Patient-Centered vs. Consumer-Driven: What Matters for Chiropractors?

In the rapidly-changing world of health care, the terms ‘patient-centered’ and ‘consumer driven’ are frequently used. The roles these refer to have profound implications for all providers. So what makes someone a patient, and someone a consumer? And why does it matter to doctors of chiropractic?

The concept of ‘patient-centered’ health care has been around for a number of years. The term ‘patient-centered medicine’ originated after World War II, and morphed into ‘patient-centered care’ in 1987. Adopted as a goal by the Institute of Medicine with a reframing of the definition, the term as it’s now used has been around since 2001. The term covers at least eight dimensions of a patient’s experience of care:

  • Respect for patient-centered values, preferences and expressed needs
  • Coordination and integration of care
  • Information, communication and education
  • Physical comfort, including pain management
  • Emotional support and the alleviation of fear and anxiety
  • Involvement of family and friends in decision-making
  • Transition and continuity to self-care responsibility
  • Access to care, with attention to the time spent waiting for care

What connects all these elements is the identification of the responsibility for assuring that these dimensions are addressed: the responsibility is on the part of the provider, the host system, and its support. The patient is at the center, but being attended to by the system that is taking care of them. For those who view the patient in terms of the original Latin root¬†pati, “one who suffers,” this organization of resources makes sense. There are many times when patients are in no condition to take care of themselves. It’s nice to be cared for.

Enter the Consumer
The term ‘consumer-driven health care’ comes from the use of the term in health care plan products, which started in the mid- and late-1990’s and allowed use of health savings accounts, health reimbursement accounts or similar direct-payment transactional tools. Coupled frequently with high-deductible plans, these products introduced a buffer for those sponsoring benefits as costs were beginning to skyrocket, asking those consuming the health care services to pay more for these up front, so that they were more directly involved in understanding (and paying for) the actual costs of care.

Although the word ‘consumer’ is in the term ‘consumer-driven health plans’ (CDHPs), they were (and are) really not consumer-driven at all, but consumer-focused in terms of increasing the degree of shared financial responsibility. In CDHPs, the consumer bears clear and overt financial responsibility on the front end of the consumption of services, using pre-tax or employer-contributed dollars to pay for care before ‘insurance’ kicks in.

Observers began to note in the early 2000s that, in fact, one of the (perhaps) unintended consequences these evolving market forces set in motion was that in the transition of greater economic responsibility to consumers, consumers began to actually act as if they had leverage. Entrepreneurs then began to respond to that dawning understanding by developing products and services that explicitly empowered consumers to operate with the same leverage they enjoy in retail markets.

This is no small force. Health care, as has been noted by others and written elsewhere in this blog, has long been characterized by an inversion of the retail supply/demand dynamic. In health care, the supply side has dictated what has been available to the demand side. Because the supply side has had no incentive to innovate and please the demand side (consumers), this has created a controlled (non-functioning) market. One of the consequences of health care reform from CDHPs to the Affordable Care Act has been that the demand side’s interests are slowly being acknowledged and accommodated, forcing the supply side to innovate. To date these innovations are modest, but consumer sensibilities, opinions, values and preferences are increasingly being sought out to inform everything from how websites function to how health care can be purchased. These innovations, and those set to follow, are probably far more disruptive than most on the supply side think. I would submit that in fact they’re going to drive health care reform and force a repositioning of everyone else in the supply chain.

What are some of the trends visible in this dynamic upheaval, and what matters to doctors of chiropractic? There are at least four trends that matter.

The democratization of information. The Internet has made access to information an ability that is evolving to have the proportions of a human right. Much of the training of health care professionals has historically been designed to transfer loads of knowledge to the provider, turning them into an information resource that no non-professional could be. But now anyone with Internet access can get information that’s sometimes more current than providers have, putting them into a new relationship with their caregivers. When patients gain information on their own, they move from a position of being passive recipients of care to being informed participants in the design of their care; they become consumers. Parallel to this, educational trends include are focusing less on master of information and focusing more on mastery of the ability to find, critically evaluate and acquire information. Mastery of the information is a secondary skill. When patients have accessed information regarding their complaints, problems, conditions and treatment options they expect a new relationship with providers. And they should have it.

The alignment of value and outcomes. Consumers make purchases on the basis of value (results over costs), and in health care this adds an entirely new dimension to the consideration of different care and case management options. When I’m paying for a shirt, I expect to pay more at an upper end clothing store than I do at a discount store. I pay more because the better shirt makes me feel better. There’s a corollary in health care: when I am paying more of my own money up front for treatment, I begin to care more about what I get in return. What providers (and patients) see in terms of clinical outcomes consumers see in terms of value. Early signs of this are visible in ‘medical tourism,’ where people travel outside the US–or to the US–for treatment that is better, cheaper, or that result in better outcomes.

