THE RELATIONSHIP BETWEEN METHOD OF PHYSICIAN-PAYMENT AND PATIENT TRUST

Context.-Trust is the cornerstone of the patient-physician relationshi p. Payment methods that place physicians at financial risk have raised concerns about patients' trust in physicians to act in patients' best interests. Objective.-To evaluate the extent to which methods of phys ician payment are related to patient trust. Design.-Cross-sectional te lephone interview survey done between January and June 1997. Setting.- Health plans of a large national insurer in Atlanta, Ga, the Baltimore , Md-Washington, DC, area, and Orlando, Fla. Participants.-A total of 2086 adult managed care and indemnity patients. Main Outcome Measure.- A 10-item scale (alpha =.94) assessing patients' trust in physicians. Results.-More fee-for-service (FFS) indemnity patients (94%) completel y or mostly trust their physicians to ''put their health and well-bein g above keeping down the health plan's costs'' than salary (77%), capi tated (33%), or FFS managed care patients (85%) (P<.001 for pairwise c omparisons). In multivariate analyses that adjusted for potentially co nfounding factors, FFS indemnity patients also had higher scores on th e 10-item;trust scale than salary (P<.001), capitated (P<.001), or FFS managed care patients (P<.01). The effects of payment method on patie nt trust were reduced when a measure based on patients' reports about physician behavior leg, Does your physician take enough time to answer your questions?) was included in the regression analyses, but the dif ferences 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 t heir physicians were paid had higher levels of trust than other patien ts (P<.01). A total of 30.2% of patients were incorrect about their ph ysicians' method of payment. Conclusions.-Most patients trusted their physicians, but FFS indemnity patients have higher levels of trust tha n salary, capitated, or FFS managed care patients. Patients' reports o f physician behavior accounted for part of the variation in patients' trust in physicians who are paid differently. The impact of payment me thods on patient trust may be mediated partly by physician behavior.