Is the Prevalence of Gatekeeping in a Community Associated With Individual Trust in Medical Care?

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Abstract
Consumer concerns about the restrictions of managed care may lead to distrust. To examine whether a community's level of gatekeeping activity is associated with an individual's trust in medical care. Cross-sectional cohort (N = 49,929). Participants in a nationally representative sample derived from the Community Tracking Survey who had health insurance, had a usual source of care, made at least 1 physician visit, and resided in one of the sampled metropolitan areas with corresponding community-level data, including the prevalence of gatekeeping activity. Four questions measuring trust in physician. Individuals from communities with a higher prevalence of gatekeeping activity report less trust than individuals from areas with a lower prevalence of gatekeeping activity, after adjusting for whether that individual had a health plan with a gatekeeper requirement. For example, in communities with the highest prevalence of gatekeeping activity relative to the lowest, the odds ratio for individuals to agree strongly that they trusted their doctor to put their medical needs above all other considerations was 0.77 (95% confidence interval, 0.71-0.84). Also, a higher prevalence of gatekeeping in the community was positively associated with the perception that a physician was strongly influenced by insurance company rules when making decisions about medical care. Conversely, a higher prevalence of gatekeeping in the community was negatively associated with the perception that a doctor might perform an unnecessary test or procedure and with concern about restricted referral for specialty care. Individuals' trust in their physicians may be influenced by wider contextual variables, like the prevalence of gatekeeping in the community.