Retail accountability. If a consumer has an unpleasant experience in a store, they shop elsewhere. They ‘vote with their feet’ by spending their money somewhere else. As provider networks have broadened and insurance plans have really become discounted purchasing services, consumer/patients are increasingly likely to vote with their feet if providers don’t meet their interests, needs and values. And as health care exchanges become better-functioning and utilized, more services and plans will appear, giving consumers greater and greater choice among amenities and price points. ¬†Those who deliver the greatest value will thrive. Those who don’t…won’t.

Market Segmentation. Target doesn’t try to be Neiman-Marcus, and Macy’s doesn’t try to be Wal-Mart. The Mayo Clinic doesn’t try to be MinuteClinic. In retail markets, consumer segmentation is normal, even expected (see Value, above). It’s early, but clear signs of this trend are visible. Consumer-facing promises such as same-day appointments, online checkin, retail clinics, proliferation of urgent care settings, executive health and wellness retreats, new health plans for the ‘young invincibles,’ etc., all point to the development of a very diverse and rich set of offerings.

Those who are in practice will need to rethink their practices, relationships, positioning, marketing and communication to these new consumer/patients coming in their doors (see the section on Seizing the Opportunity here).

Implications for Provider Education
What about those educating our providers of the future? What, specifically, about educating doctors of chiropractic might or need to change in the face of these trends?

It’s quite likely some relatively radical changes in approach may be necessary for provider education to remain relevant, and something that people will be willing to accept high costs to acquire. And it’s also likely that unless chiropractic education (and medical, for that matter) figures out how to lower the overall costs of their programs and degrees that it’s going to be increasingly difficult to enroll enough students to stay in business. There are a number of reasons for this: young people have many options; lower-cost/higher-value careers are available; increasingly their secondary and post-secondary education programs train to master the process of information acquisition, not its pure mastery; and the reality is also that most jobs high school and college students will hold in adulthood simply don’t even exist yet. Channeling into a health career forces an identity choice that many may find unappealing as a long-term commitment. Thirty years ago people stayed in careers an average of ten years. Now it’s common that people have four ‘careers’ in a ten year span.

What to do? There are several ‘design principles’ that, if adopted and employed, are more likely to successfully prepare health care providers for business viability and personal success.

Understand, accentuate, and expand on transferable skills. Because transferable skills are visible in someone’s life throughout their history, vocations, avocations and learning preferences, identifying what they are and segmenting training, outcomes assessments and business preparation to someone’s skill sets accomplishes several things: it will engage learners more thoroughly; it will permit their own innate direction to more fully express itself; and it will prepare them more for the inevitable changes that will characterize health care. And in the health care system of the future, change will be constant. (There are a number of resources to accomplish this: see What Color Is Your Parachute and the Clifton StrengthsFinders books for examples.) Permitting, encouraging, or even emphasizing this will create a broader diversity of expression within the profession of how those skills are applied. The profession will be richer for it.

Focus on relationship management, repositioning providers as resources and guides. Today’s youth are wired 24/7/365, but two people on a couch together may be texting each other instead of talking. They are adept at technical advance adoption, but forging a relationship with the necessary foundation of trust and the degree of social contract intimacy necessary to help someone with a profound health problem may be beyond their abilities, with real consequences for their professional success. People walking in the door will, in most cases, know a lot already about their problems. They’re looking for an educated guide who can establish the strongest basis for trust and an enduring relationship.

Train to ‘destination technical proficiency.’ What I mean by this is that the specificity of a chiropractic adjustment must mean more–and come to be valued more–than non-specific mobilization by someone else. This is a profound technical advantage in the ability to deliver something of higher value than someone else. That technical proficiency needs to be a strong component of chiropractic identity–and also in the public’s mind as it considers options and alternatives. In chiropractic education we may think they’re already doing this, but if the public’s confused, it doesn’t matter what we think we’re doing.

Put together, an educational program that:

  • Invests time and resources at the beginning of a student’s educational process to identify what their strengths are,
  • Lays out a plan to build on them,
  • Prepares them to skillfully and effectively be available for the kind of social contracts consumer/patients will need and expect, and
  • Prepares them to deliver unique services that cannot be obtained anywhere else

…is one that will be graduating providers more effectively prepared for the health care marketplace of the future. We will see who seizes these opportunities.



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1 Response to Patient-Centered vs. Consumer-Driven: What Matters for Chiropractors?

  1. Susan Marty says:

    Once again, thank you Stephen Bolles!
    Sue Marty

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