Balkrishnan Rajesh, Hall Mark A, Blackwelder Stephen, Bradley Donald
Division of Management, Policy, and Community Health, University of Texas School of Public Health, Houston 77030, USA.
Health Serv Res. 2004 Aug;39(4 Pt 1):813-23. doi: 10.1111/j.1475-6773.2004.00259.x.
Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers, and have been cross-sectional rather than longitudinal studies. This study examined associations among trust in a managed care insurer, trust in one's primary physician, and subsequent enrollee behaviors relating to source of care. The study also documents changes in trust in the study population following the disclosure of physician incentives.
A medium-sized (300,000 member) HMO, located in the southeastern United States.
One to two years after baseline, we randomly resurveyed a quarter (n = 558) of the initial study population of a large intervention study designed to measure the impact of disclosing HMO financial incentives on patient trust. This follow-up study was also designed to measure the effects of trust on source of care.
Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral, as well as changes in trust since baseline.
High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician (OR = 0.55, 95 percent CI: 0.33, 0.91). No long-term effects of prior disclosure of financial incentives were observed. Overall, there was a slight increase in overall trust in the insurer (1.8 percent, p < .05) but no change in trust in one's primary physician. The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey (6.6 percent, p < .01). In multivariate analyses, changing physicians was the most significant predictor of increased insurer trust (OR = 2.17, 95 percent CI: 1.37, 3.43). CONCLUSIONS. Trust in one's insurer seems to change over time more than trust in one's primary physician, and is predictive of enrollee behaviors such as seeking care from other physicians. The ability to change physicians seems to increase trust in the insurer.
医学领域中大多数关于信任的研究都聚焦于对医生的信任而非对健康保险公司的信任，并且多为横断面研究而非纵向研究。本研究考察了对管理式医疗保险公司的信任、对自己初级医生的信任以及随后参保者与医疗服务来源相关行为之间的关联。该研究还记录了在披露医生激励措施后研究人群中信任的变化。
一家位于美国东南部的中型（30万成员）健康维护组织（HMO）。
在基线后的一到两年，我们对一项大型干预研究的初始研究人群中的四分之一（n = 558）进行了随机重新调查，该干预研究旨在衡量披露HMO财务激励措施对患者信任的影响。这项后续研究还旨在衡量信任对医疗服务来源的影响。
对调查数据进行多变量回归分析，以检验基线信任水平与随后参保者行为（如在没有初级保健医生（PCP）转诊的情况下使用非PCP医生）之间的关联，以及自基线以来信任的变化。
较高的基线保险公司信任与患者从非PCP医生处寻求医疗服务的可能性较低相关（比值比（OR）= 0.55，95%置信区间（CI）：0.33，0.91）。未观察到先前披露财务激励措施的长期影响。总体而言，对保险公司的总体信任略有增加（1.8%，p <.05），但对自己初级医生的信任没有变化。保险公司信任的增加主要限于在基线调查后更换了PCP的23%的参保者（6.6%，p <.01）。在多变量分析中，更换医生是保险公司信任增加的最显著预测因素（OR = 2.17，95% CI：1.37，3.43）。结论：对自己保险公司的信任似乎比对自己初级医生的信任随时间变化更大，并且可预测参保者的行为，如从其他医生处寻求医疗服务。更换医生的能力似乎会增加对保险公司的信任。
