Healthcare customer vs. patient
A health care consumer is anyone who uses health services. From newborn care at delivery to long-term care later in life, everyone has healthcare needs which changes during lifespan. What differs from the traditional patient role is that a consumer who is a self-empowered decision maker, vs. the patient who is a passive receiver of care. People today believe they have that capacity to make informed health decisions, in a similar vein to how they make other decisions. People would like to empower themselves to move from the passive experience of being a patient to the engaged and powerful experience of being a consumer. Most importantly, we are accountable for our own wellness and should take an important role in health care or care giving decision making.
Patients are vulnerable and have no choices. A patient is also a healthcare consumer, but a consumer is not necessarily a patient. Before a person becomes a patient, they are a consumer shopping around, as they do in other retail sectors, looking for the best healthcare option. But even before they are consumers, they are humans – individuals with unique motivations and challenges. They don’t just follow doctor’s orders, they act according to deeper internal impulses and needs.
What matters most to the healthcare customers?
Quality, cost, and coverage are inextricably linked and that all must be addressed for meeting health care needs. Overall, older age group uses more healthcare services and spending more for healthcare needs. Consumers are increasingly requiring personalized care; transparency in network coverage, medical prices, and bills; convenience; and more engaging in active participation of care. Health care consumer behavior is largely influenced by medical research development and healthcare education. As results of continued learning, a role transition is seen from a traditional passive patient to an educated customer making informed decisions. More and more people understood the value of wellness and taking actions for health maintenance.
How to transition from a patient to an educated healthcare customer
Healthcare is different from other services because it is not clearly defined. In most industries, the product or service can be standardized to improve efficiency and quality. In healthcare, every consumer is structurally, chemically, and emotionally different. As health care is not a market in the usual way that markets are defined, the customers and/or patients may have limited power to shape that market. It is important to know your rights and empower yourself with health literacy. In reality, it is challenging to making a role transition from a patient to an educated health care consumer, especially when getting older becoming more vulnerable. If you’re not sure where to start, learn navigation for healthcare needs and use these practical tips:
#1 Understand your insurance coverage
Whether you get medical insurance coverage through Medicare/Medicaid or another source, it’s vital for you to completely understand your benefits. When people think about the “cost” of healthcare, many factors in the monthly premium they pay for insurance, but that is not the only cost associated with care. Other things to consider include copays and deductibles, as well as co-insurance and out-of-pocket maximums. In addition, some treatment may not be covered by your insurance or may be considered “out of network”, which affects what you would owe for the treatment or service.
When getting healthcare services, make sure you know what is covered, what providers and facilities are in and out of network, and what costs you will owe at the time of service. If you have questions about your coverage, contact your insurance provider.
#2 Engage efforts in health awareness to stay informed and educated
To make the most of your medical appointment, preparation is important.
Furthermore, to help you become the educated healthcare consumer, below are important questions to address for making an informed healthcare decision.
1. What are the benefits and expected results of this treatment/procedure?When a treatment or procedure is recommended, the patient often assumes that it will make them “better” and trust they will have a favorable outcome as the statistics presented. However, the basic question is if the treatment or procedure is truly necessary or better than a conservative plan?
2. What are the risks and side effects?Patients want to hear about the benefits of a treatment, but they often overlook the risks involved. To be an educated consumer, benefit vs. risk is a critical factor to consider especially in older age. These risks need compared with other treatments or no treatment. In the case of joint pain, for example, exercise or physical therapy is a valid alternative with a much lower risk profile than surgery.
3. What are the alternatives?Ask for alternative treatments and do your research homework on recommended treatment and other alternatives from research (using reliable resources), to fully understand what’s involved and get your questions addressed.
4. Why this treatment/procedure over the other ones and the cost estimates for each?You’ve learned about all the options the costs for these options, now you can see how the risks and benefits are balanced in your treatment plan as proposed by your health care provider. You are entitled to get a second option independently on major medical decisions and do not rush to sign consent forms in non-emergency situations.
5. After all, you will need to answer this most important question: is this treatment safe and to my best interest/benefit?
#3 Ask for pricing transparency
Ideally, if healthcare price transparency is followed, you should have information that enables you to make meaningful price comparisons before you buy a healthcare service. Price information should be easy for you to use and understand. Along with price information, you should receive information about quality, safety, patient experience, and other aspects of care that are important to you.
You should receive the information and need to understand:
▶ The total price of your care
▶ What is included in that price
▶ What is excluded from that price
However, in reality, it may not happen and you will have to inquire.
