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Population Health for Nurses

5.2 Health Care Consumer Behavior

Population Health for Nurses5.2 Health Care Consumer Behavior

Learning Outcomes

By the end of this section, you should be able to:

  • 5.2.1 Examine how the availability of health care services influences consumer behavior.
  • 5.2.2 Discuss how consumer confidence influences consumer behavior.
  • 5.2.3 Explain how the cost of health care services affects consumer behavior.

A health care consumer is someone who makes use of health care services regardless of whether they pay for those services directly or those services are provided to them at no cost. Internal and external factors affecting health care consumers’ behavior include:

  • Availability of health care services and providers
  • Consumer confidence
  • Consumer loyalty
  • Cost of health care services

Availability of Health Care Services

The availability of health care services and health care providers may be limited or absent, depending on where an individual lives. This is especially true for people who live in rural areas where the distance to the nearest clinic, hospital, or provider may be great and transportation to reach health care services may be a barrier related to cost or availability. Many rural regions of the United States have been experiencing severe shortages of primary care providers for decades (Rural Health Information Hub [RHIH], 2023), exacerbating health disparities as individuals without reasonable access to health care providers and services cannot adequately address health conditions or receive preventive care, such as screenings (CDC, 2022g).

Mental health care is essential to a population’s health, yet there are additional barriers to accessing these services—particularly for disadvantaged groups. “Mental health includes a person’s emotional, psychological, and social well-being. It affects how we think, feel, act, handle stress, relate to others, and make choices” (CDC, 2022c). The cost of mental health services has continued to rise in the United States over the last decade. According to Harvard Pilgrim Health Care (2023), “even prior to the pandemic in 2019, the cost of mental health treatment and services reached $225 billion, up 52 percent from 10 years earlier.”

Ethnic minorities experience greater mental health disparities than the rest of the population (CDC, 2023c). This is often related to limited access to health care services as well as stigma and discrimination, which may prevent individuals from seeking care. Stigma is shame or disgrace attached to an individual’s circumstance, background, personal traits, or associations. Often the result of ignorance or fear, stigmatization involves negative attitudes and beliefs toward people, which can also lead to discrimination (American Psychiatric Association (APA), 2023; Mayo Clinic, 2017). This stigma is especially acute in minority communities. For some populations, such as ethnic minorities and those struggling with chronic diseases, accessing mental health services is especially difficult. For example, ethnic minorities tend to live in areas that lack treatment facilities or health care providers qualified to offer mental health services (CDC, 2022g). In addition, stigma related to mental illness tends to prevent individuals from seeking care (Mayo Clinic, 2017). The combination of stigma and limited access to health care services means that individuals living with mental illness may not seek care until their disease has advanced to the point that more expensive treatments or even institutionalization are required, which drives up the cost of caring for an individual living with a mental illness. Caring for Populations and Communities in Crisis provides more information on mental health.

Consumer Confidence

Consumer confidence refers to how individuals feel about health care services and providers. Confidence in the health care system can be compromised. For example, a history of structural racism and discrimination in the United States may lead members of some communities, such as communities of color, to distrust the health care system. People who distrust the system tend to avoid seeking the care they need to address health conditions, such as chronic diseases (CDC, 2022f; 2022g). Individuals who are concerned that they will not be able to communicate effectively with health care providers or navigate the complexities of the health care system due to language barriers, low health literacy, or both may be reluctant to seek care (RHIH, 2022). Consumer loyalty refers to an ongoing emotional relationship between an organization and its customers. Customers loyal to an organization tend to support its mission and utilize its services (Oracle, 2023). Based on this definition of customer loyalty and consumer confidence, it is possible to conclude that mistrust in the health care system may prevent individuals from seeking care, potentially further exacerbating health disparities (CDC, 2022g).

The COVID-19 pandemic highlighted the longstanding issue of a lack of trust in the health care system among ethnic minorities and other underrepresented populations, resulting in vaccine hesitancy despite higher rates of COVID-19 infections, deaths, and hospitalizations among this demographic (Shearn & Krockow, 2023). The rapid development of the COVID-19 vaccine caused many communities—such as Black, Hispanic, and immigrant communities—to grow increasingly distrustful of the health care system because of a history of unethical research practices in which minorities were mistreated. This significantly increased the level of anxiety among these groups and made many less likely to get vaccinated (Baker, 2020). A systematic review of the literature by Shearn and Krockow (2023) attributed three main themes related to COVID-19 vaccine hesitancy among ethnic and racial minority populations: institutional mistrust, lack of confidence in the vaccine development process, and lack of reliable information or messengers. In addition to the general history of racism and discrimination encountered by this population, many are aware of a history of previous mistreatment and unethical research practices by medical researchers, such as bias in assigning minorities to study groups in clinical trials. For this reason, some equated the rapid development of the COVID-19 vaccine with fears about medical experimentation, sterilization, or eradication. Individuals who reside in the United States without legal documentation expressed concerns that data related to their vaccination would be shared with immigration enforcement (Shearn & Krockow, 2023; Rusoja & Thomas, 2021).

