Organizational changes in health care have altered the relationship between physicians and third party payers, and have the potential of affecting patient-physician relationships.20 –28
Some contend that managed care's emphasis on preventive and primary care 29 –31
has led to more cost-effective clinical practice. Others have raised concerns that managed care incentives and rules place physicians in a position with potentially conflicting obligations to patients and insurers. 32 –36
In light of significant changes, it is important to understand better factors affecting patients' trust in their physicians, a foundation of the patient-physician relationship.
Most patients in our study trusted their physicians to act in their best interests. Nearly three fourths of all respondents completely trusted their physicians to “put (their) medical needs above all other considerations.” Fewer patients completely trusted their managed care organization, which is consistent with declining social trust in all institutions, 37, 38
and with a natural inclination to trust an individual more than an organization. Nevertheless, organizations can develop and implement policies to reinforce trust.8, 39
Patients who trusted their managed care organization were more likely to trust their physicians.
Patients who reported having enough choice of physicians were more likely to trust their physician. However, having more than one health plan option was not associated with physician trust. It may be that patients are less concerned about how many health plan options are available to them as long as their health plan provides them with enough choice of physicians. Patients who had longer patient-physician relationships were also more likely to trust their physicians. Trust is developed through an iterative process of interaction and experience,8, 40
and continuity of care may provide patients with the time necessary for interpersonal trust to develop.
To varying degrees, managed care plans limit patients' choice of physicians and restrict access to specialists. For example, patients in staff-model HMOs are usually limited to physicians who are directly employed by the health plan. Conversely, point-of-service (POS) plans and preferred provider organizations (PPOs) are less restrictive and offer patients more choice of physicians outside the plan (with increased patient cost sharing). Over the past few years, HMOs have experienced little growth in their membership. In a recent survey of employers, the percentage of working Americans insured by HMO plans was unchanged at 27% from 1995 to 1996.41
Conversely, health plan options that offer patients more open access to a larger panel of physicians including specialists have experienced steady enrollment growth (POS plans from 14% to 19% and PPOs from 29% to 31% from 1995 to 1996). Currently, over 80 million people are enrolled in PPOs,42
and having a choice of physicians is most likely one of the factors contributing to their growing popularity among consumers.
Although the public appears to favor health plans with greater choice of physicians, continuity of patient-physician relationships has become more difficult to sustain in our employment-based health care system. Decisions about continuity of care are made by employers, health plans, physicians, and plan members for a variety of reasons, including issues of quality, cost, and convenience. When employers switch health plans, existing patient-physician relationships cannot be maintained if the new health plan selected by the employer has a different panel of physicians. Even when employers remain with the same health plan, physicians deselected by the plan on the basis of quality performance standards, utilization measures, credentialing, or other criteria are no longer eligible to provide care to enrollees of that plan.43–46
Physicians can also deselect health plans and choose not to be a participating provider, but this is less of an issue in mature managed care markets.47–49
Plan members may change health plans based on provider preference, plan benefits, or cost considerations.
Nearly two thirds of all respondents either did not know or incorrectly identified their physician's payment method. When patients were asked to assess the impact of different payment methods on the quality of care, most believed that payment methods would have no effect on their care. However, a large percentage of all respondents believed that paying physicians “more for ordering fewer than the average number of tests” would make their care worse.
Although patients expressed concern about certain payment strategies, their perceptions of how their own physician was paid were not significantly related to their trust in him or her. This may be because once a patient-physician relationship is established any effects of attitudes about the physician's reimbursement are minor compared with other factors that affect patient trust. The American Association of Health Plans has decided to provide information about physician payment methods to health plan members who request it. It is unclear when patients should be given such information, how this information should be presented, and who should inform them.43, 50
We were unable to contact a large number of patients originally selected from administrative records. The observed differences between the respondent and nonrespondent groups could contribute to response bias. However, it seems unlikely that having a choice of physician and maintaining continuity of care would be less relevant determinants of physician trust in the nonrespondent group.
Systems of care that foster patient trust enhance the quality of the patient-physician relationship. Our findings suggest that patients who have a choice of physicians and are in longer, stable patient-physician relationships are more likely to trust their physician. Further studies examining patient-physician relationships under different payment arrangements including capitated and indemnity methods may provide us with a better understanding of factors contributing to patients' trust in their physicians.