“Patients are not consumers”

Economist Paul Krugman, blogging at the New York Times, argues that patients should not be referred to as “consumers.” Krugman says “The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.” [Link]


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14 Responses to ““Patients are not consumers””

  1. Patients are Consumers.

    There I said it. Of course, they are not only consumers, they are people. We are all patients (to borrow the phrase from Howard Luks, MD.

    What Krugman is doing is to play with words. Consumers is supposed to be a “bad” word. It is not.

    By definition, patients consume resources. Like everybody else. They consume time resources from all their healthcare providers, monetary resources (investments in hospitals, equipment), and mineral resources in products/medicine they consume.
    Again, this is not a bad thing. We all consume.
    We are all consumers.

    That Krugman gets “sick” by the fact that somehow the consumption of the mentioned resources must be paid for somehow, is a personal problem of his.

    We are all consumers.

    /rant on rant

    • Hi Audun – it’s interesting how sensitive this issue is – more specifically, how strong a reaction some people have.

      We wrote about this in December. Excerpt:

      “There is indeed power in the words we use, because the people who hear them attach meaning to them, and as change unfolds, it’s important to distinguish between our words, the reality they represent, and all the different meanings different people intend and hear.”

      I said that only as an observation – I don’t have an opinion about which term is better.

      Having said that, I thought Krugman added useful dimensions to the conversation:

      • “…after which, the usual mantra of freedom of choice is invoked on behalf of voucherizing Medicare,” etc. Yeah, when something like this semantic issue starts to influence government policy, it changes the context – and again the intended meaning!

      But then he launches into other aspects that take the discussion into strange areas:

      • “making those decisions intelligently requires a vast amount of specialized knowledge” – I’m not sure what his point is here. E-patients know that physicians may LACK top-shelf knowledge of treatment options. But I think he’s just saying that there’s more to medical decisions than just freedom of choice as in picking a TV.
      • “often those decisions must also be made under conditions in which the patient is incapacitated” – yeah, that’s why I often say “Patient is a collective noun.” My view: if you diagram the roles in a care incident, the people on the receiving end are what I call “patient.”
      • “There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers or heroic economists.” Well, no, Paul, on this one I disagree. We have TV series on things that grip the brain, and on Maslow’s Hierarchy, nothing is more brain-gripping than survival.
      • “The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening” – agreed! But good health economists do NOT reduce it to cash flow. For instance, see health economist Jane Sarasohn-Kahn’s post last week, about people’s concern (even wealthy one) about whether they’ll have access when they need it.

      To me all this underscores our point in December: different people mean and hear different things for the same words. If we want our human discourse to advance, we need to be clear about the meanings, not the words.

      I think Krugman added a useful dimension by citing the misuse of the term to invoke “retail consumer” meanings.

      • I object most strenuously with Mr. Kruggmen and those who would bastardize our language in this fashion no less because they imagine it serves some greater good.

        It is sophistry and it is dangerous.

        Collectively people granted the full measure of their rights are not stupid. (None of you need to told this, you are proof that it is so.)

        Imagine what happens to society when its leading lights are allowed to tell us what English words are to mean and how there to be used in the future?

        Lets say that I as President of these Untied States where to declare a war on terrorism and that congress were to grant that declaration and the my director of “Homeland Security” where to announce a new terrorism alert index with only two states. State 1 being “elevated” and state 2 being “we are painting your passports brown”

        While our nation may spend more on healthcare then other Western countries with uneven coverage and a built in unsustainable rate of inflation to show for it; “What would you have me make my priority, as “Commander in Chief”?

        After all; “There’s a War on, don’t you know?”

        • Etienne, I don’t see how Krugman was “bastardizing the language.” Context is decisive: someone coming from one point of view can hear and use a word with quite different meaning than someone from another point of view. That was my point in the December post.

          Plus, language evolves. And there’s never been a successful attempt that I know of to stop it from evolving – not even from the kind of centralized mandate you express concern about. In reality, words take on the meanings people mutually understand.

          Personally, I just think the discussion itself is useful. It makes us think what we DO mean.

  2. Wow, I think Krugman shouldn’t have tried to write his thoughts in such a short piece. With a more complete explanation of why he objects to the term “consumer” in the context of healthcare, my guess is that more epatients would agree with him.

    I understand his point to be that as “consumers” of healthcare, we simply are not given sufficient access to the information we need to make the best informed decisions. There’s an asymmetry in the information available to doctors,providers, and insurers (medical info, pricing) vs. the information available to patients.

    Maybe Krugman focused on the wrong type of information. At this point, the asymmetry in pricing/cost information available to providers/payers vs. patients may be the biggest problem in the US healthcare system.

