Patients’ Trust in Their Physicians
Effects of Choice, Continuity, and Payment Method
Audiey C. Kao, MD, Diane C. Green, PhD, MPH, Nancy A. Davis, MPH,
Jeffrey P. Koplan, MD, MPH, Paul D. Cleary, PhD
length of patient-physician relationship, and perceived physi-
cian payment method predict patients’ trust in their physician.
To evaluate the extent to which physician choice,
Survey of patients of physicians in Atlanta, Georgia.
Subjects were 292 patients aged 18 years and
MEASUREMENTS AND MAIN RESULTS:
in their physician was the main outcome measure. Most pa-
tients completely trusted their physicians “to put their needs
above all other considerations” (69%). Patients who reported
having enough choice of physician (
tionship with the physician (
managed care organization (
trust their physician. Approximately two thirds of all respon-
dents did not know the method by which their physician was
paid. The majority of patients believed paying a physician
each time a test is done rather than a fixed monthly amount
would not affect their care (72.4%). However, 40.5% of all re-
spondents believed paying a physician more for ordering fewer
than the average number of tests would make their care worse.
Of these patients, 53.3% would accept higher copayments to
obtain necessary medical tests.
Scale of patients’ trust
.05), a longer rela-
.001), and who trusted their
.001) were more likely to
having a choice of physicians, having a longer relationship
with their physician, and trusting their managed care organi-
zation. Most patients are unaware of their physician’s pay-
ment method, but many are concerned about payment meth-
ods that might discourage medical use.
Patients’ trust in their physician is related to
physician relationship; physician payment method.
J GEN INTERN MED 1998;13:681–686.
patients’ trust; choice of physician; patient-
able patients have to rely on their physicians to provide
them with appropriate information, keep personal infor-
mation confidential, provide competent care, and act in
their best interests. In spite of the importance of trust to
the patient-physician relationship, there are few studies
of the factors related to patients’ trust in their physicians.
One predictor of trust in social relationships is the
length of those relationships,
rust is a fundamental aspect of the patient-physician
Even well-informed and knowledge-
and there is reason to be-
lieve this would hold for patient-physician relationships.
Having a choice of physician is important to many pa-
and it is possible that wider choices would en-
courage greater trust in the physician eventually chosen.
Recent developments in health care delivery also make it
plausible that the way physicians are paid could influence
patients’ trust in them. Reports regularly appear in the
popular press about how new managed care arrangements
may compromise the care provided to patients. Health ser-
vice researchers have shown that payment methods may
have an impact on clinical decision making.
of no empirical studies that have examined whether pa-
tients’ beliefs about how their physician is paid affect their
trust in the physician. In the study described herein, we
interviewed a probability sample of patients covered by a
large health care insurer in Atlanta. We assessed how pa-
tients thought their physicians were paid and whether their
perceptions were accurate. We also examined whether avail-
ability of a choice of physicians, length of patient-physician
relationship, or perceived physician payment method was
related to the patients’ trust in their physician.
Study Design and Sample
The study was conducted in Atlanta in a national
managed care organization. Eligible patients were enrollees
aged 18 years and older who made at least one visit to a
primary care office (family practice, internal medicine, ob-
stetrics/gynecology) during the period between January
1994 and June 1995. Patients were selected using a two-
stage, cluster sample. First, we identified all primary care
physicians who had at least 40 eligible plan members in
their practices. We randomly selected 15 salaried and 15
fee-for-service physicians from this group. There were no
physicians paid on a capitated basis in this study. Next, we
randomly selected 40 patients between the ages of 18 and
65 from each physician’s practice. To ensure an adequate
sample of elderly respondents, 300 patients who were aged
65 years and older were randomly sampled independent of
Of the 1,480 patients we attempted to reach for a tele-
phone interview, 453 were contacted and screened for eli-
gibility. Of those screened, 43 (9%) were ineligible: 18 said
they did not have a “regular doctor”; 1 did not report hav-
ing a primary care office visit over the past 2 years; 12 did
not speak English; and 12 were deemed ineligible because
they had no overall opinion of their experiences with the
sampled doctor. Of the 410 eligible patients who were con-
tacted, 292 (71.2%) completed the telephone interview.
