Speaking Up and Walking Out

Are Vulnerable Patients Less Likely to Disagree With or Change Doctors?

Published in: Medical Care Volume 56, Number 9 (September 2018), Pages 749-754

Posted on RAND.org on August 24, 2018

by Steven C. Martino, Marc N. Elliott, Joshua Mallett, Nathan Orr, Sarah J. Gaillot, Amelia Haviland

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Disparities in clinical process-of-care and patient experiences are well documented for Medicare beneficiaries with ≥1 social risk factors. If such patients are less willing to express disagreement with their doctors or change doctors when dissatisfied, these behaviors may play a role in observed disparities.


To investigate the association between social risk factors and self-reported likelihood of disagreeing with or changing doctors if dissatisfied among the Medicare fee-for-service population.


Fee-for-service beneficiaries (N=96,317) who responded to the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey. Subgroups were defined based on age, education, income, and race/ethnicity.


Respondents reported how likely they would be to express disagreement with their doctors and change doctors if dissatisfied (1=very unlikely to 4=very likely; rescaled to 0-100 points). We fit mixed-effect linear regression models predicting these outcomes from social risk factors, controlling for health status and geographic location.


Beneficiaries who were older, less educated, and had lower incomes were least inclined to express disagreement or change doctors (P<0.001). Compared with non-Hispanic whites, Asian/Pacific Islander (-9.5) and Hispanic (-3.6) beneficiaries said they would be less likely, and black (+2.8) beneficiaries more likely, to express disagreement. Asian/Pacific Islander (-8.7), Hispanic (-5.9), and American Indian/Alaska Native (-3.8) beneficiaries were less inclined than non-Hispanic whites to change doctors (P<0.01).


Reduction in health care disparities may be achieved if doctors and advocates encourage vulnerable patients to express their concerns and perspectives and if communities and caregivers provide support for changing providers when care is poor.

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