Abstract
Patient-centered care and healthcare consumerism are the two most dominant ideas about the relationship between patients and providers in the United States. To identify providers’ positions between the two perspectives, we analyzed the content of direct-to-consumer healthcare service advertisements. The advertisements were collected in the state of Nevada (N = 323) and their landing pages were analyzed for provider attributes, patient experience features, and terms referring to patients and providers. The results showed that the advertisements fully embraced the notion of patient-centeredness by commonly claiming patient-centered care and frequently using the term “patient.” The advertisements also contained multiple indicators of healthcare consumerism, although they avoided using the terms “consumer/customer/client” closely associated with consumerism. Contrary to the prominence of patient experience features, provider attributes were not common. An additional analysis of inter-specialty differences in advertising features confirmed the strong consumerism position of cosmetic surgery providers. Application of the healthcare service advertising analytic scheme developed for this study could help providers and healthcare administrators recognize how their advertising messages may reflect their values.
Keywords
Introduction
In modern American medicine, the patient–provider relationship had historically been characterized as paternalistic (1), that is whereby physicians would make decisions for their patients and patient autonomy was mostly lacking. However, the movement toward patient-centered care has reframed the patient–provider relationship as a shared partnership (2), and the more recent advent of healthcare consumerism has further influenced this relationship. In healthcare consumerism, patients make their own healthcare decisions based on their knowledge acquired through literature, the internet, and direct-to-patient advertising (3).
Defined by the Institute Of Medicine as “care that is respectful and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions (p. 40),” patient-centered care was officially adopted at the beginning of the twenty-first century as a core impetus to deliver better quality healthcare in the United States (2). Its six dimensions include: respect for patients’ values, preferences, and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support-relieving fears and anxiety; and involvement of family and friends. Aside from its ethical and moral imperative, patient-centered care has improved clinical outcomes and patients’ quality of life while reducing costs and disparities (4).
On the other hand, the views on the impact of healthcare consumerism are split. Advocates of consumerism assert that it improves the quality of care and reduces costs (5), while others are skeptical because patients can be misinformed or even manipulated to demand what is not necessarily in their best interest (6). Although patient-centered care and healthcare consumerism might overlap in patient empowerment, some bioethicists argue, healthcare should not be seen as a commodity that can be bought and sold to consumers who are willing and capable of paying for it (7,8).
The ambivalence toward healthcare consumerism is observable in people's attitudes toward the terms used to refer to patients. Even before healthcare consumerism fully established itself in the U.S. public policy documents, a hospital manager told providers, “continue to call them patients but treat them like customers” (9). Indeed, the public favors the traditional term, patient, over alternatives like client, customer, or consumer (10). Also, patients said they were more comfortable with being patients rather than taking on the role of highly engaged consumers (11). On the other hand, we know little about the providers’ perspective on patient-centered care and consumerism (12).
Healthcare service advertisements might offer a window into the providers’ perspective. According to the positioning theory of strategic communication, an organization intentionally adopts a position and implements speech acts that align with it. The outwardly expressed position, in turn, supports the legitimacy of the organization to claim the position and guides further actions (13). Healthcare service advertisements constitute the most widely disseminated speech acts by providers, and occasional controversies over explicitly commercial healthcare service advertisements offer rare glimpses into the struggle between the mandate for profits and the higher expectation placed on healthcare providers to transcend the reality of the market-based U.S. healthcare economy (14,15).
To date, studies cataloging the content of healthcare service advertisements are rare. Two studies that analyzed cosmetic surgery advertisements concluded that doctors’ professional attributes, such as training and board certification, were prevalent (16,17). Consumer ratings and awards were also present, although not as common as professional attributes (17). Consumer ratings (eg, Yelp.com, Healthgrades.com) are consumer-driven quality indicators that were perceived by physicians to be less accurate than the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey conducted by the U.S. government (18). Also, in a rare empirical examination of the relationship between Yelp ratings and objective patient outcomes, higher Yelp ratings were related to higher patient mortality from some procedures when other relevant variables (eg, share of Medicaid patients, Black patients, resident-bed ratio, etc) were controlled; Yelp ratings were not related to two other outcome measures used in the study (19). Similarly, higher patient satisfaction scores from the HCAHPS survey were associated with unintended, undesirable outcomes such as higher hospital readmission and mortality rates (20). Hence, consumer ratings may meet the definition of healthcare consumerism (i.e., patients make their own healthcare decisions based on their knowledge acquired through the internet and other sources), but not necessarily contribute to high-quality care, the ultimate goal for which patient-centered care was introduced in the first place (2). Given the increasing emphasis on a provider's personality as a key factor in selecting a provider (21), one could also view the provider's personality as an aspect of healthcare consumerism, especially since no consistent relationships have been found between providers’ personality attributes and improved patient outcomes (22).
