Managed care members talk about trust

doi:10.1016/S0277-9536(01)00070-3

Social Science & Medicine

Volume 54, Issue 6, March 2002, Pages 879-888

https://doi.org/10.1016/S0277-9536(01)00070-3 Get rights and content

Abstract

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 Sates, 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.

Section snippets

Background

A market-based health system makes several assumptions. First, a market assumes that individuals know best how they would like to spend their limited resources; a fair distribution of resources results from the collective exercise of individual preferences. Second, a market system assumes consumer sovereignty, that consumers are well-informed choosers of health insurance and health care and can choose from enough diverse options to allow real choice. In organizations, and certainly in health

What is Trust?

We can learn a great deal about institutional trust from the literature on interpersonal trust. According to Diego Gambetta, interpersonal trust is “the specific expectation that another's actions will be beneficial rather than detrimental” (Gambetta, 1998). A trust-based relationship is composed of a number of elements (Baier, 1986; Jackson, 1995). First there is vulnerability, reliance, and dependence on the part of the truster. In health care this vulnerability arises from the experience of

Design

Semi-structured, open-ended interviews were used as the means for a diverse group of informants living in southeast Michigan, US to describe their expectations and experiences with managed care. Forty persons took part in 31 face-to-face interviews, nine interviews with couples and 22 with individuals. Interviewees were selectively sampled through area employers (11/40), community-based organizations (14/40), and personal contacts (11/40), and upon referral by other interviewees (3/40) (for

Trust

Trust and distrust emerged spontaneously as a fundamental issue during the majority of enrollee interviews. Twenty interviews included one or more participant discussions of trust regarding specific physicians or physicians generally, and 12 interviews included one or more participant discussions of trust regarding hospitals or insurers. In all, 22 interviews included numerous, unsolicited, codable narratives about trust.

Discussion

Because it was unsolicited, the frequency and intensity of informants’ narratives about trust was striking. Not only the rich references to trust, but the contexts and patterns were interesting, important and informative. What is trust? How does the literature on trust shed light on the findings of this study?

Diego Gambetta called trust “the disposition by one party (the truster) to place something of value (the trust object) into the discretionary power of another (the trustee) with the

Conclusion

Informants in this study of their own accord raised the critical importance of trust in health care. Their testimony directly suggests that relying on the market-based health system assumptions of informed, imaginative consumers selecting health insurance wisely is likely to be insufficient. Lack of information and misleading marketing practices, of course, may confuse consumers. The issue informants kept referencing, however, was the dynamic of trust, where their concerns (their “trust

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View full text

Managed care members talk about trust

Abstract

Section snippets

Background

What is Trust?

Design

Trust

Discussion

Conclusion

Maintaining trust in the surgeon-patient relationshipChallenges for the new millennium

Archives of Surgery

The case against persuasive advertising by health maintenance organizations

New England Journal of Medicine

The healer's power

Choice of payment plan in the Medicare capitation demonstration

Medical Care