“Client” or “Patient”: Does it Make a Difference?
In behavioral health the terms “client” or “patient” are used to describe people receiving treatment services. The differences are often related to the type of the provider’s profession or license. Consumers of services provided by medical professionals, physicians, nurses, and pharmacists are referred to as “patients” as well as services provided in hospitals or sub-acute medical levels of addiction services such as ASAM Level 3.7 (medically monitored intensive inpatient treatment) and ASAM Level 4 (medically managed intensive inpatient treatment). Nonmedical behavioral health clinicians like psychologists also usually refer to the people as “patients” and other behavioral health practitioners such as social workers, professional counselors or alcohol and drug counselors may refer to the people they treat either way, but more commonly as “clients.”
Programs which provide services in the public sector— meaning publically funded and/or nonmedical—which differ in which state agency licenses them almost universally use the term “clients.” Medicare uses “patient” and Medicaid often use “consumers.” In terms of state licensing regulations, historically, licensing of medical professionals fell under the Department of Health while behavioral health services, particularly addiction services fell under state drug or alcohol or addiction services, although some of these services have been moved under the Department of Health or Mental Health.
Early residential addiction treatment, which was not originally even licensed, was started by AA members who stepped into the void left by the abdication of the responsibility of medical and behavioral health professionals to treat people with substance use disorders (SUDs). These early folks were not clinicians of any stripe and what they did was share their strength, hope, and experience. These early programs had no medical staff, physicians or nurses, and if patients needed withdrawal management services they were transferred to a hospital or a free-standing detox facility. This was a model which mirrored today’s ambulatory surgery centers, although they remained overnight until their detoxification was complete, and then hopefully returned to the treatment center. Some of these programs began to use the term “patients” in order to gain credibility even though there was no medical component.
Structured outpatient treatment such as intensive outpatient (IOP) and partial hospitalization (PHP) may use either term, with IOP more likely to use “client” since many provide no medical services and PHP more likely to use “patient” either because of the medical and psychiatric comorbidity of the individuals treated or because they were either owned or operated by a hospital or physician, often a psychiatrist.
If you have read this far, you might be wondering, “So what?” Does it make a difference? Please read on.
In early SUD treatment there was great opposition to the “medical model,” a term coined by psychiatrist R. D. Laing in his book The Politics of the Family and Other Essays, for the “set of procedures in which all doctors are trained” (1971). However, for many of these nonclinical people who started or worked in early treatment programs, the medical model was an anathema associated with inappropriate and often harmful treatments provided to alcoholics by physicians who had little or no understanding of addiction. This resistance to the medical model is still evident (but diminishing) as evidenced by the past reluctance to the use of psychotropic drugs (much more accepted recently) and addiction agonist and antagonist drugs (currently not as commonly accepted).
This separation between medical and behavioral health services found its way into commercial insurance reimbursement for addiction treatment. Insurance companies “carved out” behavioral health benefits as separate from medical benefits. In my own history, I recall arguing with insurers about whether the problem under consideration was a medical or behavioral health problem, which was especially problematic when medical and behavioral benefits were provided by different insurance companies.
Initially, insurers would reimburse for inpatient treatment provided in a medically monitored intensive inpatient level of care (ASAM Level 3.7), but absolutely refused to reimburse for residential treatment, clinically managed high-intensity residential treatment, ASAM Level 3.5 (e.g., “We don’t pay for residential treatment”). Over time they recognized that it was less expensive to reimburse for residential treatment compared with inpatient and they began doing so.
While the ASAM Criteria refers to all the consumers of treatment as “patients” (2013), The DSM assiduously avoids calling the people referred to in the manual as anything with the exception of adolescent or adult (2013). The ASAM Principles of Addiction Medicine also uses “patient” rather than “client” (2014). The Merriam Webster dictionary defines a client as “a person who pays a professional person or organization for services” (2016a) while it defines a “patient” as a “person who receives medical care or treatment” (2016b). “Client” is usually considered one who seeks advice while “patient” is one who seeks treatment.
So back to the question of “So what?” What is the importance of language here? I think that there are three benefits to referring to persons receiving addiction treatment services as “patients.”
- “Patient” seems more associated with health care professionalism than “client.”
- When performing managed care reviews, whether admission or continued treatment, the MCO reviewer is attempting to decide whether people are “sick enough” to warrant insurance payment for their treatment. “Patient” fits much better into this model than “client.” Looking at it another way, attorneys have clients, accountants have clients, and even prostitutes have clients. What we have is people who have a need for health care services. Put yourself in the place of the MCO reviewer. Who would you think is more deserving of approval of payment? Medicare, which often sets the bar for reimbursement refers to the people covered by Medicare and receiving services paid for by Medicare as “patients.”
- I personally doubt how much of a difference the access to insurance benefits as the result of the Affordable Care Act will make in admissions to addiction treatment. The real reason why we are seeing such a small percentage of people who need treatment who demand treatment (estimated at 10 percent) is usually not the lack of insurance reimbursement, but more often feelings of shame, stigma, and denial. Is it not possible that an individual needing treatment might feel less shamed and stigmatized by the term “patient” than “client?”
As we move toward outcomes-based or value-based reimbursement as Medicare has done with their merit-based incentive payment system (MIPS) in 2017 (CMS, n.d.), in which a hospital is financially penalized for patients’ needs to be readmitted within thirty days of discharge for the same problem for which they were previously admitted, I suspect (and hope) that we will call the people we treat “patients” as Medicare, which sets the bar for all of the payers, does.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author.
Centers for Medicare and Medicaid Services (CMS). (n.d.). Quality payment program. Retrieved from https://qpp.cms.gov/
Laing, R. (1971). The politics of the family and other essays. New York, NY: Routledge.
Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Miller, M. M. (Eds.). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Carson City, NV: The Change Companies.
Merriam-Webster. (2016a). Client. Retrieved from http://www.merriam-webster.com/dictionary/client
Merriam-Webster. (2016b). Patient. Retrieved from http://www.merriam-webster.com/dictionary/patient
Ries, R. K., Fiellin, D. A., Miller, S. C., Saitz, R. (Eds.). (2014). The ASAM principles of addiction medicine. Philadelphia, PA: Lippincott, Williams, & Wilkins.