With no published data on patient experience promoted in healthcare service advertisements, convenience can be deemed as indicating either patient-centeredness or consumerism, because most convenience-enhancing measures could be adopted to enhance patient access as much as to gain competitive advantages over other providers. On the other hand, amenities such as luxurious interiors and valet parking can be more clearly classified as indicators of consumerism.
Furthermore, references to “patients” versus “consumers/clients/customers” can suggest how providers wish to position themselves and their care. In health policy documents in the United Kingdom, the term “consumer” was used strategically to support the consumerist orientation of the incumbent political party (23). At the individual level, some providers also expressed apprehension about using “consumers/clients/customers” due to its connotation to healthcare consumerism (24). In fact, providers may simply refer to patients as “you” to avoid ambivalence while appealing to audiences who are accustomed to “synthetic personalization”—use of second-person pronouns in commercial advertising to give an impression of mass audiences that they are treated as individuals (25).
Lastly, the notion of clusivity in linguistics is adopted to identify the positioning of providers in healthcare service advertisements. In many languages, we, a first-person plural pronoun, could be either inclusive or exclusive of the addressee (26). When applied to the current analysis, clusivity could reveal the boundary of the first-person plural pronoun in the ads. For example, use of we inclusive of both the provider and patient could be considered as a manifestation of patient-centeredness. On the other hand, the co-presence of we and “our doctor(s)” may suggest that we include administrative staff only, indicating a distance between providers and patients.
Based on the reasoning above, various features of healthcare service advertisements are mapped as the elements of patient-centered care and/or healthcare consumerism (Figure 1), and a research question is generated to examine how providers position their services on patient-centeredness and consumerism in online advertisements.
Patient-centeredness and consumerism in healthcare service advertising content.
RQ1. How do healthcare providers position their service(s) in online advertisements through the use of (1) provider attributes, (2) patient experience features, and the terms (3) referring to patients and (4) referring to providers?
The two current studies of provider advertisements analyzed cosmetic surgery advertisements only (16,17). Because we analyzed advertisements for multiple specialties, we created a research question exploring cross-specialty differences.
RQ2. Are there differences in the positioning of healthcare services across specialties?
Method
Online Advertisement Sample
The unit of analysis was the landing page of each online healthcare service advertisement located through internet searches. A landing page was the first page people saw when they clicked on an online healthcare service advertisement, also known as a click-through. Forty-five keywords were compiled from medical specialty names (e.g., pediatrics, neurology, psychiatry, ophthalmology, etc.) (27) and the names of diseases and non-medical healthcare specialties most commonly searched online (e.g., diabetes, sore throat, arthritis, dentist, etc.) (28,29). Subsequently, a set of four search terms were created for each of 45 diseases and healthcare specialties (e.g., pediatrician; pediatric clinic; pediatric specialist; pediatric doctor). Because most provider searches are local, the search phrases were further extended by the name of one of the two most populous cities in the state where the advertisements were collected. Two research assistants collected ads independently. To counter the calibrated search engine results based on the city's location and browser cache memories, they used a proxy server service and disabled browser cookies. Each person conducted 360 searches because there were 360 different combinations of 45 disease/specialties, four search phrases, and two cities (eg, pediatrician, Reno; pediatric clinic, Reno; pediatric specialist, Reno; pediatric doctor, Reno; pediatrician, Las Vegas; pediatric clinic, Las Vegas; pediatric specialist, Las Vegas; and pediatric doctor, Las Vegas. After eliminating duplicates and irrelevant ones, 323 unique advertisements were analyzed.
