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Commentary Suggests Strategies to Rebuild Patient Trust in Healthcare System

Doctor seated behing desk facing seated patient.

Patient mistrust of the healthcare system, which has come under new focus during the COVID-19 pandemic, is partly the result of an increasingly consumer-oriented healthcare system, according to a new commentary by a Weill Cornell Medicine investigator.

"Trust is the glue that holds all of healthcare together,” said lead author Dr. Dhruv Khullar, an assistant professor of population health sciences and of medicine at Weill Cornell Medicine. “If trust starts to decline, it inhibits the way we can care for patients, and it creates challenges for public health responses, as we’re seeing with the COVID-19 pandemic.”

The Dec. 15 viewpoint article in JAMA, coauthored with Debra L. Ness of the National Partnership for Women and Families and Gwen Darien of the National Patient Advocate Foundation, recommends reforms that focus on rebuilding relationships with patients. 

Part of a wider trend of eroding trust in institutions, mistrust toward the healthcare system also has a particular cause: the “inherent contradiction” that it operates like any profit-oriented industry while at the same time holding the moral obligation to care for patients regardless of ability to pay, the authors write.

“There’s this tension in consumerist, profit-driven healthcare, with an individual being asked not just to be a patient but to behave as consumer or buyer,” Dr. Khullar said. “What most people want is to engage in a trusting relationship.” For people of color and low-income groups, trust has been further eroded by a lack of equitable access to quality care, and in some cases a history of biased and unethical treatment, according to the paper.

The authors point to the rise of high-deductible health plans (HDHPs), which enrolled over 45 percent of commercially insured adults in 2018. HDHPs were supposed to “empower” patients with greater responsibility for their health costs. In practice, the plans often force patients to make hard decisions without enough information or expertise and deters them from seeking needed care, the authors write. Patients should instead be able to turn to their providers, who can be incentivized to refer them to high-quality, low-cost care, they suggest.

The authors also recommend accelerating the shift away from the dominant “fee-for-service” model, which incentivizes billing for more services, to “value-based” payments based on quality of care. To be effective, these models should incorporate patient feedback, known as “patient-reported outcomes” or PROs. They should also encourage equitable care by adjusting to account for “social risk,” so clinicians are not penalized for seeing poorer or sicker patients.

Finally, the authors offer suggestions for building “authentic partnerships” in communities. Non-profit healthcare systems, which are obligated under the Affordable Care Act to dedicate part of their revenue to their community’s health to maintain tax-exempt status, can broaden their giving.

“As hospitals become the nexus of economic and social activity in a lot of communities,” Dr. Khullar said, “they need to work ‘upstream,' to not just provide care when people are sick in hospitals, but improve health before someone gets sick.”

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