Managed Care - March 2008 - (Page M4) Good Medicine, Good Business, Great Leadership: The Trust Prescription For Health Care DAVID A. SHORE, PHD Associate Dean and Founding Director, Forces of Change Program and Trust Initiative, Harvard University School of Public Health P eople who are employed by or work in concert doctors and nurses, who established long-term relationwith MCOs may labor under the illusion that they ships with their patients. Today, they are commonly reare in the health care business. In fact, they are in ferred to as providers, a term that also obscures the difthe trust business. ference between physicians and hospitals. Trust in people and institutions in the United States has been eroding. In 1960, 55 percent of Trust vs. quality people agreed with the statement that Quality metrics were devised to dispel “most people can be trusted,” but by 2000 the myth that every doctor is above averless than 35 percent felt this way (Purdy age and to demonstrate that great dispar2003). Americans also have expressed a ity exists in the delivery of many health loss of confidence in the leadership of care services, but the marketplace has major institutions over the past four been slow to embrace the concept. That is decades (Figure). In a 2007 Harris poll, because in the marketplace, trust trumps only 37 percent of Americans expressed a quality. Trust trumps all the key variables in health care — quality, service, technol“great deal” of confidence in medical leadership, while 45 percent said they had ogy, and value — because trust serves as “only some” confidence and 17 percent a proxy for each. If a patient trusts a physihad “hardly any” (Harris 2007a). In this cian, the patient assumes the physician survey, medicine fell third among 16 inpossesses the appropriate technology and D A V I D A . S H O R E , P hD stitutions ranked by public confidence in offers good quality, service, and value. their leaders, being tied with higher education and trailMere competence does not build trust; competence is the ing only small business (54 percent) and the military (46 cost of doing business, an expectation of the marketplace. percent). But in 1966, when 73 percent of the public was In an audience of medical directors I addressed recently, greatly confident in its medical leadership, no other ineveryone in attendance indicated that his or her own stitution ranked higher. Since then, no other institution doctor was average or above average. This audience was has suffered as steep a decline in the confidence of its not an atypical group; the same results are seen when the leadership. question is put to, say, the owners of fine jewelry stores. As for its trust of particular businesses, the public especially lacks trust in certain segments of the health care Consequences of lack of trust industry. Another Harris poll showed that only 5 percent Although patients may have difficulty assessing the of the public thinks that MCOs are generally honest and quality of care they receive, they are quite comfortable in trustworthy (Harris 2007b); the only industries that rank indicating, in verbal and nonverbal ways, whether they lower are tobacco and oil companies. Pharmaceutical trust the people who care for them. When patients lack and health insurance companies are trusted by 11 pertrust in their physicians, they delay seeking care, and cent and 7 percent, respectively, while hospitals are they visit the emergency department more frequently, trusted by only 28 percent of the public (Harris 2007b). which results in poor clinical outcomes and the most exThe erosion of trust in the health care profession also pensive care (see, for example, Safran 1998, Trachtenberg is reflected in contemporary terminology. In earlier, more 2005). When patients trust their health care providers, trusting times, health care professionals were known as they are more likely to keep appointments, reveal relevant 4 MANAGED CARE / SUPPLEMENT
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