Who Do You Trust? Americans' Perspectives on Health Care, 1997-2001

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Who Do You Trust? Americans' Perspectives on Health Care, 1997-2001

Tracking Report No. 3 | August 2002 | Marie C. Reed, Sally Trude

A turbulent backlash against managed care during the mid-1990s set consumers and health care providers against health plans in a contest over who should control medical decision making. Updated findings from HSC's Community Tracking Study Household Survey indicated that consumer confidence in the health care system and trust in physicians grew slightly between 1997 and 2001, possibly as managed care plans loosened restrictions and state legislatures passed patient protection laws. Even so, strong evidence of continued public worry persisted. Trust levels among people in fair or poor health showed no improvement, and more than 40 percent of privately insured Americans continued to believe their physician was heavily influenced by health plan rules when making treatment decisions.

Losing Faith

The managed care backlash of the mid-1990s produced a wave of changes in the health care system and spawned numerous state patient protection laws across the country. In their push to control costs, health plans and employers had imposed restrictions on consumer access -- limiting the choice of in-network physicians, requiring gatekeeper referrals to specialists, and implementing physician profiling, utilization management, and capitated payment arrangements. Both patients and providers reacted negatively. Consumers in managed care plans were less inclined to trust that their doctor would prioritize the patient's health over the plan's cost concerns.

States responded with a variety of patient protection measures, including rules granting direct access to certain specialists, provisions for seeing out-of-network physicians, financial incentive disclosure requirements, and external review processes for appealing plan decisions. Plans also adapted by expanding physician networks, scaling back prior authorization requirements, relaxing utilization management controls, and moving away from capitation, which many viewed as incentivizing providers to withhold care.

Despite these changes, perceptions about health plans' sway over medical decision making shifted little between 1997 and 2001. Throughout this period, close to 45 percent of privately insured Americans agreed that their doctor was strongly influenced by insurance company rules when making care decisions. HMO enrollees were considerably more likely to hold this view -- nearly half of HMO members in 2001 felt their doctor was strongly influenced by plan rules, compared with fewer than 40 percent of those in other plan types. Over time, however, the proportion of HMO members reporting perceived plan influence edged downward slightly.

More Trust in Doctors, More Freedom to Choose

Although views about plan influence on clinical decisions barely moved, privately insured Americans in 2001 were somewhat more likely to agree that their doctor would put medical needs above all other considerations. Among HMO enrollees, the share trusting their doctors rose from 90 percent to 92 percent between 1997 and 2001. Trust among non-HMO enrollees increased less -- by under one percentage point to 94 percent -- but the gap between the two groups narrowed slightly.

Provider choice was another area where consumers noticed improvement. By 2001, 70 percent of the privately insured were very satisfied with the choice of primary care physicians in their plan, up from 67 percent in 1997, with most of the gain occurring among HMO members. HMO patients were also less likely in 2001 to worry that their doctor might not refer them to a specialist when needed. These shifts coincided with a period when premium increases were modest and many employers -- competing for talent in tight labor markets -- absorbed much of the cost.

No Progress for Those in Poor Health

People in fair or poor health -- those with the greatest need for medical services -- remained less trusting of the system. More than 50 percent of sicker Americans in 2001 perceived strong health plan influence on their doctors' decisions, compared with 43 percent among those in good health. Trust in physicians did not improve for those in poorer health between 1997 and 2001, even as healthier individuals reported modest gains. Similarly, referral concerns stayed elevated for the sicker population -- 20 percent expressed worry in 2001, against 13 percent of healthier individuals. Whether these persistent gaps reflected actual negative experiences or simply the absence of reassuring signals remained unclear, but the data showed plainly that recent system changes had failed to ease the concerns of those who needed care most.

Fewer Provider Changes, Steadier Plan Choices

A common concern during the managed care backlash was that patients lost continuity of care when their doctor dropped out of a plan's network. Between 1997 and 2001, the share of privately insured people who changed health care providers declined from 12 percent to 11 percent. Even among those who switched plans -- voluntarily or otherwise -- fewer changed doctors in 2001 than four years earlier. People were also less likely in 2001 to attribute their change of doctor to their health plan (24 percent versus 29 percent in 1997), with the decline particularly sharp among HMO members (from 37 percent to 28 percent), likely reflecting broader provider networks.

The rate of health plan switching itself held relatively steady after rising from about 17 percent in 1997 to 18 percent in 1999. People were more likely in 2001 to switch plans because of a job change and less likely to switch in pursuit of a cheaper plan or better services. Changes in employer offerings remained the single largest reason for switching, cited by more than 35 percent of plan changers throughout the period.

Prospects for the Future

Health plans had broadened networks and relaxed restrictions in response to consumer pressure. These concessions came during a time of moderate premium growth and strong economic conditions. As premiums accelerated and the labor market softened, employers were likely to push back by raising deductibles, copayments, and employee premium contributions -- moves that could rekindle consumer dissatisfaction. The question going forward was whether the modest gains in trust and satisfaction recorded between 1997 and 2001 would survive an environment of rising costs and renewed belt-tightening.

Data Source

This report drew on data from three rounds of the Community Tracking Study Household Survey (1997, 1999, and 2001), a nationally representative telephone survey of the civilian, non-institutionalized population. All changes cited were statistically significant at the p<0.05 level.

Sources and Further Reading

Kaiser Family Foundation -- Employer Health Benefits Survey -- Annual data on employer-sponsored health insurance.

Health Affairs -- Peer-reviewed health policy research.

Robert Wood Johnson Foundation -- Health policy research and programs.

Commonwealth Fund -- Research on health care coverage.