeling more empowered. Unfortunately, the availability of data that may assist patients in making informed choices is way behind the decisions that patients face.

Nonetheless, for various reasons, patients are now interacting with physicians and other health care providers in very different ways. As a result, there exists a very different environment in the examination room. This trend also has seemingly provided permission for business perspectives to be introduced more explicitly into health care. As a result, some advocate for an overt change of title for those being cared for from “patient” to “customer” (for more, see http://www.bloomberg.com/news/2013-01-03/to-fix-health-care-turn-patients-into-customers.html). Others strongly disagree, advocating for the specialized knowledge that only a highly-trained provider possesses (see http://www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=0). My take is that there is more complexity to the situation than can be captured by two simple alternatives and that people take on many roles when they engage in a health care system. (I also don’t use the term “consumer” because patients don’t consume, or use up, anything. They co-create value in the form of improved health by engaging in the system).

One potentially enlightening framework may be found in thinking about the various roles that patients may play when they engage in health care: User, Buyer, and Payer (see Michel, Brown, & Gallan (2008). “An Expanded and Strategic View of Discontinuous Innovations: Deploying a Service-Dominant Logic.” Journal of the Academy of Marketing Science, 36(1): 54-66). A patient enacts all three roles when she alone decides which physician to see, pays entirely out of pocket, and engages in the health care experience. This may be seen, for instance, when a person shops for, buys, and obtains cosmetic surgery.

However, most of health care divides the three roles among various actors in a service network. Most likely, an insurance company (or the government) has a significant effect on which provider a patient might see, or even the system that is most cost-effective based on coverage. In this case, a third-party is the payer, and has some influence on buying. Additionally, a primary-care physician may refer a patient for specialized care, and alone decides the best provider for a particular patient. In this case, the physician is the buyer. But, ultimately, the user is the patient, and has to manage his care despite, or as a result, of all the decisions made on his behalf.

But we all know that health care is more complex than that simple example. Increasingly, insurance companies (and even the government) are not paying for everything, which shifts risk to patients. Thus, the patient is thrust into the payer role, and has good reason to behave in ways that may appear to be an (overly) empowered consumer. Moreover, patients demand that they see specific providers (a primary provider that they’ve seen for years), forcing them to find ways to “work the system” to cover as much out-of-pocket costs as possible. And, physicians are strongly considering things like communication skills and “bedside manner” when considering referrals to specialists, an indication of the channel power of the patient.

The point is that a patient who progresses through a series of health care encounters for a specific condition finds himself engaging in various roles at various times – such as when he sets an appointment, checks-in, is present for the consultation, etc. The parking lot attendant and billing clerk most likely think of him as a customer. The nurse, physician, and most other clinical personnel think of him as a patient. And when he is in front of each of these people, he is acting most like the title they assign him.

So, after all, I don’t think it really matters what we call “patients.” Let’s let each member of the service network decide for him- or herself. But let’s recognize that patients are multidimensional people – the very people we created a health system to serve. And the complexity of that system is placing increasing demands on people to perform well in all their various roles. The most important thing is that we do our best to support patients in all of their roles as they do their best to navigate a relatively unfamiliar and multifaceted system.

I welcome your comments and insights.