In this study, a total of 18 variables have been identified as associated with 'satisfaction with amount of PCP choice' when analyzed in each of the five domains of the conceptual framework. The 'system and insurer trust' domain was not fully tested due to data limitation and poor model fit. However, the variable 'trust in providers in general' of this domain had strong potential influence on interpersonal provider trust [38]. It should be reconsidered for examination in future studies. Analyses validated four of the five domains to be associated with 'satisfaction with amount of PCP choice' when each domain was examined independently. When the significant variables of these four domains were examined together in a single model to identify their relationship with 'satisfaction with amount of PCP choice', the domain 'consumer characteristics' was no longer associated with 'satisfaction with amount of PCP choice'.
Having 'enough insurer choice' was associated with 'satisfaction with amount of PCP choice' but not 'provider trust'. This appeared to be logical as plan choice preceded and necessarily impacted provider choice. Eighty-three percent of participants (n = 150) who reported enough insurer choice also reported enough PCP choice. Among participants who reported not enough insurer choice, 33 percent (n = 414) reported not enough PCP choice. 'Enough insurer choice' appeared to have some relationship with 'enough PCP choice.' 'Enough PCP choice', on the other hand, was found to be associated with provider trust. This confirmed the existing knowledge that enough or some amount of PCP choice was associated with provider trust.
When a plan had the characteristic of charging less if the providers were within network, it was strongly associated with greater odds in the reporting of 'satisfaction with amount of PCP choice.' This result suggested that this plan characteristic, which has the connotation of cost saving, was relatively popular among consumer preferences. A plan characteristic and consumer preference match explained the greater odds reported. Early studies of consumer behavior in plan choice suggested consumers were cost sensitive [46] while others saw provider choice as more important than benefits coverage [47]. Since Preferred Provider Organization (PPO) plans were gaining popularity over HMO plans in past years [48], it was not unreasonable to postulate that consumers had to make trade-offs between plan cost and provider choice, and that consumer preference might oscillate between the two depending on other factors, such as the proportion of employer contribution in health benefits.
'Years with the PCP' has some association with 'satisfaction with amount of PCP choice.' The duration of the patient-physician relationship indicated that the patient volunteered to stay with the provider for that length of time, or that they were required to stay with the provider for some reasons. Patients would have switched providers if the relationships were not good and they have a choice or a better choice. Nevertheless, involuntary provider switch behavior appeared to be more an issue of "employer-imposed disruption". Voluntary disenrollment from PCP practice was, however, associated with trust [49]. In the provider trust model, the variable 'years with the PCP' was also associated with the outcome of provider trust. In this case, the association was likely due to the issue of continuity of care, which may enhance provider trust [50].
'Long waiting time to appointment' has some negative association with both 'satisfaction with amount of PCP choice' and 'provider trust.' The consumer might not know if a certain provider has a 'long waiting time to appointment' unless they had known the provider before or had made efforts to find out how long it normally takes to secure an appointment. The variable also reflected the consumer preference for access to prompt appointments. The association with 'provider trust' would likely be due to a patient's perception of the provider's level of control in providing efficient services. "Control" refers to the physician's autonomy in providing needed services to the patient in a timely manner, which is a building block of physician trust [37].
The association of 'second opinion on the PCP' (due to concern of care) with lower provider trust involved a temporal issue of whether provider trust was already low at the time a second opinion was sought or if the second opinion confirmed the consumer's concern and hence decreased trust. This is a limitation of the cross-sectional study design not being able to measure the dynamic dimension of trust. Regardless of whether trust was low, declined before, after, or continued to decline after a second opinion on the PCP, the experience of having sought a second opinion on the PCP demarcated a decrease in trust.
Eight variables associated with 'satisfaction with amount of PCP choice' were analyzed in the model of 'provider trust' with and without potential confounders. Consumers' perception of the PCP's care being extremely effective was strongly associated with both 'satisfaction with amount of PCP choice' and with 'provider trust'. This finding was consistent with the consumer preference for professionally qualified providers [19], for having information about the provider's performance including error rates and adverse outcomes [31], and with the definitions of trust that the provider has the competencies to enhance the technical aspects of care [37].
Contrary to the existing knowledge that minorities, especially Blacks and Hispanics, preferred a provider of the same ethnic background or who speaks the same language [51], this study found that 'racematch' was not significantly associated with 'satisfaction with amount of PCP choice'. It was also interesting to find that 'consumer education' was negatively associated with 'provider trust.' It suggested the higher the education level the more likely that the consumer would "challenge" the provider's competencies in patient care. It was not clear if the high proportion of female subjects (67%) in the sample might have contributed to the association of 'consumer being female' to 'satisfaction with amount of PCP choice' and to 'provider trust'.
Novel findings
Variables associated with 'satisfaction with amount of PCP choice' have never been explored before. This study identified eight variables that were associated with consumers' satisfaction with the amount of PCP choice. Having spoken to one's PCP outside of the medical office was strongly associated with reporting of enough PCP choice. Regardless of the contexts, interaction outside of the medical office may have created a sense of harmony with the PCP, such as having visited similar stores or lived in the same communities. Socialization out of the medical environment may also create a sense of friendship with the PCP. At the same time, the selected provider may just be the provider that the consumer preferred or knew from before. Nevertheless, interaction outside of the medical office was not associated with provider trust. This was most likely because this kind of interaction would not change the PCP's role as a healthcare agent, their autonomy and their competencies to take care of the patient.