Coding Variables
The advertisements were first coded for the specialty/department of the advertised service(s). Because the task required advanced knowledge of healthcare specialties, the principal investigator made the judgments in consultation with co-investigators. The advertising content was analyzed by two coders (Krippendorff's α ≥.80). See Table 1 for the coding scheme.
Coding of Healthcare Service Advertising Features.
Provider Attributes
Each advertisement was analyzed for these professional attributes coded as patient-centeredness indicators: experience; education; affiliation with a professional organization, university, or hospital; research. On the other hand, these were coded as consumerism indicators: non-medical awards or consumer ratings, media appearance, and personality.
Patient Experience
First, an advertisement was coded for claiming patient-centeredness if explicitly mentioning any of the six dimensions of patient-centeredness, in addition to the phrase patient-centered(ness) itself. Second, an advertisement was marked for claiming convenience if mentioning the ease of obtaining care from the provider. Third, an advertisement was coded as containing an amenity claim if mentioning extra features that were not directly related to clinical care. Wordlists indicating patient-centeredness, convenience, and amenity claims were created a priori and subsequently expanded in the inter-coder reliability training process.
Patient References
Each advertisement was coded for the presence of these terms: patient, consumer, client, customer, and you/your/yours.
Provider References
Whether an advertisement used plural first-person pronouns (we/our/us) to refer to providers was coded. Further, the advertisements were examined for the presence of the words “our doctor(s)/provider(s).”
Statistical Analysis
RQ1 was answered with frequencies. To answer RQ2, we conducted six logistic regression analyses. First, based on providers’ health science degrees and advertised services, four distinct provider groups were created by dummy-coding the values to “0” no and “1” yes: MD/DO primarily performing cosmetic surgery; MD/OD not primarily performing cosmetic surgery; dentist; chiropractor. Next, we regressed provider's consumerism and professional attributes (summed for each and then dummy-coded to high and low by the median-split method), patient-centeredness, convenience, and amenities on the four predictor variables. Among the patient and provider references, only “our provider(s)/doctor(s)” had sufficient variance and thus was included in the regression analyses.
Results
Over half of the 323 advertisements were for medical or osteopathic doctors (n = 200, 62%). Dental medicine/science doctors were the second (n = 53, 16%), followed by chiropractic doctors (n = 22, 7%). The services promoted in the advertisements were diverse, including dentistry (n = 53, 16.4%), cosmetic surgery (n = 41, 13.0%), and many others. See Table 2 for the full lists of healthcare providers and services promoted in the advertisements.
Coding Variables, Categories, Intercoder Reliability Statistics, and Frequencies, N = 323.
Other provider degrees included: optometry doctor; podiatry doctor; counselor/therapist; doctor of psychology; nurse practitioner/physician assistant; doctor of physical therapy; doctor of nursing; and midwife.
Other services included: optometry (n = 19, 5.9%); urgent care (n = 17, 5.3%); obstetrics/gynecology (n = 15, 4.6%); orthopedic surgery (n = 13, 4.0%); ophthalmology (n = 12, 3.7%); family medicine (n = 11, 3.4%); podiatry (n = 11, 3.4%); general surgery (n = 8, 2.5%); ENT, pain care (n = 7, 2.2% each); dermatology, internal medicine (n = 6, 1.9% each); allergy/immunology, neurology, screening/prevention (n = 5, 1.5% each); cancer, pediatrics, urology (n = 4, 1.2% each); alternative medicine, emergency medicine (n = 3, 0.9% each); cardiovascular diseases, physical medicine, radiology, unrelated multiple specialties (n = 2, 0.6% each); colon rectal surgery, endocrinology, infectious diseases, lung/pulmonary care, rheumatology, travel medicine (n = 1, 0.3% each).
Provider Attributes
Overall, professional attributes were not prevalent. Among these, experience (n = 76, 24%) was the most prevalent, followed by board certification (n = 72, 22%), professional organization affiliation (n = 65, 20%), training (n = 40, 12%), and university/hospital affiliation (n = 30, 9%). Provider attributes indicating a consumerism position were similarly uncommon. The two most common ones were personality (n = 89, 28%) and ranking/consumer rating (n = 84, 26%). Media appearance (n = 20, 6%) and research (n = 13, 4%) were rarely featured. In sum, the prevalence rates of provider attributes were less than 30% and rates of consumerism and professional attributes were comparable.