Health Care Costs and Consumer Behavior

Cost determines if an individual can afford to pay for health care services. Those with limited income often must choose between health care and basic needs such as food and shelter. In this situation, they may choose not to seek health care services altogether, which further exacerbates health disparities related to chronic diseases such as diabetes, heart disease, and obesity (CDC, 2022g).

Cost of Health Insurance

Health care costs impact the behavior of individuals who lack the means to pay for health care services. For example, ethnic minorities, such as Hispanic and Black clients, tend to have higher rates of uninsured than their White counterparts. This is especially true of individuals living in rural and urban areas and of the “working poor,” individuals who do not make enough money to purchase health insurance but who make too much money to qualify for Medicaid (Commonwealth Fund, 2021). When individuals lack the means to pay for health care services, their use of health care services tends to decrease, which leads to more negative health outcomes for the client.

Cost of Prescription Drugs

The cost of prescription medications also affects consumer behavior. Prescription drug prices have risen steadily in the last two decades in the United States. According to a report by the American Association of Retired Persons (AARP, 2021), every year since 2006, the cost of specialty prescription drugs has increased at a rate that far exceeds the general inflation rate. Such specialty medications are used to treat cancer, rheumatoid arthritis, multiple sclerosis, and other conditions and are used widely by older adults. Approximately three in 10 adults report not taking their medications as prescribed due to cost (Kirzinger et al., 2023). Among this group, 21 percent did not fill the prescription, 21 percent took an over-the-counter medication instead of getting the prescription filled, and 12 percent reported cutting the pills in half or skipping doses to save costs. Other common strategies clients use to decrease drug costs include using generic drugs, asking the health care provider to prescribe a different medication (a less expensive alternative, a higher dose that can be split in half, or a different form of the drug—a cream instead of a gel, for example), or trying alternative therapies (CDC, 2019b).

Cost of Delaying Care

According to the CDC (2022g), racial and ethnic minorities tend to be impacted by disease at greater levels than their White counterparts. The same can be said of older adults, who tend to have more health issues than their younger counterparts. In many cases—because of the cost of, mistrust in, or lack of easy access to health care services and providers in their communities—individuals may wait until their disease is more advanced before they seek health care. For example, a person who does not receive care during prediabetes may be impacted by kidney failure secondary to diabetes, which is far more expensive than preventing or even managing diabetes before it has damaged the kidneys.

The COVID-19 pandemic also ushered in a time of economic challenges. Job losses peaked during the pandemic, especially for minority populations who worked in low-paying industries impacted by pandemic-caused closures (Center on Budget and Policy Priorities, 2022). These job losses coincided with a rise in health care costs, which exacerbated the tendency of many ethnic minorities to not seek health care, contributing to negative health outcomes among groups who were already struggling before the arrival of the pandemic.

Cost of Disease Care

Ethnic minorities and older adults may also be more likely to be the recipients of public health insurance programs such as Medicaid and Medicare. The types and severity of health conditions experienced by these demographics make health care costs covered by government insurance programs even greater. For example, as the percentage of older adults in the United States grows, the dollars Medicare pays will continue to rise. This is especially true as the large numbers of aging baby boomers become eligible for Medicare at age 65.

When individuals lack adequate health insurance, they tend to use hospital emergency departments more frequently (Figure 5.4) (Udalova et al., 2022). Laws prevent health care organizations from turning clients away when they present to the emergency department. When individuals lack health insurance, health care organizations may have to provide uncompensated care, which leads to increased costs for the facility (American Hospital Association, 2023c). Individuals from underrepresented communities and those with lower incomes tend to use an emergency department for preventable care more than their counterparts in other communities (Udalova et al., 2022). Thus, the cost of paying for health insurance for underrepresented populations leads these populations to use the emergency department for services best addressed in another setting (Udalova et al., 2022).

A photograph shows the entrance to a hospital emergency department.
Figure 5.4 Individuals who lack access to other health care providers or health insurance may seek treatment at a hospital emergency department. (credit: “Saratoga Hospital emergency entrance, Saratoga Springs NY” by Peter/Flickr, CC BY 2.0)

Healthy People 2030

Reduce Emergency Department Visits for Nonfatal Injuries

According to Healthy People 2030, there were approximately 9,325 emergency department visits for nonfatal injuries per 100,000 people in 2017. To address this issue, Healthy People 2030 established a goal to reduce the number of visits for nonfatal injuries to approximately 7,711 per 100,000 people by 2030. The most recent data from 2020 show this goal has been exceeded.

(See ODPHP, 2023b.)

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