Received from the Department of Health Care Policy, Harvard
Medical School, Boston, Mass. (ACK, PDC), and the Prudential
Center for Health Care Research, Atlanta, Ga. (DCG, NAD, JPK).
Address correspondence and reprint requests to Dr. Cleary:
Department of Health Care Policy, Harvard Medical School,
180 Longwood Ave., Boston, MA 02115.
Kao et al., Patients’ Trust in Their Physicians
In 1996, we developed a 16-item scale to assess pa-
tients’ trust in their physician (unpublished manuscript).
To develop our new scale, we modified an existing scale by
modifying the wording of some items to refer specifically
to the patient’s physician.
Several new items related to
confidentiality and reliability were included and tested. In
addition, one other competency item was added and
seven items were added that assessed patients’ trust in
their physicians to provide necessary care under various
cost constraints and administrative restrictions. We used
factor analyses and other standard psychometric tech-
niques, such as examining item-criterion correlations and
the internal consistency of different subsets of items to
select items that formed a unidimensional measure of
trust in physician. The resulting scale had an internal
) of 0.90.
The patient questionnaire also included questions
about whether patients had “enough choice” of physicians,
whether patients had more than one health plan option,
and length of relationship with their physician. To assess
awareness of payment methods, respondents were asked to
identify their physician’s payment method as fee-for-service
(doctor’s pay is based on “the number of tests and proce-
dures that are carried out”), capitation (doctor’s pay is based
on “some fixed monthly amount,” which is dependent on the
“number of patients in doctor’s practice”), or salary (doctor’s
pay is based on “a straight salary”). Respondents also were
asked how they thought their care would be affected if their
physician was “paid each time he/she carries out a test
rather than a fixed monthly amount” and “paid more for or-
dering fewer than the average number of tests.” The respon-
dents who believed that the physician getting paid more for
ordering fewer tests would adversely affect their care were
asked if they would be willing to “pay a higher copayment to
get the tests that (they thought they) needed.” To evaluate
patients’ general trust in people, the Survey of Cynicism
and Benevolence of People scales were used. Information
on patients’ race, education, income, and health status was
also collected in the interviews. The measure of health sta-
tus was a single rating of perceived health (excellent, very
good, good, fair, poor). Information on patients’ age, gender,
length of enrollment in health plan, and number of primary
care office visits was obtained from administrative files.
To assess the relation between patient trust and hy-
pothesized determinants of trust, we estimated linear re-
gression models. The dependent variable in our models
was the patient trust score. The independent variables in-
cluded having enough choice of physicians, having more
than one health plan option, length of the patients’ relation-
ship with their physician, patients’ trust in their managed
care organization, and physician payment method. Pa-
tients’ perception of their physician’s payment method (fee-
for-service, salary, or capitation) was specified as a series
of dummy variables, and the omitted group comprised pa-
tients who said they did not know how their physician was
paid. Control variables included gender, race, education,
self-reported health status, general trust in people, length
of enrollment in the health plan, and number of primary
care office visits. Patients with missing data for any of
these variables (
48) were excluded from the regression
analysis. We analyzed patients who did not respond to the
income question (
54) by using different income specifi-
cations (quartile, median, and continuous) and a dummy
variable representing missing data in the regression mod-
els. The coefficient of the explanatory variables and their
significance were statistically unchanged in these regres-
There were some differences between the patients who
completed the telephone interview and those who did not.
More of the respondents than nonrespondents were female
(77.7% vs 66.1%,
.05). Respondents also had more pri-
mary care office visits (
SD) than nonrespondents (3.9
3.3 vs 3.2
.05). There was no statistically
significant difference between the respondents and non-
respondents in mean age. Information on race, education,
income, and self-reported health status was not available
The characteristics of survey respondents are presented
in Table 1. Approximately two thirds of the respondents in-
correctly identified their physician’s payment method or
said they did not know how their physician was paid (Ta-
Table 1. Characteristics of Respondents (n
Less than high school
High school graduate
Some post high school
Self-reported health status,
SD, years 46
SD of enrollment in health plan
SD of primary care office visits
Volume 13, October 1998
ble 2). More patients of salaried physicians correctly iden-
tified their physician’s payment method than patients of
fee-for-service physicians, but this difference in aware-
ness of payment methods was not statistically significant.
