Before managed care became the dominant force that it is, patients and doctors had the opportunity to get to know each other well. Doctors treated multiple generations within families. This helped establish a strong bond among patients and their doctors.

While it might have intended to mean preventing expensive care, managed care began to mean organized care. Run by institutions such as health maintenance organizations.

Insurances began to decide which doctors you could see. If you changed jobs or if your employer changed insurance plans, you had to change your doctor again.

This shift, which is now happening in almost every part of the world, altered the patient-doctor relationship forever.

With the growth of organized care, the medical equation became more of a transaction. A give and take. Patients became “customers.” Doctors became “providers.”

Some health policy experts suggest that managed care permanently damaged primary care in America.

From the position of being the vanguards of medicine, primary care doctors increasingly became those whom patients approached mainly for prescriptions or referrals to specialists.

Using a fee-for-service model, organized care repeatedly taught our health systems on what is more valued. Fixing complicated sickness. Not maintaining good health. Medicare, a government insurance, pays 10x more for stent placement than for a consultation regarding preventing stent placement.

In our world, it seems absurd to even think why someone would pay more for a less complex transaction like coaching someone to avoid heart disease.

Well, we get more of what we pay more for.

Naturally, the health care industry became less interested in primary care. Doctors would have to work harder, seeing more patients per day just to stay afloat. Whereas as specialists, a handful of procedures would be enough to cover costs.

Multimillion-dollar ask-your-doctor advertisement campaigns made even more customers out of patients. They demanded that their doctors prescribe the drugs they learned about on TV.

When something went wrong, medical providers became liable for malpractice. A test or two would protect them to prove that they had taken the right steps.

Finally, when Wall Street took over health care, it just became clearer that more medicine was better for business.

More drugs. More tests. More hospitalizations. More became the new better.
But in this business of more medicine, the doctor-patient equation took a backseat. Frustrated doctors. Sicker patients.

Today, doctors are aware that the patient in front of them feels entitled to the care she’s about to buy. She has a choice to ignore the doctor’s recommendation. If something goes wrong, she or her family would even come back and sue him.

Patients are aware that the doctor in front of them could have other factors influencing the medical decision. Pressure from administration. Influence of the drug company. Skewed insurance incentives.

Patient engagement is becoming a field in itself. There are more and more technologies to improve a provider’s ability to engage patients. Apps. Social media. Video chats.

We can keep trying new tactics to improve patient engagement. However, there’s an elephant in the doctor’s room. It’s staring at us all the time. It’s called low trust.

Health care is making the classic mistake that many startups make.

When something’s not working (like customers ignoring you), startups like to employ more tactics. Facebook likes. Twitter followers. The problem may actually lie in something more basic, such as being transparent with your customers.

The starting point of patient engagement needs to be about building trust with patients and their families. Before, during, and after every medical encounter. Throughout their journey of suffering.

Openness is the basic foundation of trust. As is evident in health care, the cost of low trust is extremely high. Without trust, patient engagement is moot.

Praveen Suthrum is president and co-founder, NextServices and blogs at redo | healthcare.

Image credit: Shutterstock.com