Before getting a procedure or other service, ask your healthcare provider about what price you can expect. Although the exact price will be different for each patient (usually depending on insurance coverage), every healthcare system has a list of charges for all of the services it provides called a “chargemaster.” Think of it like the sticker price for a healthcare service.
You most likely won’t pay the sticker price if you have insurance, but knowing the amount on the chargemaster does give you a ballpark estimate of what the service will cost. It is best to call your insurance for pre-authorization and knowing the case-specific estimates prior to treatment. Many healthcare systems also offer discounts for patients who self-pay (meaning they do not go through insurance). In some cases, self-paying may be even more cost effective than going through your health insurance and you can request to be self-pay prior to receiving the care.
Patients are responsible for more and more of their medical costs each year, so it’s important to be aware of those costs and how to make smart healthcare decisions to not only save money but also be healthier to begin. Afterwards, it is very important to review your bills for any service received – verify your information, ask for an itemized list, research billing codes, don’t be afraid to request clarification if charge is more than the estimate and the reason, or negotiate the additional charges, be your own advocate. Do not make payment until you are 100% comfortable. Track your medical/dental bills and health insurance claims for each year.
#4 Shop around for quality services
When you making a major purchase, you would research, learn and compare with other options, but many often fail to do this with healthcare, because it is more complicated. In general, Hospitals often charge more for services, like laboratory testing and CT scans, compared to freestanding or outpatient clinics, so it pays to shop around for the best price. Many insurance providers offer online tools to estimate how much a service will cost with different healthcare providers. You can also use sites like Healthcare Bluebook to find what a fair price is for a service. Getting your imaging done at an outpatient imaging center or outpatient surgery at an ambulatory surgical center (ASC) may save you a lot, if it is an option.
#5 The best and most cost-effective medicine is prevention
It’s essential to stay up to date on your routine screenings because that is the best way to detect health problems before they become serious and expensive to treat. Plus, preventive care doesn’t cost anything extra to you or your family. Get health screenings when recommended, and use wellness blood draws and health screenings recommended for your age group. Keep your annual wellness visits, as your doctor can help identify any issues early, while treatment is easier and more successful.
Note: If you have a history or symptoms of the condition you are getting screened for (such as colon cancer or glaucoma), your screening may no longer be covered by insurance because it would be considered “diagnostic.” Talk to your doctor about whether your routine testing is simply a screening test or a diagnostic test.
#6 Take advantages of perks and incentives
Many insurance plans offer incentives for healthy choices. Some programs may reimburse the cost of your gym membership or give you discounts on wearable fitness devices. Other programs may even pay incentives for getting preventive screenings. You are entitles to take advantage of these offers for your health benefit.
#7 Dental Care and Cost Awareness
Since Medicare does not cover dental, many older Americans loses dental insurance after age 65 unless you pay for private dental insurance. Medicare advantage programs may offer limited dental coverage. However, oral health is very important for aging. To learn more, go to Aging and Oral Health.
Use the website link below to determine costs before any dental procedure will help you determine fair prices in your area. It is also what insurance companies should be using to determine fair costs to consumers:
https://www.fairhealthconsumer.org/dental
To be an educated healthcare customer -
Summary:
Quality, cost, and coverage are most important to healthcare consumers.
When you get good quality health care, it means that your care is:
▶ Provided by skilled and knowledgeable professionals who give you personalized attention. They treat you with respect, listen carefully, give explanations you can understand, and involve you in decisions about your care.
▶ Unbiased and focus on what types of care work best for your interest and benefits, based on the latest evidence from medical research and clinical experiences.
▶ Safe and GCP (Good Clinical Practice) compliant
▶ Timely and convenient: You can access the care you need when you need it.
▶ Clear price transparency, reasonable charges, not overbilling
It’s important to know that getting good quality care does not happen automatically.
Price as a quality indicator depends on a number of factors: the quality of the information regarding the service and its price, the consumer’s degree of education in the respective field, the provider’s promotional policy, the risk associated with acquiring the service in question determined by the customer’s ability to assess quality;
Non-monetary prices include the time, effort and discomfort associated with the search, buying and usage of the service. Consumers refer to these costs as “effort costs” or “stress costs”.
Such costs are usually higher for healthcare services, because the consumer is directly involved in the provision of the service, which involves travelling, waiting, acquiring information, understanding how the service is provided and actually participating in its provision.