The perception of having enough insurer choice, the consumers' report of satisfaction with their insurers, and health plans that 'charged less if providers within network' were strongly associated with 'satisfaction with amount of PCP choice'. 'Insurer satisfaction' included satisfaction with plan characteristics and/or insurer services in medical claims. Consumers who preferred cost saving would find such plan characteristic attractive and be more ready to report 'satisfaction with amount of PCP choice'. In contrast, consumers who preferred PCP choice more than cost saving would feel this plan characteristic restricted their access to preferred providers, and would be less likely to report 'satisfaction with amount of PCP choice'. Thus the associated variables appeared to reflect on the cost sensitivity of consumers [52], and not so much on the amount of PCP choice being available. In which case, even some amount of choice would be sufficient to constitute as "enough PCP choice." Results also highlighted the dilemma of trade off between increasing cost and limits in PCP choice for the consumer. On the other hand, the popularity of PPO Model over HMO plans suggested there was another sector of consumers who preferred greater access of PCP choice to cost saving [48], though it was not indicated in this study finding.
Consumers who had upset/dispute experience(s) with PCPs, or who experienced long waiting time to get an appointment, had a moderately lower likelihood of reporting 'satisfaction with amount of PCP choice'. It was not clear how serious the dispute(s) were and how frequent the dispute(s) occurred. Respondents had responded to the 'enough PCP choice' survey item before they were asked the 'dispute with PCP' item. Unless recent dispute(s) or repeated disputes made the experiences into long-term memory, the dispute experiences should not be affecting participants' response to the item of 'enough PCP choice.' Furthermore, the lower reporting of 'satisfaction with amount of PCP choice' may be an indicator that the PCP profiles were poor matches with the consumer preferences. Long waiting time to get an appointment was not associated with provider trust. Quality of and/or duration of visit may have made up for the deficiency in appointment schedules and had slight influence on provider trust, if any.
It was understood at the outset of the study that the evaluation of satisfaction with PCP choice may make a difference in responses depending on when the data was collected. It was interesting to discover that elements occurred after PCP choice or after PCP assignment may or may not "compensate" for an initial perception of the amount of PCP choice available. At the system level the implications of this study findings point to the direction of rethinking the consumerism of demanding more PCP choice. Is it necessary that consumers be given "adequate" amount of choice? Will it be better if consumers be assisted with information in selecting a PCP who best suits their preferences, or who is known to be very professional?
Furthermore, it is possible that patients may have projected their experiences with the physicians into the reporting of 'satisfaction with amount of PCP choice'. Satisfaction is the evaluation of past events. The timing of when to measure satisfaction with PCP choice is not necessarily better at one time than another. However, the interpretations of satisfaction with the amount of PCP choice measured immediately after the choice was made or given will have to be different from that measured several years after the choice was made. This study found some plan characteristics variables associated with 'satisfaction with amount of PCP choice'. The associations prompted the reconsideration of whether giving patients more PCP choice (say through health plan design) is an efficient or effective means of driving the healthcare market. The patient-physician experience may also have some influences on the perception of the adequacy in amount of PCP choice. In this study, patients had seen their PCPs at least twice in the past year, the experience with the PCP would inform the overall associations of medical encounters and thus 'satisfaction with amount of PCP choice' and 'provider trust.'
Study strengths and limitations
A limitation of the study is that although the study sample was a random national sample, it did not match exactly the general U.S. population given the study inclusion criteria and racial differences in telephone subscription rate. The data was collected in 1999. It did not necessarily reflect all changes over the past few years in the healthcare market, such as voluntary or mandatory hospital or provider performance public reporting. Evolvement of healthcare in the past few years has included the shift towards greater consumer cost-sharing, and the popularity of PPO over HMO plans [48]. Other than the role of information on choice behavior, the dilemma of choice has been mostly on cost-choice trade-offs. The timeliness of the data for analysis should not be of concern. Despite the availability of increasing national and local publication or reports on health plan and provider performances, and information to assist plan and/or provider choice, there had been few published studies of the effects of performance data on consumer choice behavior [53]. Much about performance report utilization, information usefulness, and consumer satisfaction with information quality remained to be explored [54]. Another limitation of this study was the lack of data on performance report utilization in the national dataset which prohibited this element from being examined in any of the models.
Other limitations of this study include those inherent with secondary data analysis. The lack of overlapping observations in the variable 'trust in providers in general' prohibited its application for analyses. The cross-sectional study design did not account for the longitudinal dimensions of choice and of trust, and for the dynamic dimension of trust. Evaluation of variables of 'satisfaction with amount of PCP choice' was retrospective. For consumers who have had their PCP for many years, it was debatable whether their experiences with their PCP currently and over the years might have influenced their perceptions and hence 'satisfaction with amount of PCP choice.' As in any cross-sectional study design, results of this study can only be viewed as associations among variables with the outcomes of interest rather than causality.
Future studies
Results suggested the adapted conceptual framework can be modified. Figure 1, titled 'PCP choice satisfaction-related associations and outcomes with modifications based on empirical findings of this study', illustrates the relationships of the four relevant domains. 'Consumer characteristics' was no longer significant. The revised conceptual framework constituted four renamed domains: plan related, provider related, trust related, and information related. Other than plan or provider related variables, trust or information related variables require more exploration. Conflicting information and biased marketing materials often lead to information distrust [30]. 'Trust in provider performance reports' should also be explored under the 'trust related' domain in future studies to see its influence on consumer choice behaviors.
The provider's professionalism has never been explored as a predictor of provider trust before and it deserves attention in future studies. Future studies of healthcare public reporting, of provider specific information, and of trust in information available to assist choice will unveil the roles of information in consumer preferences, in consumer satisfaction, and in provider trust. If possible, examining all the known predictors of provider trust in one study may provide a holistic view of what is relatively important in predicting provider trust and in sustaining trust.