The majority of respondents (60.4%) completely trusted
their physician “to put their medical needs above all other
considerations when treating their medical problems” (Ta-
ble 3). Few patients did not trust their physician at all
(1.7%). Approximately 30% of the respondents completely
trusted their managed care organization “to put their medi-
cal needs above all other considerations,” while approxi-
mately 10% of the respondents did not trust their health
plan at all (Table 3).
In a multivariate model, several variables were signifi-
cant independent predictors of patients’ trust in their phy-
sician (Table 4). Patients who said they had enough choice
of physicians were more likely to trust their physician
.001). Having a choice of health plan was not associ-
ated with a higher physician trust score. A longer patient-
physician relationship was associated with a higher pa-
tient trust score (
.05). Patients’ trust in their managed
care organization was also positively associated with trust
in their physician (
.001). Patients of fee-for-service
physicians were not more likely to trust their physicians
than patients of salaried physicians. Patients who thought
their physicians were paid on a capitated basis were less
likely to trust their physicians, but this association was not
statistically significant. Healthier patients also tended to
trust their physicians more, but this association was not
statistically significant. Cynicism and belief in the good-
ness of people were not significantly associated with pa-
tients’ trust in their physician.
Nearly three fourths of all respondents believed that
payment methods that may encourage use of medical ser-
vices would have no effect on the quality of their care (Ta-
ble 5). However, more patients of fee-for-service physi-
cians (17.6%) than of salaried physicians (6.8%) believed
their care would improve if their physician was paid “each
time (a test is carried out) rather than a fixed monthly
amount.” More patients of salaried physicians (20.3%) be-
lieved these incentives would make their care worse than
patients of fee-for-service physicians (10.3%).
More than half of all respondents believed that paying
a physician more for ordering fewer than the average num-
ber of tests would have no effect on the quality of their care
(Table 5); however, 40.5% believed these payment methods
would adversely affect their care. There was no significant
difference between the groups with salaried and fee-for-
service physicians in perceived effect of payment methods
that may discourage use of medical services in their care.
Among the patients who believed that incentives that might
discourage use of medical services would make their care
worse, 53.3% would be willing to make a higher copayment
to receive tests they thought they needed. There was no sig-
nificant difference between the groups with salaried and
fee-for-service physicians in their willingness to make a
higher copayment to obtain necessary medical tests.
Organizational changes in health care have altered the
relationship between physicians and third party payers,
and have the potential of affecting patient-physician rela-
Some contend that managed care’s empha-
sis on preventive and primary care
cost-effective clinical practice. Others have raised concerns
that managed care incentives and rules place physicians in
a position with potentially conflicting obligations to patients
In light of significant changes, it is im-
portant to understand better factors affecting patients’ trust
in their physicians, a foundation of the patient-physician
Most patients in our study trusted their physicians to
act in their best interests. Nearly three fourths of all respon-
dents completely trusted their physicians to “put (their)
medical needs above all other considerations.” Fewer pa-
tients completely trusted their managed care organization,
has led to more
Table 2. Awareness of Payment Methods of Patients with Salaried or Fee-for-Service Physician
Patient Identification of
Physician’s Payment Method
Salaried Physician, n (%)
Fee-for-Service Physician, n (%)
156) Total, n (%)
Said they did not know
Table 3. Overall Trust in Physician and
Managed Care Organization
How much do you agree with this statement?n (%)
I trust (physician’s name) to put my medical
needs above all other considerations when
treating my medical problems.
Not at all
I trust (name of health plan) to put my medical
needs above all other considerations.
Not at all
Kao et al., Patients’ Trust in Their Physicians
which is consistent with declining social trust in all institu-
and with a natural inclination to trust an individ-
ual more than an organization. Nevertheless, organizations
can develop and implement policies to reinforce trust.
Patients who trusted their managed care organization were
more likely to trust their physicians.
