Goold Susan Dorr, Klipp Glenn
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor 48109-0429, USA.
Soc Sci Med. 2002 Mar;54(6):879-88. doi: 10.1016/s0277-9536(01)00070-3.
Informed choice of health insurance could morally justify later, potentially harmful rationing decisions the way informed consent justifies potentially harmful medical interventions. In complex and technical areas, however, individuals may base decisions more on trust than informed choice. We interviewed enrollees in managed care plans in Southeast Michigan, United States, to explore in detail their expectations and experiences in choosing and using their health plan. Diverse subjects participated in semi-structured interviews about health insurance choices, experiences, and expectations. Results are presented for the theme of trust (and distrust), which emerged spontaneously in discussions about health care and health insurance. Forty subjects diverse in age, ethnicity, and income took part in 31 interviews. Interviewees mentioned many of the elements of interpersonal trust in specific physicians, often in the context of discussions about care experiences, doctor payment, and conflict of interest. Elements included physical and emotional vulnerability, expectations of goodwill, advocacy and competence. and belief in professional ethics. Trust in the medical profession had more hesitancy, and often included mention of honesty or ethics. Elements of trust in hospitals included vulnerability to financial loss, and expectations of competence (quality). Elements of trust in health insurance plans often emerged in discussions about catastrophic illness coverage denials, and profit, and were more often negative. Vulnerability, worry, fear and security were prominent. Fiscal rather than clinical competence was emphasized, while expectations of goodwill remained. Enrollees in managed care plans spontaneously discussed trust and distrust in individuals and institutions during conversations about their insurance expectations and experiences. Similarities and differences in the elements and the context of these discussions illuminate distinctions between these healthcare relationships of trust.
明智地选择医疗保险在道德上可以为后来可能有害的配给决策提供正当理由，就像知情同意为可能有害的医疗干预提供正当理由一样。然而，在复杂和技术领域，个人做出决策可能更多基于信任而非明智选择。我们采访了美国密歇根州东南部管理式医疗计划的参保人，以详细探究他们在选择和使用健康计划方面的期望和经历。不同的受试者参与了关于医疗保险选择、经历和期望的半结构化访谈。本文呈现了在关于医疗保健和医疗保险的讨论中自发出现的信任（和不信任）主题的结果。40名年龄、种族和收入各异的受试者参与了31次访谈。受访者在讨论护理经历、医生薪酬和利益冲突时，经常提到对特定医生人际信任的诸多要素。这些要素包括身体和情感上的脆弱性、善意期望、支持和能力，以及对职业道德的信念。对医疗行业的信任则更具迟疑性，且经常提到诚实或道德。对医院信任的要素包括易遭受经济损失以及对能力（质量）的期望。对医疗保险计划信任的要素经常出现在关于重大疾病保险赔付拒绝和利润的讨论中，且更多是负面的。脆弱性、担忧、恐惧和安全感较为突出。强调的是财务而非临床能力，同时对善意的期望依然存在。管理式医疗计划的参保人在谈论他们的保险期望和经历时，自发地讨论了对个人和机构的信任与不信任。这些讨论要素及背景中的异同揭示了这些医疗信任关系之间的差异。
