Lower fiduciary trust in physicians’ medical decision-making among those with high medical cost burdens includes perceptions of both overuse and underuse of services: patients with high burden are less likely to believe that their physician will refer them to a specialist (i.e., receiving fewer services than needed), while at the same time more likely to believe that their physician is performing unnecessary tests (i.e., receiving more services than needed). Such response patterns may reflect a consistent belief that the physician is more interested in financial gain from the patient than ensuring they are receiving appropriate and necessary services.
The negative association between high medical cost burdens and patients’ trust and assessments of quality of care received was largest and most consistent for nonelderly adults with private insurance. High medical costs may provoke negative feelings among privately insured persons since there is an expectation that their coverage should protect them from incurring high costs. Uninsured and persons enrolled in Medicaid/other state coverage generally have lower incomes, lower levels of fiduciary trust, and lower overall assessments of quality of care compared to privately insured persons, and therefore may be more accustomed to negative experiences with health care.
The fact that high medical cost burdens may lead to patient unhappiness and dissatisfaction with the health-care system is perhaps not surprising, but the crucial issue is whether lack of trust associated with high medical cost burdens is long-lasting and detrimental to care and compliance with medical regimens, as has been demonstrated in prior research6-9
. Some medically related financial problems are temporary and therefore may not have serious or long-term consequences for patient care. However, some persons experience persistently high medical costs and out-of-pocket expenses, usually because of chronic conditions that require ongoing treatment.21
Other research has shown that high financial barriers increase medication nonadherence, including among elderly with chronic conditions.22,23
. The extent to which low levels of trust in the physician contribute to these lower compliance rates is unknown. Also, while efforts to strengthen the patient-physician relationship through greater patient-centeredness and stronger medical homes may improve patient trust in physicians, it is unknown whether these efforts can mitigate the negative consequences of high medical cost burdens or instead will be thwarted by them.
Because the results from this study are based on cross-sectional analyses, it is not possible to determine conclusively that high medical cost burdens actually cause lower trust and lower assessments of quality of care. It is possible that persons with less trust in physicians’ medical decision-making increase their out-of-pocket costs through overuse or inefficient use of services, for example, by constantly seeking second and third opinions or having expensive tests rerun. However, this would suggest that lower trust leads to greater utilization rather than lower utilization of health care, which is contrary to previous research6
. Moreover, the logistic regression analyses controlled for measures of health-care utilization, the inclusion of which had little impact on the results.
Another limitation of the analysis is that the survey did not include information on characteristics of the practice setting and the health plan that could also be correlated with high medical cost burdens, but are not controlled for in the analysis.
Greater understanding of the effects of high medical cost burdens on the patient-physician relationship is needed because out-of-pocket expenses are increasing for American families, especially for privately insured persons.1
Also, many policymakers are advocating for Consumer Directed Health Care (CDHC), including high deductible health plans in which roughly the first $1,000 to $2,000 of health-care bills are paid entirely out of pocket or from a tax-advantaged Health Savings Account. Advocates believe that greater cost-consciousness among patients will help to both lower health costs and improve quality of care. However, the extent to which greater cost-consciousness may also result in greater skepticism by patients about physicians’ treatment recommendations is unknown.
High medical cost burdens among the population threaten not only the financial well-being of American families, but may also pose a threat to the patient-physician relationship. That the general public is highly concerned and aware of rising health-care costs is evident from public opinion polls.5
Such concerns may translate into greater distrust of physician’s motives in making medical decisions about their care when patients discover that their health insurance does not protect them from financially burdensome expenses. As policymakers consider the question of “affordable” health coverage, they also need to consider the impact on patient care of setting affordability standards too high.