To be an educated healthcare customer,
Health coaching support
Make health a priority and take actions to make good things happen. Everyone faces challenges; consider seeking support from trustworthy resources and engage with positive influences. Health coaching can help you to be an educated healthcare customer. Contact Qualitylifeforum@outlook.com for your health coaching needs.
© All rights reserved
References:
https://www.forbes.com/sites/dangingiss/2019/07/11/why-an-aging-population-means-healthcare-customer-experience-must-adapt/?sh=5b86e3cc3351
https://blogs.perficient.com/2022/02/07/your-healthcare-audience-patient-consumer-or-human/
https://www.hfma.org/industry-initiatives/healthcare-dollars-and-sense/consumer-educational-guides.html
https://reverehealth.com/live-better/5-tips-to-be-a-smart-healthcare-consumer/
https://www.cchwyo.org/news/2020/february/10-ways-you-can-be-a-wise-healthcare-consumer/
https://www.sciencedirect.com/science/article/pii/S1877042811002886
Disclaimer: This information is for educational and informational purposes only. It is not medical advice. Consult your healthcare professional for personal conditions.
A health care consumer is anyone who uses health services. From newborn care at delivery to long-term care later in life, everyone has healthcare needs which changes during lifespan. What differs from the traditional patient role is that a consumer who is a self-empowered decision maker, vs. the patient who is a passive receiver of care. People today believe they have that capacity to make informed health decisions, in a similar vein to how they make other decisions. People would like to empower themselves to move from the passive experience of being a patient to the engaged and powerful experience of being a consumer. Most importantly, we are accountable for our own wellness and should take an important role in health care or care giving decision making.
Patients are vulnerable and have no choices. A patient is also a healthcare consumer, but a consumer is not necessarily a patient. Before a person becomes a patient, they are a consumer shopping around, as they do in other retail sectors, looking for the best healthcare option. But even before they are consumers, they are humans – individuals with unique motivations and challenges. They don’t just follow doctor’s orders, they act according to deeper internal impulses and needs.
What matters most to the healthcare customers?
Quality, cost, and coverage are inextricably linked and that all must be addressed for meeting health care needs. Overall, older age group uses more healthcare services and spending more for healthcare needs. Consumers are increasingly requiring personalized care; transparency in network coverage, medical prices, and bills; convenience; and more engaging in active participation of care. Health care consumer behavior is largely influenced by medical research development and healthcare education. As results of continued learning, a role transition is seen from a traditional passive patient to an educated customer making informed decisions. More and more people understood the value of wellness and taking actions for health maintenance.
How to transition from a patient to an educated healthcare customer
Healthcare is different from other services because it is not clearly defined. In most industries, the product or service can be standardized to improve efficiency and quality. In healthcare, every consumer is structurally, chemically, and emotionally different. As health care is not a market in the usual way that markets are defined, the customers and/or patients may have limited power to shape that market. It is important to know your rights and empower yourself with health literacy. In reality, it is challenging to making a role transition from a patient to an educated health care consumer, especially when getting older becoming more vulnerable. If you’re not sure where to start, learn navigation for healthcare needs and use these practical tips:
#1 Understand your insurance coverage
Whether you get medical insurance coverage through Medicare/Medicaid or another source, it’s vital for you to completely understand your benefits. When people think about the “cost” of healthcare, many factors in the monthly premium they pay for insurance, but that is not the only cost associated with care. Other things to consider include copays and deductibles, as well as co-insurance and out-of-pocket maximums. In addition, some treatment may not be covered by your insurance or may be considered “out of network”, which affects what you would owe for the treatment or service.
When getting healthcare services, make sure you know what is covered, what providers and facilities are in and out of network, and what costs you will owe at the time of service. If you have questions about your coverage, contact your insurance provider.
#2 Engage efforts in health awareness to stay informed and educated
To make the most of your medical appointment, preparation is important.
- Make a wellness check and self-assessment, including intake, output, diet, sleep, mental focus, pain level, or specific symptoms. For the initial visit, prepare medical history in advance.
- Prepare for Appointments: make a list of health issues and medication/supplement questions you have for your healthcare provider and prioritize. Summarize changes and updates from previous visit as appropriate.
- Take an Active Role in Appointments - feel free to bring up your health concern to discuss and take notes as needed. Take parts in your treatment plan.
- Reduce prescriptions cost - you may be able to switching to a generic brand. Ask your doctor or pharmacist if a generic version of your medication is available and safe.
