Despite the profound and pervasive importance of trust in medical settings, there is no commonly shared understanding of what trust means, and little is known about what difference trust actually makes, what factors affect trust, and how trust relates to other similar attitudes and behaviors. To address this gap in understanding, the emerging theoretical, empirical, and public policy literature on trust in physicians and in medical institutions is reviewed and synthesized. Based on this review and additional research and analysis, a formal definition and conceptual model of trust is presented, with a review of the extent to which this model has been confirmed by empirical studies. This conceptual and empirical understanding has significance for ethics, law, and public policy.

/pdf/trust-in-physicians-and-medical-institutions-what-is-it-can-4rud87bmyx.pdf

Trust in physicians and medical institutions: what is it, can it be measured, and does it matter?

Subjective unmet need and utilization of health care services in Canada: What are the equity implications?

CONTEXT: Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks.

/pdf/vulnerability-and-unmet-health-care-needs-the-influence-of-580ihrd47h.pdf

Vulnerability and unmet health care needs. The influence of multiple risk factors.

This paper synthesizes results from peer-reviewed literature published from 1997 to mid-2001, on various dimensions of health maintenance organization (HMO) plan performance. Results from seventy-nine studies suggest that both types of plans provide roughly comparable quality of care, while HMOs lower use of hospital and other expensive resources somewhat. At the same time, HMO enrollees report worse results on many measures of access to care and lower levels of satisfaction, compared with non-HMO enrollees. Quality-of-care results in particular are heterogeneous, which suggests that quality is not uniform—that it varies widely among providers, plans (HMO and non-HMO), and geographic areas.

HMO plan performance update: an analysis of the literature, 1997-2001.

Racial and ethnic disparities in health and health care are well documented (Smedley, Stith, and Nelson 2002). Yet, a full understanding of the causal mechanisms of these disparities remains elusive. Three threads of work stimulated this paper. First, patient preferences may play a pronounced role in explaining disparities—patients' values and beliefs, including their level of trust in clinical advice, influence the level of care they receive (Smedley, Stith, and Nelson 2002). Specifically, a patient's comfort level with an intervention can influence his or her willingness to seek or accept treatment, be it physical or emotional. Second, physicians' advice and behavior may vary depending on perceived patient attributes (Smedley, Stith, and Nelson 2002). Third, racial and ethnic minorities have lower levels of trust and satisfaction with their providers—physicians, hospitals, health plans, and the health care system in general (Meredith and Sui 1995; Auslander et al. 1997; Taira et al. 1997; Morales et al. 1999; Doescher et al. 2000; LaVeist, Nickerson, and Bowie 2000; Murray-Garcia et al. 2000; Morales et al. 2001; Weech-Maldonado et al. 2001; Collins et al. 2002; Corbie-Smith, Thomas, and St. George 2002; Shi et al. 2003).

We wondered whether trust and satisfaction could be explained by the type of plan in which many racial and ethnic minorities find themselves. Prior studies suggest that individuals—regardless of race and ethnicity—enrolled in more heavily managed care plans like capitated or group model health maintenance organizations (HMOs) report less favorable assessments of the care provided by their physicians. Racial and ethnic minorities are more likely to be enrolled in restrictive, tightly managed care plans than whites, thereby explaining their lower levels of trust and satisfaction (Center for Studying Health System Change 2000). Unequal Treatment astutely points out that much of the previous research on racial and ethnic disparities controls for insurance status on a very general level (e.g., insured versus uninsured, privately insured versus publicly insured, etc.), but it does not adequately control for the generosity or restrictiveness of a particular insurance coverage. Findings from this research therefore leave open the possibility that racial disparities in care result to some degree from the disproportionate enrollment of racial and ethnic subgroups in more restrictive health plans (Smedley, Stith, and Nelson 2002). Our study attempts to fill this gap in the literature on trust and satisfaction.

From a public policy standpoint, it is important to understand these differences because trust and satisfaction have been linked to health outcomes (Morales et al. 2001). Patient assessments of health care are associated with service utilization (Zastowny, Roghmann, and Cafferata 1998), the decision to switch health plans (Newcomer, Preston, and Harrington 1996; Allen and Rogers 1997; Schlesinger, Druss, and Thomas 1999), and treatment compliance (Hall and Dornan 1990).

Racial and Ethnic Disparities and Perceptions of Health Care: Does Health Plan Type Matter?

OBJECTIVE: To inform the debate about managed care by examining how different types of private insurance-indemnity insurance, PPOs, open model HMOs, and closed model HMOs-affect the use of health services and consumer assessments of care. DATA SOURCES/DATA COLLECTION: The 1996-1997 Community Tracking Study Household Survey, a nationally representative telephone survey of households, and the Community Tracking Study Insurance Followback Survey, a supplement to the Household Survey, which asks insurance organizations to match household respondents to specific insurance products. The analysis sample includes 27,257 nonelderly individuals covered by private insurance. STUDY DESIGN: Based on insurer reports, individuals are grouped into one of the four insurance product types. Measures of service use include ambulatory visits, preventive care use, hospital use, surgeries, specialist use, and whether there is a usual source of care. Consumer assessments of care include unmet or delayed care needs, satisfaction with health care, ratings of the last physician visit, and trust in physicians. Estimates are adjusted to control for differences in individual characteristics and location. PRINCIPAL FINDINGS: As one moves from indemnity insurance to PPOs to open model HMOs to closed model HMOs, use of primary care increases modestly but use of specialists is reduced. Few differences are observed in other areas of service use, such as preventive care, hospital use, and surgeries. The likelihood of having unmet or delayed care does not vary by insurance type, but the reasons that underlie such access problems do vary: enrollees in more managed products are less likely to cite financial barriers to care but are more likely to perceive problems in provider access, convenience, and organizational factors. Consumer assessments of care-including satisfaction with care, ratings of the last physician visit, and trust in physicians-are generally lower under more managed products, particularly closed model HMOs. CONCLUSIONS: The type of insurance that people have-not just whether it is managed care but the type of managed care-affects their use of services and their assessments of the care they receive. Consumers and policymakers should be reminded that managed care encompasses a variety of types of insurance products that have different effects and may require different policy responses.

Does type of health insurance affect health care use and assessments of care among the privately insured

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Does type of health insurance affect health care use and assessments of care among the privately insured