Trust is vital to the provision of quality health care. Quality outcomes have shown a correlation with exceptional health care experiences, with patients associating higher trust in health care professionals with “more beneficial health behavior, fewer symptoms, and improved quality of life.” Sadly, trust in American health care is on the decline. Stress placed on the health care system by the COVID-19 pandemic amplified growing concerns, with forty-eight percent of Americans expressing eroding confidence in the system’s ability to handle major crises. The decrease in trust in the health care system mirrors that seen in government, media, and science, where political polarization, inequality, and failures of leadership have led to growing skepticism in our country’s ability to overcome difficult challenges.
Other factors have widened the trust gap in the U.S. health care system. Nearly half of working-age, insured adults reported receiving medical bills in the past year for a service they thought should have been free or covered under their insurance. Further, seventeen percent of respondents said their insurer denied coverage for care recommended by their doctor. Nearly sixty percent of adults experiencing coverage denials said care was delayed as a result. Thirty-three percent of patients have been unable to see a doctor in the past year due to availability issues, and over half have had their appointments delayed by their practitioner. Health care practitioners are aware of delays, with sixty-five percent reporting that their facilities experience delays and thirty percent citing outdated tech systems as major hurdles for patient scheduling.
While the insurance system is certainly fraught with challenges, practitioner fraud also contributes to declining public trust in the health care system. The Senior Medicare Patrol (SMP) program empowers and funds Medicare beneficiaries in reporting health care fraud. In 2023 alone, SMP recoveries exceeded $111 million, and SMP estimates that Medicare fraud results in losses of $60 billion annually. In the first six months of 2024, the U.S. Department of Justice (DOJ) filed “criminal charges against 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals” for alleged participation in fraud schemes totaling $1.6 billion in actual losses. Reporting of these charges is motivating fodder for public mistrust of the professionals whom they rely on in times of health stress.
Blame can be spread further, as pharmaceutical companies use monopoly ownership of medications to raise prices to unconscionable levels. Hospital pricing games are rampant, with many hospitals claiming large operating losses while sitting on balance sheets with tens of billions of dollars. Profits are translated into salaries and benefits for health care executives in the range of several million dollars a year. Of the ten highest-paid corporate executives in the US in 2020, three were from a single health care company, with the CEO alone reportedly receiving compensation totaling $568 million. Mergers and acquisitions of hospital systems and physician practices theoretically designed to create savings through economies of scale almost always increase prices. By 2021 over half of US debt collections were for medical bills, a number not seen in other developed nations. Practice stress and debts can pressure willful and negligent financial misdeeds. It is an injustice to ignore the role greed has in fomenting distrust by the public. These notions force conflicts between health care profit, patient access, and costs to achieve high-quality services.
How can trust be restored in U.S. health care? Opportunities abound and are beyond the scope of this commentary. Possibilities include (and are not limited to) moving away from fee-for-service and toward value-based care, leveraging AI platforms to improve access, and shifting care to the home. Enhancement of the patient experience deserves exploration and has been discussed as a means of rebuilding trust between patients and providers. Authors have implored providers to no longer see patients as being separate components of the health care system who receive the services that practitioners and administrators design and deliver but rather as integral partners in the design and delivery of their own care. Patient engagement has been called the “next blockbuster drug” of health care, with data pointing toward improved relationships between patients, care partners, and providers, as well as better outcomes and more cost-effective care.
Our business colleagues have long understood the value of the customer’s voice, and recent research points to relationship marketing as a key tactic for service organizations to create long-term competitive advantage. Relationship marketing, defined as efforts “to closely know each customer, create two-way communication with consumers, and manage mutual relationships with customers and consumers,” has gained favor over more transactional marketing strategies that focus primarily on individual sales. Relationship marketing instead aims to build and strengthen connections with customers. The effect of relationship marketing on customer trust is significant, with better relationship marketing efforts directly and positively impacting customer trust.
The idea of building a connection between patients and their practitioners lies at the heart of the field of narrative medicine. With its primary tenets deriving from the work of Drs. Rita Charon and John Launer, narrative medicine is built upon the central concept that attention to narrative (either the patient’s story, the clinician’s story, or a story constructed by both) is vital to patient care. Narrative medicine thus serves to “fortify health care with the capacity to skillfully receive the accounts persons give of themselves … and be moved to action by the stories of others.” Narrative medicine training involves close reading of literary pieces, responsive telling, attentive listening, reflective writing, open receiving of shared stories, and mindful affirmation of the emotions of oneself and others. By connecting with each other relationally, clinicians ought to be better able to answer the patient’s question, “What would you do if you were me?” Like relationship marketing, shared approaches to medical decision-making acknowledge the humanity of patients and clinicians rather than viewing the relationship as episodic transactional actors in isolated encounters. Industry has long understood that the consumer’s experience is the “nucleus” of value creation. Health care has the opportunity to similarly value and champion the patient experience by embracing the principles and further developing the humanities-based tenets of narrative medicine.
Matthew Sherrer is an associate professor and director of care team collaboration at the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Department of Anesthesiology and Perioperative Medicine. With clinical interests in collective intelligence and value in health care, he is a founding member and physician liaison for the Anesthesia Care Team Optimization Committee at UAB—a team making unprecedented strides in building inclusive and respectful anesthesia care teams. He is also the program director for UAB’s Perioperative Leadership Fellowship, the only one of its kind in the Southeast. A graduate of the UAB Heersink School of Medicine, Dr. Sherrer is a board member of the Association of Anesthesia Clinical Directors (AACD) and is committed to developing future physician leaders and creating fulfilling work experiences for all members of the anesthesia care team.
He can be reached on X @MattSherrerMD and LinkedIn. He is also the co-host of the Fresh Flow podcast and has publications on PubMed.
Martin Nowak is a health care consultant.