Patients who reported having enough choice of physi-
cians were more likely to trust their physician. However,
having more than one health plan option was not associ-
ated with physician trust. It may be that patients are less
concerned about how many health plan options are avail-
able to them as long as their health plan provides them
with enough choice of physicians. Patients who had longer
patient-physician relationships were also more likely to
trust their physicians. Trust is developed through an itera-
tive process of interaction and experience,
ity of care may provide patients with the time necessary for
interpersonal trust to develop.
To varying degrees, managed care plans limit patients’
choice of physicians and restrict access to specialists. For
example, patients in staff-model HMOs are usually limited
to physicians who are directly employed by the health plan.
Table 4. Association of Patient Trust Score with Choice, Continuity, Physician Payment Method,
and Trust in Managed Care Organization
95% Confidence Interval
Having enough choice of physician*
Having a choice of health plan
Length of relationship in years
Identified physician payment method as fee-for-service
Identified physician payment method as salary
Identified physician payment method as capitation
Trust in their managed care organization*
Above median income
Income data missing
Self-perceived health status
Believe in the benevolence of people
Length of health plan enrollment in years
Number of primary care office visits
†p ? .05.
‡Reference group comprises patients with salaried physician.
§Omitted group comprises patients who said they did not know how their physician was paid.
?Reference group comprises patients with annual income less than $45,000.
Table 5. Perceived Effect of Payment Methods on Quality of Care of Patients with Salaried or Fee-for-Service Physician
Perceived Effect Salaried Physician, n (%)Fee-for-Service Physician, n (%)Total, n (%)
Do you think paying your doctor each time he/she
carries out a test rather than a fixed monthly
amount would make your care:*
Have no effect
Do you think paying your doctor more for ordering
fewer than the average number of tests would
make your care:
Have no effect
(n ? 118)
(n ? 136)
(n ? 121)
(n ? 138)
*p ? .01 for the comparison of each response between the groups with salaried and fee-for-service physicians.
Volume 13, October 1998
Conversely, point-of-service (POS) plans and preferred pro-
vider organizations (PPOs) are less restrictive and offer pa-
tients more choice of physicians outside the plan (with in-
creased patient cost sharing). Over the past few years,
HMOs have experienced little growth in their membership.
In a recent survey of employers, the percentage of working
Americans insured by HMO plans was unchanged at 27%
from 1995 to 1996.41 Conversely, health plan options that
offer patients more open access to a larger panel of physi-
cians including specialists have experienced steady enroll-
ment growth (POS plans from 14% to 19% and PPOs from
29% to 31% from 1995 to 1996). Currently, over 80 million
people are enrolled in PPOs,42 and having a choice of physi-
cians is most likely one of the factors contributing to their
growing popularity among consumers.
Although the public appears to favor health plans with
greater choice of physicians, continuity of patient-physician
relationships has become more difficult to sustain in our
employment-based health care system. Decisions about
continuity of care are made by employers, health plans,
physicians, and plan members for a variety of reasons, in-
cluding issues of quality, cost, and convenience. When em-
ployers switch health plans, existing patient-physician re-
lationships cannot be maintained if the new health plan
selected by the employer has a different panel of physi-
cians. Even when employers remain with the same health
plan, physicians deselected by the plan on the basis of qual-
ity performance standards, utilization measures, credential-
ing, or other criteria are no longer eligible to provide care to
enrollees of that plan.43–46 Physicians can also deselect
health plans and choose not to be a participating provider,
but this is less of an issue in mature managed care mar-
kets.47–49 Plan members may change health plans based on
provider preference, plan benefits, or cost considerations.
Nearly two thirds of all respondents either did not
know or incorrectly identified their physician’s payment
method. When patients were asked to assess the impact
of different payment methods on the quality of care, most
believed that payment methods would have no effect on
their care. However, a large percentage of all respondents
believed that paying physicians “more for ordering fewer
than the average number of tests” would make their care
Although patients expressed concern about certain
payment strategies, their perceptions of how their own
physician was paid were not significantly related to their
trust in him or her. This may be because once a patient-
physician relationship is established any effects of atti-
tudes about the physician’s reimbursement are minor com-
pared with other factors that affect patient trust. The Amer-
ican Association of Health Plans has decided to provide
information about physician payment methods to health
plan members who request it. It is unclear when patients
should be given such information, how this information
should be presented, and who should inform them.43,50
We were unable to contact a large number of patients
originally selected from administrative records. The ob-
served differences between the respondent and nonrespon-
dent groups could contribute to response bias. However, it
seems unlikely that having a choice of physician and main-
taining continuity of care would be less relevant determi-
nants of physician trust in the nonrespondent group.
