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Based on findings from 1990 National Co-morbidity Survey, it is estimated that nearly 20% of the U.S. population is affected by mental disorders during a given year. Approximately 5.4% of adults are considered to have a serious mental illness that interferes with their social function, and half of them suffer from severe and persistent mental illness (SMI). Mental illness imposes a high socioeconomic burden that is second only to cardiovascular disease (Kessler, Berglund, Zhao et al., 1996; Kessler, McGonagle, Zhao et al., 1994). Among individuals with SMI, 40% do not seek any treatment from either general medical or specialty mental health providers (Regier, Narrow, Rae et al., 1993). In addition, persons with SMI tend to have more co-morbid health and/or substance abuse conditions. They also have higher mortality rates for both natural and unnatural causes compared to the general population (Bazemore, 1996; Berren, Hill, Merikle et al., 1994; Black, Warrack, & Winoker, 1995; Newman & Bland, 1991). However, among individuals with co-morbid physical and mental health conditions, only one-third of them receive mental health treatment from either general health or mental health care providers. In Florida, evaluation results of Medicaid health services indicate between 15% and 20% of individuals with SMI did not use any mental health services. These findings lead us to question why individuals who likely should be receiving services do not use them. One theory is that the level of trust a person has in his or her provider is an important factor associated with disabled individuals' use of health/mental health services. Valey and his colleagues found that trust, honesty, and respect are essential ingredients for successful treatment (Valey, Krone, & Gerbino, 1998). Other investigators have found that people’s trust in their health care providers has an important influence on various health care outcomes including, adherence to treatment, satisfaction with the services received, continuation of relationships with service providers, and remaining in the same health plan (Chen, 2001; Kao, Green, David et al., 1998a; Kao, Green, Zaslavsky et al., 1998b; Thom & Campbell, 1997). These results suggest that people’s trust in their health care providers is an important factor associated with their health service utilization behaviors. The purpose of this study was to examine the relationships among Medicaid recipients’ trust in their health care providers and their service use. Using mail survey and administrative claims data to answer the following specific questions: 1. What are characteristics of enrollees of the four health care financing arrangements? 2. What is the relationship between enrollees’ level of trust in their health care providers and their service use? 3. What is the prevalence of enrollees discontinuing service use? To what extent is their discontinuation of services related to their trust in their health care professionals? 4. To what extent is trust associated with the use of high or low cost treatment modalities? The results of this analysis show that adult HMO and HMO/FFS enrollees were significantly younger than adults enrolled in either the FFS or PMHP plan. Adult and child enrollees in the HMO and HMO/FFS plans were more likely to be African-American compared to adult and child enrollees in both the FFS or PMHP plans. With respect to health status, adult HMO/FFS enrollees were in significantly poorer physical health compared to adults enrolled in the FFS and PMHP plans. Adult HMO/FFS enrollees also experienced significantly more psychiatric symptoms compared to adults in the PMHP plan. No significant differences were found in children’s psychiatric symptoms across the four health care plans. Enrollees’ level of trust in their health care providers was significantly related to the use of services among both adults and children. Adults service users and the caregivers of children who used services during the year preceding the mail survey reported significantly higher levels of trust in their health care providers compared to enrollees who did not use service. In addition, the type of health care plan (i.e., managed versus non-managed) in which individuals were enrolled was also a significant predictor related to trust in health care professionals among adult enrollees. Adults enrolled in a managed physical health plan had significantly lower levels of trust in their health care providers and were less likely to use services compared to adults enrollees in a nonmanaged plan. However, this finding did not hold for children. Rather, a child’s age was a significant predictor of caregivers’ levels of trust in their children’s health care providers. Caregivers with younger children were significantly more likely to trust their children’s health care providers compared to caregivers with older children. Approximately 18% to 20% of enrollees in the FFS and PMHP plans stopped using services for a period of six months or longer during year preceding the mail survey. A substantially higher proportion of the HMO and HMO/FFS enrollees discontinued services, more than 70%. These disproportionate rates of stopping service use are likely attributable to lack of managed care encounter data. Therefore, additional data is required to more comprehensively examine the effects of different health arrangements on discontinuation of services and its relationship to enrollees’ trust in their health care providers. Examination of termination of service use and the use of high cost services in relation to the FFS enrollees trust in their health care providers, revealed no significant relationships. However, only including enrollees from one health plan in the analysis limits our ability to assess whether managed care impacts service utilization and its relationship with trust. Trust remains a primary concern of many scholars, researchers, and health care providers (Blumenthal, 1996; Mechanic, 1996, 1997; Mechanic & Schlesinger, 1996). Further study including managed care service utilization data is needed to more fully understand the relationship between enrollees’ trust in their health care providers and their service utilization patterns.


DE LA PARTE INST (FMHI)-Circulating Collection; call no. RA790.65.F6 C44 2003

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"Florida Agency for Health Care"