Patient Experience Features
Claims of patient-centeredness (n = 227, 70%) appeared frequently. Of the six dimensions of patient-centeredness, (1) information/communication/education, (2) respect for patients’ values/preferences/expressed needs, and (3) emotional support were frequently mentioned. Also common were mere recitations of the terms patient-centered care or patient focus. On the other hand, references to (4) physical comfort, (5) involvement of family and friends, and (6) coordination and integration of care were rare.
Convenience features indicating both patient-centeredness and consumerism were common (n = 131, 41%). Most frequently mentioned convenience features included multiple locations, online bill pay, and same-day appointments.
Amenity features indicating consumerism were not as common (n = 58, 18%). Physical facilities (eg, luxury suites and modern waiting rooms) and events appeared more often than others.
Patient References
Patient was the most common (n = 297, 86%), which contrasted sharply with the scarcity of the terms client/customer (n = 29, 9%). Included in the 29 counts for client/customer were 20 advertisements that used both patient and client/customer. Among the small number of advertisements featuring the terms client/customer were psychiatry/counseling (n = 8), cosmetic surgery (n = 4), and chiropractic advertisements (n = 4). The term consumer was observed in only one advertisement (0.3%), a cosmetic surgery advertisement that also used patient, client, and customer. Thirty-six advertisements (11%) did not contain any of these terms to refer to patients. At the same time, most advertisements engaged their audiences by addressing them directly with second-person pronouns (n = 305, 94%). Altogether, second-person pronouns appeared the most often, followed by the patient. Consumers/clients/customers were rarely used.
Provider References
Plural third-person pronouns (n = 318, 98%) were featured in almost all advertisements. At the same time, the strong presence of another term, “our provider(s)/doctor(s)” (n = 256, 79%), suggested that many of the plural first-person pronouns did not include the provider(s) in charge of patient care.
Differences Across Specialties
Except for the two models predicting patient-centeredness and amenities, all other models were statistically significant at the 0.05 level (see Table 3). None of the odds ratios were statistically significant for dentist advertisements. Advertisements for the practices led by MDs/ODs who were not performing cosmetic surgery had one statistically significant regression coefficient. They were more likely to emphasize convenience (OR = 2.48, p = .006) than others. Advertisements for chiropractic services also had one significant regression coefficient, which was the consumerism attributes of the providers (OR = 4.11, p = .007). Cosmetic surgery service advertisements by MDs/ODs were distinguished from all other advertisements in five out of the six features. They were more likely to feature providers’ consumerism (OR = 11.28, p = 3E-06) and professional attributes (OR = 3.09, p = .017). They were also more likely to emphasize amenities (OR = 3.24, p = .049) and distinguish their providers from the rest of the office staff by calling them “our provider(s)/doctor(s)” (OR = 10.2, p = .03). On the other hand, cosmetic surgery service advertisements were less likely to claim convenience (OR = .28, p = .022) than others.
Regression Models Predicting Advertising Features by Provider Specialties N = 323.
*p < .05; **p < .01; ***p < .001
1. For the regression models, Exp(B) (odds ratio) is reported.
2. The references for the predictor variables are all ads except for ads for the specialty.
Discussion
This study provided a view of how healthcare providers position themselves through online advertisements. Our data revealed that providers fully embraced their position as patient-centered providers, as demonstrated by the prevalent claims. At the same time, the scarcity of using the terms “consumer/client/customer” contrasted sharply with the dominant use of the word “patient,” suggesting that providers were reluctant to advertise using terminology closely associated with consumerism.
Instead, the advertisements seemed to take the consumerism position rather indirectly. Not only did a substantial proportion of advertisements overtly publicize convenience and the availability of amenities at their sites of care, but they also directly addressed patients by calling them with second-person pronouns, an advertising strategy known as synthetic personalization (25). By commonly using the third-person references, “our doctors/providers,” to refer to providers in charge of patient care, the advertisements also inadvertently revealed that it was not providers but someone else—staff or customer care representatives—who were addressing the prospective patients.
