Journal of General Internal Medicine

, Volume 24, Issue 3, pp 415–420 | Cite as

High Medical Cost Burdens, Patient Trust, and Perceived Quality of Care

  • Peter J. CunninghamEmail author
Health Policy



The financial burden of medical care expenses is increasing for American families. However, the association between high medical cost burdens and patient trust in physicians is not known.


To examine the association between high medical cost burdens and self-reported measures of patient trust and perceived quality of care.


Cross-sectional household survey based on random-digit dialing and conducted largely by telephone, supplemented by in-person interviews of households with no telephones. The sample for this analysis includes 32,210 adults who reported having a physician as their regular source of care. Measures of patient trust include overall trust, confidence in being referred to a specialist, and belief that the physician uses more services than necessary. Perceived quality measures include thoroughness of exam, ability to listen, and ability to explain.


In adjusted analyses, persons with high medical cost burdens had greater odds of lacking trust in their physician to put their needs above all else (OR = 1.43, CI = 1.19, 1.73), not referring them to specialists (OR = 1.39, CI = 1.22, 1.58), and performing unnecessary tests (OR = 1.42, CI = 1.20, 1.62). Patients with high medical cost burdens also had more negative assessments of the thoroughness of care they receive from their physician (OR = 1.26, CI = 1.02, 1.56). The association of high medical cost burdens with patient trust and perceived quality of care was greatest for privately insured persons.


The rising cost of medical care threatens a vital aspect of the effective delivery of medical care–patient trust in their physician and continuity of care. Exposing patients to more of the costs could lead to greater skepticism and less trust of physicians’ decision-making, thereby making health-care delivery less effective.


medical cost burden patient trust perceived quality of care 



Support for this research was provided by the Commonwealth Fund. The author would like to thank Ann O’Malley, M.D., and Sara Collins, Ph.D., for their helpful comments on an earlier draft of this manuscript.

Conflict of Interest

The author asserts that there are no known conflicts of interest regarding the conduct or outcome of this research. The author is employed by the Center for Studying Health System Change, which is a subsidiary of Mathematica Policy Research, Inc., a for-profit company with an Employee Stock Ownership Plan.


  1. 1.
    Banthin J, Bernard D. Changes in financial burdens for health care; national estimates for the population younger than 65 years, 1996-2003. JAMA. 2006;296:2712-9.PubMedCrossRefGoogle Scholar
  2. 2.
    Banthin J, Cunningham P, Bernard D. Trends in the financial burden of health care expenditures, 2001-2004. Health Affairs (forthcoming).Google Scholar
  3. 3.
    May JH, Cunningham P. Tough Tradeoffs: Medical Bills, Family Finances and Access to Care. Issue Brief #85. Washington, D.C: Center for Studying Health System Change (2004) Available at (accessed November 9, 2008).
  4. 4.
    Collins SR, Kriss JL, Davis K, Doty MM, Holmgren AL. Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families. [Commonwealth Fund website]: Available at (accessed November 9, 2008).
  5. 5.
    Employee Benefit Research Institute. 2006 Health confidence survey: Dissatisfaction with health care system doubles since 1998. [EBRI web site] Accessed November 9, 2008).
  6. 6.
    Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79:613-39.PubMedCrossRefGoogle Scholar
  7. 7.
    Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-20.PubMedGoogle Scholar
  8. 8.
    Thom DH, Ribisl KM, Stewart AK, Luke DA. Further validation and reliability testing of the trust in physician scale. The Stanford Trust Study Physicians. Med Care. 1999;37:510-7.PubMedCrossRefGoogle Scholar
  9. 9.
    O’Malley AS, Sheppard VB, Schwartz M, Mandelblatt J. The role of trust in use of preventive services among low-income African-American women. Prev Med. 2004;38:777-85.PubMedCrossRefGoogle Scholar
  10. 10.
    Beal AC, Doty MM, Hernandez SE, Shea KK, Davis K. Closing the Divide: How Medical Homes Promote Equity in Health Care: Results from the Commonwealth Fund 2006 Health Quality Survey. Available at Accessed November 9, 2008.
  11. 11.
    O’Malley AS, Forrest CB. Beyond the examination room: primary care performance and the patient-physician relationship for low-income women. J Gen Intern Med. 2002;17:66-74.PubMedCrossRefGoogle Scholar
  12. 12.
    Pearson SD, Raeke LH. Patients’ trust in physicians: many theories, few measures, and little data. J Gen Intern Med. 2000;15:509-13.PubMedCrossRefGoogle Scholar
  13. 13.
    Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000;9:1156-63.PubMedCrossRefGoogle Scholar
  14. 14.
    Kao AC, Green DC, Zaslavsky AM, Koplan JP, Cleary PD. The relationship between method of physician payment and patient trust. JAMA. 1998;280(19):1708-14.PubMedCrossRefGoogle Scholar
  15. 15.
    Mechanic D, Schlesinger M. The impact of managed care on patients’ trust in medical care and their physicians. JAMA. 1996;275(21):1693-7.PubMedCrossRefGoogle Scholar
  16. 16.
    Reschovsky JD, Kemper P, Tu H. Does type of health insurance affect health care use and assessments of care among the privately insured? Health Serv Res. 2000;35(1):219-37.PubMedGoogle Scholar
  17. 17.
    Strouse R, Carlson BL, Hall J. Community Tracking Study: Household Survey Methodology Report 2003 (Round 4). Technical Publication No. 62. Washington, D.C: Center for Studying Health System Change. Available at: Accessed November 9, 2008.
  18. 18.
    Shah BV, Barnwell BG, Bieler FS. SUDAAN User’s Manual, Release 7.0. Research Triangle Park, NC: Research Triangle Institute Inc; 1996.Google Scholar
  19. 19.
    Anderson LA, Dedrick RF. Development of the trust in physician scale: a measure to assess interpersonal trust in patient-physician relationships. Psych Rep. 1990;67:1091-100.Google Scholar
  20. 20.
    Ku L, Coughlin TA. Sliding-scale premium health insurance programs: four states’ experiences. Inquiry. 1999/2000:36;471-80.Google Scholar
  21. 21.
    Monheit AC. Persistence in health expenditures in the short run: prevalence and consequences. Med Care. 2003:41(7, Supplement):III53–64.PubMedCrossRefGoogle Scholar
  22. 22.
    Safran DG, Neuman P, Schoen C, et al. Prescription drug coverage and seniors: findings from a 2003 national survey. Health Affairs, 2005 (Web Exclusive): W5-152-W5-156.Google Scholar
  23. 23.
    Soumerai SB, Pierre-Jacques M, Zhang F, et al. Cost-related medication nonadherence among the elderly and disabled: a national survey one year before the Medicare drug benefit. Arch Intern Med. 2006;166(17):1829-35.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  1. 1.Center for Studying Health System ChangeWashingtonUSA

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