  3. Dave,

    Respectfully, of course Paul Krugman is abusing the language(to use a less provocative term) by insisting that we (or health care economists) should not refer to health care consumers as what they are. To do so is to deny that healthcare consumers and therefore markets exist as such.

    I am insisting on the standards of “oldspeak” it is true. (The Newspeak term for the English language).

    I imagine that his point was that heath-care un-consumers are already being abused by markets that are less then free or fair. Under these circumstances abusing them still further by issuing them vouchers and setting them all lose would not result so much in cost savings as cost shifting. This in his view would be unconscionable.

    A fair point to be sure. Please don’t presume that I would necessarily disagree. (Although after re-reading my rant I can’t say that I blame you a bit. Sorry)

    Forgive the shorthand here, but by way of a case in point, I recall reading about an NCI study that estimated some 42% of cancer patients would better off with the treatment available in the context of a clinical trial yet only 3% of them ever hear about such options from then own doctors.

    This is an indictment of the lack of the free flow of information that is every human beings birth rite. This is not ameliorated by denying consumers and therefore their right to know even exist.

    Maybe I have lost too many people dear to me and have been working on this issue for too long to see straight.

    Still I wish that we would hold our thought leaders to a higher standard. Even if they are running late for a lunch date.

    Thank you all for the opportunity to clarify what I meant just a bit.

  4. We are consumers and we aren’t. We act like them in many ways, but we aren’t given the same options that a true consumer would have.

  5. I’m on a train to DC with Jane Sarasohn-Kahn, the health economist who writes the great Health Populi blog. Yesterday she posted American health consumers still health rationing in 2011.

    In the post she wrote about a new Kaiser Family Foundation poll, which shows that patients are making LOTS of trade-off decisions because healthcare has become such an economic burden. (See the post for many salient details.)

    I asked Jane how she defines consumer: someone who engages in decisions about what to consume (buy or use). In health, because people pay co-pays and deductibles, they have to make a conscious choice whether to partake of a prescribed treatment, or not.

    She added: The KFF survey shows that people are making choices – not necessarily well-informed, but choices – and that means they most definitely are consumers.

    She ended by touching on Krugman’s column:

    While I am sympathetic to Krugman’s arguments, the KFF poll shows us that “patients” are, indeed, health consumers.

  6. […] more thoughtful commentary on this article. […]

  7. Diagnosing Krugman (The Economist compares Krugman’s mental model to that of birther~ism)

    SOMETIMES people believe something so patently ridiculous, so detached from evidence and good sense, that it is more useful to diagnose it than to debate it.


  8. Ben Geisler says:


    Good comments here! I recently blogged something along these lines:
    I understand Krugman’s sentiment and agree that patients are more than consumers just as doctors have more obligations than their own (financial) good.
    However, it is not just House Republicans, as he seems to suggest, that favor “consumer-based” medicine. Business economists Michael Porter and Elizabeth Teisberg base their entire theory to shift competition from health plans (Krugman mentions the failed Medicare Advantage idea) to individual clinicians and facilities based on the patients’ informed decisions in the market.
    Patient-driven medicine is also more than just vouchers for seniors. E-patients or former hospital CEO Paul Levy rightly point out that patients are the most under-utilized resource in medicine and that health care process should not just be patient-centered but patient-driven.

    Clinicians’ help to patients to navigate the health care system is essential. Patients will often be guided, for instance, in referrals to specialists by their primary care physician, if they happen to have one. America’s health care system, unfortunately, is so fragmented that in reality patients often need to find their information on their own, at least at some point along the way, or through families and friends.
    I feel strongly that patients should essentially be engaged and empowered and have access to a wealth of information, from medical conditions to outcomes of individual medical providers or facilities.
    Comparing and selecting providers of clinical services (yes, I would call doctors and others that) even if they might not pay the entire bill is an essential feature of engaged and empowered consumers.

    Nevertheless, health care will never be a perfect market. Patients need to put difficult-to-digest information into context to be able to make use of them. A discussion with the clinician of your choice is most often invaluable and often cannot replace other ways to interpret information. Since Krugman is an economist, I am wondering why he missed out on naming the imperfect condition in question: information asymmetry.

    • Traditionally science gives knowledge to clinicians, who in turn pass on this knowledge to medical patients.

      In a modern healthcare setting patients need assistance in the acquisition of knowledge and given the opportunity to discuss knowledge they have gathered relevant to their treatment with their own doctors.

      Inputs from a broad enough base of medical patients in the form of information relevant to their individual circumstances is what a market corrupted by the lack of such inputs needs to right itself.

      I believe I am merely restating what is as oblivious to a celebrity economist as it must be to most who contemplate these questions.

      It is possible I suppose to both have had a brilliant academic career and to be an opinion journalist with little talent.

      Under the circumstances perhaps we expect too much of Mr. Krugman.

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