A Two-Way Street: Building Trust Between People with Medicaid and Primary Care Doctors

October 15, 2020

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Trust is central to relationships between patients and health care providers. Patients who are more trusting of their providers tend to be more satisfied with their treatment, behave in ways that are more beneficial to their health, report fewer symptoms and have a higher quality of life.

Research and interventions related to trust overwhelmingly focus on patients’ trust in physicians. But trust should be reciprocal in order to facilitate sustained physician-patient partnerships.  Physicians need to trust their patients to provide reliable information, participate in complex and potentially high-stakes decisions and follow treatment plans.

This research compares the views of people insured by Medicaid and primary care doctors who treat people with Medicaid regarding how to build mutual trust. The research involved representative surveys of each population and separate focus groups with each population. This research was supported by a grant from the Robert Wood Johnson Foundation.

Findings include:

  1. Primary care doctors and people with Medicaid agree that trust should be mutual. Both feel equally responsible for building it and both feel that it takes time to develop. Doctors overwhelmingly trust patients with Medicaid unless that trust is broken. But more people with Medicaid express wariness, with nearly 4 in 10 saying doctors need to earn their trust.
  2. Primary care doctors and people with Medicaid agree that in order for doctors to gain patients’ trust, good listening and communication are top priorities. But the two groups have different priorities regarding other ways doctors can gain patients’ trust. People with Medicaid prioritize doctors following basic safety protocols, while doctors think it is more important to consider their patients’ finances and lifestyles. Few people with Medicaid say that a doctor’s race or gender affects their trust.
  3. Nearly 4 in 10 people with Medicaid say they have been treated by a primary care doctor whom they did not trust. Most people who have had those negative experiences say that as a result, they have behaved in ways that could negatively affect their health, such as stopping medications or delaying care. More of those who have been treated by a doctor they did not trust also say they have behaved in ways that could damage doctors’ trust in them.
  4. Primary care doctors largely feel that patients with Medicaid are just as trustworthy as patients with other types of insurance. But when patients with Medicaid are actively engaged in their care, such as by participating in decisions or voicing their health goals, primary care doctors trust them more. These doctors are less trusting, however, when patients with Medicaid leave out information, exaggerate symptoms or insist on specific treatments.

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This report compares the views of people with Medicaid and of primary care doctors on how to build mutual trust. Based on representative surveys of both populations, main findings include:

Finding 1: Primary care doctors and people with Medicaid agree that trust should be mutual. Both feel equally responsible for building it and both feel that it takes time to develop. Doctors overwhelmingly trust patients with Medicaid unless that trust is broken. But more people with Medicaid express wariness, with nearly 4 in 10 saying doctors need to earn their trust.

Finding 2: Primary care doctors and people with Medicaid agree that in order for doctors to gain patients’ trust, good listening and communication are top priorities. But the two groups have different priorities regarding other ways doctors can gain patients’ trust. People with Medicaid prioritize doctors following basic safety protocols, while doctors think it is more important to consider their patients’ finances and lifestyles. Few people with Medicaid say that a doctor’s race or gender affects their trust.

Finding 3: Nearly 4 in 10 people with Medicaid say they have been treated by a primary care doctor whom they did not trust. Most people who have had those negative experiences say that as a result, they have behaved in ways that could negatively affect their health, such as stopping medications or delaying care. More of those who have been treated by a doctor they did not trust also say they have behaved in ways that could damage doctors’ trust in them.

Finding 4: Primary care doctors largely feel that patients with Medicaid are just as trustworthy as patients with other types of insurance. But when patients with Medicaid are actively engaged in their care, such as by participating in decisions or voicing their health goals, primary care doctors trust them more. These doctors are less trusting, however, when patients with Medicaid leave out information, exaggerate symptoms or insist on specific treatments.

Recommendations for Building Mutual Trust in Primary Care

  1. By demonstrating that they take safety seriously, doctors can help build trust with patients.
  2. Increasing patient activation and engagement may increase doctors’ trust in patients.
  3. Creating time and space in primary care practices for mutual communication can build reciprocal trust.
  4. Doctors can build trust by finding ways to discuss social determinants of health without alienating patients.
  5. Developing the evidence base for how and why doctors should build trust in patients can help move health care away from paternalism and toward centering patients.

This report summarizes findings from two representative surveys: one of 1,008 adults 18 years and older who are covered by Medicaid and one of 402 primary care doctors who treat people with Medicaid.

The survey of people with Medicaid was fielded from August 9 to September 13, 2019, online for Public Agenda by Ipsos using the probability-based web-enabled KnowledgePanel. Respondents completed the Medicaid beneficiary survey in English or Spanish. The data are weighted to the characteristics of lower-income Americans based on the March 2018 Current Population Survey.

The survey of primary care doctors who treat people with Medicaid was fielded from August 9 to September 13, 2019. Only doctors who treat people with Medicaid were surveyed. That survey was fielded online for Public Agenda by Ipsos using a sample drawn from the Physicians Consulting Network panel, a double opt-in panel of physicians and other medical professionals recruited through a license with the American Medical Association. Respondents completed the physician survey in English. The data are weighted to balance the sample to known characteristics of primary care doctors.

Before developing the surveys, Public Agenda conducted four focus groups in December 2018: two with people with Medicaid in New York City and Philadelphia and two with primary care doctors who treat people with Medicaid, also in New York City and Philadelphia.

For a complete methodology providing more detail about the focus groups and surveys, please go to https://publicagenda.org/wp-content/uploads/2020/10/A-Two-Way-Street-Methodology.pdf.  For sample characteristics and the surveys’ toplines with full question wording, please go to https://publicagenda.org/wp-content/uploads/2020/10/A-Two-Way-Street-Topline-Sample-Characteristics.pdf or email research@publicagenda.org.

 

 

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Researchers Examine Trust Between Patient and Provider (AcademyHealth Blog, July 21, 2020)

Trust Should Be A Two-Way Street (ABIM Foundation Blog, December 8, 2020)

In Patients We Trust: Why Clinicians Need To Believe And Respect Patients (Health Affairs, April 29, 2021)