Systems of care that foster patient trust enhance the
quality of the patient-physician relationship. Our findings
suggest that patients who have a choice of physicians and
are in longer, stable patient-physician relationships are
more likely to trust their physician. Further studies exam-
ining patient-physician relationships under different pay-
ment arrangements including capitated and indemnity
methods may provide us with a better understanding of
factors contributing to patients’ trust in their physicians.
This work was funded by the Prudential Center for Health Care
Research. During the conduct of this study, Dr. Cleary was a
consultant to the Prudential Center for Health Care Research.
The authors thank Barbara McNeil, MD, PhD, and Carol
McPhillips-Tangum, MPH, for their helpful comments on the
study, Sean Lee for data programming, and Linda Emanuel,
MD, PhD, for her review of the manuscript.
1. Beauchamp T, Childless J. Principles of Biomedical Ethics. 3rd
ed. New York, NY: Oxford University Press; 1989.
2. Katz J. The Silent World of Doctor and Patient. New York, NY: Free
3. Macklin R. Enemies of Patients. New York, NY: Oxford University
4. Rodwin M. Medicine, Money and Morals. New York, NY; Oxford
University Press; 1993.
5. Emanuel EJ, Dubler NN. Preserving the physician-patient rela-
tionship in the era of managed care. JAMA. 1995;273:323–9.
6. Barber B. The Logic and Limits of Trust. New Brunswick, NJ: Rut-
gers University Press; 1983.
7. Gambetta D, ed. Trust: Making and Breaking Cooperative Rela-
tions. New York, NY: Blackwell; 1988.
8. Kramer RM, Tyler TR, eds. Trust in Organizations: Frontiers of
Theory and Research. Thousand Oaks, Calif: Sage; 1996.
9. Mechanic D. Changing medical organization and the erosion of
trust. Milbank Q. 1996;74:171–89.
10. Blendon RJ, Knox RA, Brodie M, Benson JM, Chervinsky G.
Americans compare managed care, Medicare, and fee-for-service.
J Am Health Policy. 1994;4:42–7.
11. Hoerger TJ, Howard LZ. Search behavior and choice of physician
in the market for prenatal care. Med Care. 1995;33:332–49.
12. Mechanic D, Ettel T, Davis D. Choosing among health insurance
options: a study of new employees. Inquiry. 1990;27:14–23.
13. Mitchell JH, Dunn JP. Employee’s choice of a health plan and
their subsequent satisfaction. J Occup Med. 1984;26:361–6.
14. Hillman AL, Pauly MV, Kerstein JJ. How do payment methods af-
fect physicians’ clinical decisions and the financial performance of
health maintenance organizations? N Engl J Med. 1989;321:86–92.
15. Hillman AL. The impact of physician payment methods on high-
risk populations in managed care. J Acquir Immune Defic Syndr
Hum Retrovirol. 1995;8(Suppl 1):S23–30.
16. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med.
17. Anderson LA, Dedrick RF. Development of the trust in physician
scale: a measure to assess trust in patient-physician relation-
ships. Psychol Rep. 1990;67:1091–100.
686 Download full-text
Kao et al., Patients’ Trust in Their Physicians
18. Kanter DL, Mirvis PH. The Cynical Americans: Living and Working in
an Age of Discontent and Disillusion. San Francisco, Calif: Jossey-
19. Janoff-Bulman R. Assumptive worlds and the stress of traumatic
events: applications of the schema construct. Soc Cognition. 1993;7:
20. Coleman PG, Shellow RA. Privacy and autonomy in the physician-
patient relationship: independent contracting under Medicare and
implications for expansion into managed care. J Leg Med. 1995;
21. Wennberg JE. Health care reform and professionalism. Inquiry.
22. Sederer LI, Mirin SM. The impact of managed care on clinical
practice. Psychiatr Q. 1994;65:177–88.