The explicit embrace of patient-centered care and more implicit endorsement of healthcare consumerism points to an advertising strategy that draws on the “best of both worlds.” Similarly, the low number of advertisements using the terms “clients/customers/consumers” may reflect providers’ strategic positioning: Providers may suspect that while the patients consider consumer ratings and amenities in deciding where to get care, these same patients do not want to be called by a consumerism construct. Indeed, commercially savvy providers know what people want—to be called patients but treated like a customer (9)—and strategically deploy the terms.
Contrary to the prominence of patient experience claims, none of the provider attributes searched for in this analysis appeared frequently. This contrast is brought into focus by the fact that amenities, the least commonly claimed patient experience, were more prevalent than providers’ training. The absence of provider attributes goes against the notion of patient-centered care as “two-person medicine,” whereby the provider is as integral to the medical encounter as the patient (1). The scarcity of professional attributes also weakens the common defense of healthcare consumerism: When patients are led to pay more attention to convenient locations and fancy facilities than to the professional training of their providers, their decision may not lead to the best health outcomes.
Further, we suggest that it would be a mistake to consider the comparable presence of professional and consumerism attributes as an equilibrium between patient-centeredness and consumerism. Instead, we argue, it signals a surge in consumerism where providers feel obligated to hone their customer service skills to get good consumer reviews and invest in reputation management to earn consumer awards and, in turn, use the consumer-driven metrics of quality of care to promote their services. The growing emphasis on consumerism elements vis-à-vis waning prominence of professional attributes is also problematic for providers’ self-image. Well-trained providers who continue to learn and grow through affiliations with their professional colleagues are the foundation of a patient–provider relationship. Yet, the advertisements may suggest that providers’ professional credentials matter to their patients less than consumer ratings.
Providers cannot occupy the position of respected professionals and sustain the storyline of trusted guardians of public health if their intrinsic values and speech acts do not align with the desired position. The results of inter-specialty comparisons may provide indirect evidence for this assertion. The advertisements for cosmetic surgery services stood out for the far stronger presence of consumerism indicators such as provider consumerism attributes, amenities, and “our doctor(s).” At the same time, cosmetic surgery advertisements were much less likely to promote patient convenience features than others. In this consumerism context where patient convenience is slighted, the strong emphasis on the professional attributes of providers could be seen as a mere strategic device to differentiate themselves from their competitors. Then, it may be no coincidence that plastic surgeons are more often questioned for their ethics than other providers (30) and that the public has less professional respect for plastic surgeons than for other doctors in general (31).
For healthcare providers and marketers who wish to align their positions with their speech acts, the indicators of patient-centeredness and consumerism laid out in Figure 1 could provide guidance. By choosing to highlight some and not others, they can articulate their positions and convey them to the public more clearly. Heightened awareness of patient-centeredness and consumerism indicators in healthcare service advertisements could also serve the members of the public by allowing them to screen providers whose positions articulated in the advertisements align with theirs and hence reducing a potential gap between their expectations and actual experience.
Limitations
There are several limitations of this study. First, we analyzed only the landing page of the online advertisements. Still, the decision to feature certain aspects of the healthcare practice but not others on the landing page reflects their marketing strategy and priorities. Related, some of the advertisements may have been designed by marketing agencies with a more curated focus than others. Second, the advertisements were collected in two designated market areas in one state. Third, the classification of consumerism and patient-centeredness indicators needs more discussion. For instance, not all provider professional attributes examined in this study are equally significant to patient care, and further differentiation may be necessary (e.g., board certification vs society membership). Likewise, the patient convenience factors promoted in the advertisements may have implications beyond convenience, sometimes with opposite effects on the clinical outcomes. For example, same-day appointments or flexible hours may prevent emergency visits and unnecessary hospitalization, whereas a promise of multiple procedures in one visit even before seeing the patient could compromise patient safety.
Conclusions and Recommendations for Practice
We found that healthcare service providers embrace both patient-centeredness and consumerism in their online advertisements. In representing providers, the advertisements downplayed their professional credentials while emphasizing certain consumerism attributes. Some inter-specialty differences in the embrace of consumerism and patient-centered care were also found.
We suggest that providers take a closer look at their advertisements. Application of the healthcare service advertising analytic scheme developed for this study could help providers and healthcare administrators recognize how their advertisements may reflect their values. Subsequently, the scrutiny may spur realignment between the advertising messages and their goals and values.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This work was supported by the National Science Foundation (grant number 1759113).