- Review your lab results online from patient portal when it becomes available. For significant laboratory abnormalities, request a repeat before treatment consideration.
Furthermore, to help you become the educated healthcare consumer, below are important questions to address for making an informed healthcare decision.
1. What are the benefits and expected results of this treatment/procedure?When a treatment or procedure is recommended, the patient often assumes that it will make them “better” and trust they will have a favorable outcome as the statistics presented. However, the basic question is if the treatment or procedure is truly necessary or better than a conservative plan?
2. What are the risks and side effects?Patients want to hear about the benefits of a treatment, but they often overlook the risks involved. To be an educated consumer, benefit vs. risk is a critical factor to consider especially in older age. These risks need compared with other treatments or no treatment. In the case of joint pain, for example, exercise or physical therapy is a valid alternative with a much lower risk profile than surgery.
3. What are the alternatives?Ask for alternative treatments and do your research homework on recommended treatment and other alternatives from research (using reliable resources), to fully understand what’s involved and get your questions addressed.
4. Why this treatment/procedure over the other ones and the cost estimates for each?You’ve learned about all the options the costs for these options, now you can see how the risks and benefits are balanced in your treatment plan as proposed by your health care provider. You are entitled to get a second option independently on major medical decisions and do not rush to sign consent forms in non-emergency situations.
5. After all, you will need to answer this most important question: is this treatment safe and to my best interest/benefit?
#3 Ask for pricing transparency
Ideally, if healthcare price transparency is followed, you should have information that enables you to make meaningful price comparisons before you buy a healthcare service. Price information should be easy for you to use and understand. Along with price information, you should receive information about quality, safety, patient experience, and other aspects of care that are important to you.
You should receive the information and need to understand:
▶ The total price of your care
▶ What is included in that price
▶ What is excluded from that price
However, in reality, it may not happen and you will have to inquire.
Before getting a procedure or other service, ask your healthcare provider about what price you can expect. Although the exact price will be different for each patient (usually depending on insurance coverage), every healthcare system has a list of charges for all of the services it provides called a “chargemaster.” Think of it like the sticker price for a healthcare service.
You most likely won’t pay the sticker price if you have insurance, but knowing the amount on the chargemaster does give you a ballpark estimate of what the service will cost. It is best to call your insurance for pre-authorization and knowing the case-specific estimates prior to treatment. Many healthcare systems also offer discounts for patients who self-pay (meaning they do not go through insurance). In some cases, self-paying may be even more cost effective than going through your health insurance and you can request to be self-pay prior to receiving the care.
Patients are responsible for more and more of their medical costs each year, so it’s important to be aware of those costs and how to make smart healthcare decisions to not only save money but also be healthier to begin. Afterwards, it is very important to review your bills for any service received – verify your information, ask for an itemized list, research billing codes, don’t be afraid to request clarification if charge is more than the estimate and the reason, or negotiate the additional charges, be your own advocate. Do not make payment until you are 100% comfortable. Track your medical/dental bills and health insurance claims for each year.
#4 Shop around for quality services
When you making a major purchase, you would research, learn and compare with other options, but many often fail to do this with healthcare, because it is more complicated. In general, Hospitals often charge more for services, like laboratory testing and CT scans, compared to freestanding or outpatient clinics, so it pays to shop around for the best price. Many insurance providers offer online tools to estimate how much a service will cost with different healthcare providers. You can also use sites like Healthcare Bluebook to find what a fair price is for a service. Getting your imaging done at an outpatient imaging center or outpatient surgery at an ambulatory surgical center (ASC) may save you a lot, if it is an option.
#5 The best and most cost-effective medicine is prevention
It’s essential to stay up to date on your routine screenings because that is the best way to detect health problems before they become serious and expensive to treat. Plus, preventive care doesn’t cost anything extra to you or your family. Get health screenings when recommended, and use wellness blood draws and health screenings recommended for your age group. Keep your annual wellness visits, as your doctor can help identify any issues early, while treatment is easier and more successful.
Note: If you have a history or symptoms of the condition you are getting screened for (such as colon cancer or glaucoma), your screening may no longer be covered by insurance because it would be considered “diagnostic.” Talk to your doctor about whether your routine testing is simply a screening test or a diagnostic test.
#6 Take advantages of perks and incentives
Many insurance plans offer incentives for healthy choices. Some programs may reimburse the cost of your gym membership or give you discounts on wearable fitness devices. Other programs may even pay incentives for getting preventive screenings. You are entitles to take advantage of these offers for your health benefit.