23. Dubler NN. Individual advocacy as a governing principle. J Case
24. Rosenthal TC, Teimenschneider TA, Feather J. Preserving the pa-
tient referral process in the managed care environment. Am J
25. Korcok M. Capitation begins to transform the face of American
medicine. Can Med Assoc J. 1996;154:688–91.
26. Flynn MB. Power, professionalism, and patient advocacy. Am J
27. Apple GJ. Who bears the risk when physicians are also insurers?
Minn Med. 1995;78:23–7.
28. Clouthier M. The evolution of managed care. Trends Health Care
Law Ethics. 1995;10:67–72.
29. Solberg LI, Isham G, Kottke TE, et al. Competing HMOs collaborate
to improve preventive services. Jt J Qual Improv. 1995;21: 600–10.
30. Morrow RW, Gooding AD, Clark C. Improving physicians’ preven-
tive health care behavior through peer review and payment meth-
ods. Arch Fam Med. 1995;4:165–9.
31. Robinson JA, Robinson KJ, Lewis DJ. Balancing quality of care
and cost-effectiveness through case management. Anna J. 1992;
32. Angell M. The doctor as double agent. Kennedy Inst J Ethics.
33. Orentlicher D. Managed care and the threat to the patient-physi-
cian relationship. Trends Health Care Law Ethics. 1995;101:19–24.
34. Swee DE. Health care system reform and the changing physician-
patient relationship. N J Med. 1995;92:313–7.
35. Rodwin MA. Conflicts in managed care. N Engl J Med. 1995;
36. Nelms CR Jr. Ethical physicians cannot serve two masters. Minn
37. Lipset SM, Schneider W. The Confidence Gap: Business, Labor, and
Government in the Public Mind. New York, NY: Free Press; 1983.
38. Sheppard BH, Lewicki RJ, Minton JW. Organizational Justice: The
Search for Fairness in the Workplace. Lexington, Mass: Lexington
39. Gray BH. Trust and trustworthy care in the managed care era.
Health Affairs. 1997;16:34–49.
40. Duck S, Perlman D, eds. Understanding Personal Relationships.
Beverly Hills, Calif: Sage; 1985.
41. National Survey of Employer-Sponsored Health Plans. New York,
NY: Foster Higgins; 1996.
42. Group Health Association of America/American Medical Care and
Review Association Managed Health Care Directory. Washington,
DC: AMCRA; 1995.
43. Mechanic D, Schlesinger M. The impact of managed care on pa-
tients’ trust in medical care and their physicians. JAMA. 1996;
44. Montague J. Managed care is dumping many physicians, but
some aren’t going to take it lying down. Striking back. Hosp
Health Netw. 1994;68:38–44.
45. Bailey CW Jr. How to avoid being dropped from managed care
plans. Postgrad Med. 1994;95:59–62.
46. Guglielmo WJ. How to avoid deselection. Med Econ. 1996;73:
47. Graddy B. TMA takes aim against deselection. Tex Med. 1994;
48. Ortolon K. Deselection, round two: TMA takes due process with
managed care organizations to US Congress. Tex Med. 1994;
49. Brouillette JN. Bilateral deselection. J Fla Med Assoc. 1995;82:423.
50. Morreim EH. Economic disclosure and economic advocacy. New
duties in the medical standard of care. J Leg Med. 1991;12:
JOURNAL OF GENERAL INTERNAL MEDICINE SUBSCRIBERS
Do we have your new address?
Send us your new address three months before it becomes effective, so we will
have time to get it into our computer system and ensure that your copies of
JGIM continue to arrive uninterrupted. Send your old mailing label, your new
address with zip code, the effective date of your new address, and your current
Nonmember subscribers notify:
Blackwell Science, Inc.
Commerce Place, 350 Main St.
Malden, MA 02148
SGIM members notify:
Janice L. Clements
Society of General Internal Medicine
2501 M Street, NW, Suite 575
Washington, DC 20037