Health Care Costs and Financing

Physicians seem to manage potential conflicts with managed care financial arrangements to retain patient trust

Concerns have been raised about the potentially negative impact of managed care cost-containment strategies on the physician-patient relationship. However, a new study found that, despite the potential for conflicts of interest for physicians under financial arrangements designed to limit overuse of care, physicians have avoided compromising their patients' trust in and satisfaction with them.

The investigators surveyed 595 patients with diabetes or hypertension enrolled in 1 of 3 health plans in Minnesota about their trust in and satisfaction with their physicians. They also surveyed the patients' 389 physicians about cost-containment strategies to which they were subject. Patients were generally very trusting of their physicians: 43.5 percent trusted their physician completely, 50 percent mostly, 6 percent somewhat, and 1 percent a little. Patients also rated their physicians highly.

After adjusting for patient and physician characteristics, patients whose physicians were required to serve as a gatekeeper (for specialty referrals and tests) for more than 50 percent of their patients tended to rate their physicians somewhat lower than other patients, but did not differ in levels of physician trust. Those whose physicians received performance reports on their use of diagnostic tests and other resources did not differ from other patients in level of trust or ratings of physicians.

Patients of doctors whose compensation was based on fee-for-service arrangements were less trusting of their physician than patients whose physicians were paid by salary, but did not differ significantly in levels of satisfaction. The size of physicians' bonuses and withhold payments were not associated with patients' trust or satisfaction, nor were incentive payments to physicians based on a variety of factors. The findings are not generalizable to settings outside of Minnesota, a State where managed care organizations are nonprofit and there is little racial diversity.

The study was supported in part by the Agency for Healthcare Research and Quality (HS09936).

See "The influence of cost containment strategies and physicians' financial arrangements on patients' trust and satisfaction," by Nancy L. Keating, M.D., M.P.H., Mary Beth Landrum, Ph.D., Bruce E. Landon, M.D., M.B.A., and others, in the April-June 2007 Journal of Ambulatory Care Management 30(2), pp. 92-104.

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