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Am J Manag Care. 2003 Mar;9(3):238-44.

Patient reports of coverage denial: association with ratings of health plan quality and trust in physician.

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Center for Ethics in Managed Care and the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass, USA.



To evaluate whether HMO patients' reports of denial of coverage were associated with their ratings of health plan quality and trust in their physician.


Cross-sectional survey.


Within a mixed-model HMO, we surveyed 2000 adult patients who had seen a clinician at least once during the previous year.


Of the 2000 patients, 921 (46%) responded. Denial of coverage within the previous 12 months was reported by 64 (7%) patients. Among the denials, 42% were for specialist referral, 32% were for tests or treatments, 18% were for a certain length of hospital stay, and 8% were for a hospital admission. Patients scoring in the lowest quartile on physical functioning were more than twice as likely as other patients to report denial of coverage (12.2% vs 5.1%, P = .001). In multivariable analyses, poor physical functioning remained the only significant independent variable associated with reporting denial of coverage (odds ratio = 3.0; 95% confidence interval, 2.4, 3.6). More than half (53%) of patients reporting denial of coverage said that they had considered leaving the health plan because of concerns about quality of care. These patients also were less likely to express high trust in their primary care physician (64% vs 78%, P < .001).


Patients with poor physical functioning were more likely to report denial of coverage. Perceived denial of coverage was associated with lower ratings of health plan quality and with significantly less trust in patients' own primary care physicians.

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