#7 Dental Care and Cost Awareness
Since Medicare does not cover dental, many older Americans loses dental insurance after age 65 unless you pay for private dental insurance. Medicare advantage programs may offer limited dental coverage. However, oral health is very important for aging. To learn more, go to Aging and Oral Health.
Use the website link below to determine costs before any dental procedure will help you determine fair prices in your area. It is also what insurance companies should be using to determine fair costs to consumers:
https://www.fairhealthconsumer.org/dental
To be an educated healthcare customer -
- Always have your dentist provide a pre-treatment estimate for any services. Get estimates up front and check if it is reasonable. Sadly, there are a lot of places deeply gouging consumers and insurance companies and you cannot fully rely on recommendations to determine what is really needed against an unnecessary upsell. You may receive a very expensive treatment plan from deep cleaning, multiple fillings, crown replacement, to orthodontic and cosmetic works. The best thing to do is taking time to evaluate your needs and prioritize necessary treatments.
- If you have dental insurance, read your policy handbook as this will list your limitations and exclusions with your plan. You always want to be aware of how often you can have a procedure within a calendar year. Confirm with your insurance company if your provider is participating or non-participating. The in-network providers will have a contracted rate with your insurance policy at a discounted rate. When you use any dental service outside of your network, they can charge you the full price for the procedure.
- If you don’t have any dental insurance, shop for a self-pay rate with discount.
- Also be sure to read documents regarding billing before signing, make sure you understand what the maximum you can be charged even if you sign something prior to work being done. It’s time consuming but worth it. Don’t sign anything until you are 100% comfortable.
- Review billing statement to ensure all charges are billed correct or address othewise, before make payment.
- Your best defense is good self-care routine (flossing, brushing, and mouth rinse) for oral health maintenance.
Summary:
Quality, cost, and coverage are most important to healthcare consumers.
When you get good quality health care, it means that your care is:
▶ Provided by skilled and knowledgeable professionals who give you personalized attention. They treat you with respect, listen carefully, give explanations you can understand, and involve you in decisions about your care.
▶ Unbiased and focus on what types of care work best for your interest and benefits, based on the latest evidence from medical research and clinical experiences.
▶ Safe and GCP (Good Clinical Practice) compliant
▶ Timely and convenient: You can access the care you need when you need it.
▶ Clear price transparency, reasonable charges, not overbilling
It’s important to know that getting good quality care does not happen automatically.
Price as a quality indicator depends on a number of factors: the quality of the information regarding the service and its price, the consumer’s degree of education in the respective field, the provider’s promotional policy, the risk associated with acquiring the service in question determined by the customer’s ability to assess quality;
Non-monetary prices include the time, effort and discomfort associated with the search, buying and usage of the service. Consumers refer to these costs as “effort costs” or “stress costs”.
Such costs are usually higher for healthcare services, because the consumer is directly involved in the provision of the service, which involves travelling, waiting, acquiring information, understanding how the service is provided and actually participating in its provision.
To be an educated healthcare customer,
- Recognize that you could pay very different amounts for healthcare services depending on where you go.
- Shop around when you can, but don’t sacrifice quality for price.
- Don’t make the mistake of assuming that a high price translates into high quality.
- Seek out information on the quality of care as well as the out-of-pocket expenses you can expect.
- Most importantly, always review your medical/dental billing statements carefully and verify each charge is correct or take actions to resolve billing issues before paying.
Health coaching support
Make health a priority and take actions to make good things happen. Everyone faces challenges; consider seeking support from trustworthy resources and engage with positive influences. Health coaching can help you to be an educated healthcare customer. Contact Qualitylifeforum@outlook.com for your health coaching needs.
© All rights reserved
References:
https://www.forbes.com/sites/dangingiss/2019/07/11/why-an-aging-population-means-healthcare-customer-experience-must-adapt/?sh=5b86e3cc3351
https://blogs.perficient.com/2022/02/07/your-healthcare-audience-patient-consumer-or-human/
https://www.hfma.org/industry-initiatives/healthcare-dollars-and-sense/consumer-educational-guides.html
https://reverehealth.com/live-better/5-tips-to-be-a-smart-healthcare-consumer/
https://www.cchwyo.org/news/2020/february/10-ways-you-can-be-a-wise-healthcare-consumer/
https://www.sciencedirect.com/science/article/pii/S1877042811002886
Disclaimer: This information is for educational and informational purposes only. It is not medical advice. Consult your healthcare professional for personal conditions.
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