CONTEXT: Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care. OBJECTIVE:To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want. DESIGN: Telephone survey during 1997.PARTICIPANTS: Patients (N = 2,052; 58% response) insured by a large national health insurer. MEASUREMENTS:Patient trust, overall ratings of physicians, and having considered changing physicians. RESULTS:Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P < .001) and 5 of 6 with lower overall ratings (P < .001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6).CONCLUSIONS: Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.

The long-term trend of consolidation among US health plans has raised providers' concerns that the concentration of health plan markets can depress their prices. Although our study confirmed that, it also revealed a more complex picture. First, we found that 64 percent of hospitals operate in markets where health plans are not very concentrated, and only 7 percent are in markets that are dominated by a few health plans. Second, we found that in most markets, hospital market concentration exceeds health plan concentration. Third, our study confirmed earlier studies showing that greater hospital market concentration leads to higher hospital prices. Fourth, we found that hospital prices in the most concentrated health plan markets are approximately 12 percent lower than in more competitive health plan markets. Overall, our results show that more concentrated health plan markets can counteract the price-increasing effects of concentrated hospital markets, and that-contrary to conventional wisdom-increased health plan concentration benefits consumers through lower hospital prices as long as health plan markets remain competitive. Our findings also suggest that consumers would benefit from policies that maintained competition in hospital markets or that would restore competition to hospital markets that are uncompetitive.A s the long-term trend of consolidation among US health plans continues, providers have voiced growing concern that health plans will acquire such market power that they will be able to depress the prices paid to providers. The American Hospital Association has argued that health plan consolidation leads to "reimbursement to hospitals and physicians that is below competitive levels," thereby threatening both the quality of care and patients' access to it. 1The American Medical Association has proposed legislation that would allow physicians to bargain collectively with health plans without fear of antitrust prosecution, so as to "level the playing field" in price negotiations. 2,3Despite the importance of these issues, and the growing interest in them, there is limited empirical evidence regarding the relationship between concentrated health plan markets-that is, markets where most people with private health insurance purchase it from one to just several insurers-and the prices that plans pay to providers. There have also been few studies of the relationships among the level of concentration in the market of health plans; the level of concentration in the market of hospitals; and the prices that hospital charge. 4,5 This article adds to the literature by studying how both health plan market concentration and hospital market concentration interact to affect hospital prices in the United States.

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This paper analyzes hospital cost shifting using a natural experiment generated by the Balanced Budget Act (BBA) of 1997. I find evidence that urban hospitals were able to shift part of the burden of Medicare payment reduction onto private payers. However, the overall estimated degree of cost shifting is small and varies according to a hospital's share of private patients. At hospitals where Medicare is a small payer relative to private insurers, up to 37% of BBA cuts was transferred to private payers through higher payments. In contrast, hospitals with greater reliance on Medicare were more financially distressed, as these hospitals saw large BBA cuts but were limited in their abilities to cost shift.