Kao A C, Green D C, Zaslavsky A M, Koplan J P, Cleary P D
Institute for Ethics, American Medical Association, Chicago, IL, USA.
JAMA. 1998 Nov 18;280(19):1708-14. doi: 10.1001/jama.280.19.1708.
Trust is the cornerstone of the patient-physician relationship. Payment methods that place physicians at financial risk have raised concerns about patients' trust in physicians to act in patients' best interests.
To evaluate the extent to which methods of physician payment are related to patient trust.
Cross-sectional telephone interview survey done between January and June 1997.
Health plans of a large national insurer in Atlanta, Ga, the Baltimore, Md-Washington, DC, area, and Orlando, Fla.
A total of 2086 adult managed care and indemnity patients.
A 10-item scale (alpha = .94) assessing patients' trust in physicians.
More fee-for-service (FFS) indemnity patients (94%) completely or mostly trust their physicians to "put their health and well-being above keeping down the health plan's costs" than salary (77%), capitated (83%), or FFS managed care patients (85%) (P<.001 for pairwise comparisons). In multivariate analyses that adjusted for potentially confounding factors, FFS indemnity patients also had higher scores on the 10-item trust scale than salary (P<.001), capitated (P<.001), or FFS managed care patients (P<.01). The effects of payment method on patient trust were reduced when a measure based on patients' reports about physician behavior (eg, Does your physician take enough time to answer your questions?) was included in the regression analyses, but the differences remained statistically significant, except for the comparison between FFS managed care and FFS indemnity patients (P=.08). Patients' perceptions of how their physicians were paid were not independently associated with trust, but the 37.7% who said they did not know how their physicians were paid had higher levels of trust than other patients (P<.01). A total of 30.2% of patients were incorrect about their physicians' method of payment.
Most patients trusted their physicians, but FFS indemnity patients have higher levels of trust than salary, capitated, or FFS managed care patients. Patients' reports of physician behavior accounted for part of the variation in patients' trust in physicians who are paid differently. The impact of payment methods on patient trust may be mediated partly by physician behavior.
信任是医患关系的基石。使医生面临财务风险的支付方式引发了人们对患者是否信任医生会为患者的最大利益行事的担忧。
评估医生支付方式与患者信任之间的关联程度。
1997年1月至6月期间进行的横断面电话访谈调查。
佐治亚州亚特兰大、马里兰州巴尔的摩-华盛顿特区地区以及佛罗里达州奥兰多的一家大型全国性保险公司的健康计划。
总共2086名成年管理式医疗和赔偿保险患者。
一个包含10个条目的量表（α = 0.94），用于评估患者对医生的信任。
与薪资制（77%）、按人头付费制（83%）或管理式医疗服务收费制（FFS）患者（85%）相比，更多的服务收费（FFS）赔偿保险患者（94%）完全或大部分信任他们的医生会“将他们的健康和福祉置于控制健康计划成本之上”（两两比较，P <.001）。在对潜在混杂因素进行调整的多变量分析中，FFS赔偿保险患者在10项信任量表上的得分也高于薪资制患者（P <.001）、按人头付费制患者（P <.001）或FFS管理式医疗服务患者（P <.01）。当基于患者对医生行为的报告（例如，你的医生是否花足够的时间回答你的问题？）的一项指标纳入回归分析时，支付方式对患者信任的影响有所降低，但差异仍具有统计学意义，FFS管理式医疗服务患者与FFS赔偿保险患者之间的比较除外（P = 0.08）。患者对医生支付方式的认知与信任并无独立关联，但37.7%表示不知道医生支付方式的患者比其他患者具有更高的信任水平（P <.01）。共有30.2%的患者对医生的支付方式判断错误。
大多数患者信任他们的医生，但FFS赔偿保险患者比薪资制、按人头付费制或FFS管理式医疗服务患者具有更高的信任水平。患者对医生行为的报告解释了不同支付方式下患者对医生信任差异的部分原因。支付方式对患者信任的影响可能部分由医生行为介导。
