By Donna M. Bergman

January 14, 2027

Healthcare’s shift toward value-based care depends on more than better incentives and fewer unnecessary services. This article explores how distrust drives cost, complicates clinical decisions, and why designing care experiences that help patients feel heard, understood, and guided may be essential to making the model work.

A friend recently complained to me that his primary care physician refused to refer him to a specialist. A nurse in the office told him the doctor rarely refers patients out and that he makes more money if he doesn’t.

Maybe the doctor was withholding care. But more than likely, his physician was actually trying to help him.

What struck me was not whether the referral was warranted, but how quickly a clinical judgment had been interpreted as a financial decision.

That’s when I realized we often misunderstand one of healthcare’s largest challenges. We think we have a care delivery problem. Increasingly, we have a trust problem.

The Impact

Value-based care is a growing payment model in which physicians, medical groups, and health systems are rewarded not simply for the services they provide, but for the outcomes and value they create. Payers and government programs commonly measure that value through quality care gap closure, utilization, and patient experience.

A large part of value-based care contracting now involves holding physicians accountable for the total cost of care.

Better care may mean less care or less intervention. Patients do not understand the why in many cases, so less care often feels like a denial of care.

The better we become at avoiding unnecessary care, the more important trust becomes.

The Trust Paradox

When physicians practiced in a fee-for-service environment, they were rewarded based upon the volume and complexity of the care delivered.

Patients understood this. More care was seen as better care.

In value-based care models, rewards shift to appropriate care. This is much harder for patients to understand.

Patients may struggle with value-based care not because the model is irrational, but because they cannot always distinguish appropriate clinical restraint from financially motivated denial.

This is further complicated by the way information has changed. In the past, patients often had too little information and relied almost entirely on physicians to explain what was happening and why. Today, patients have access to an abundance of information, but many lack a reliable way to judge its quality. In that environment, a decision to avoid unnecessary care can be easily interpreted as withholding care.

Trust is the only thing that makes the transition to value-based care possible.

The Cost of Distrust

Many of healthcare’s cost, quality, and utilization challenges are downstream symptoms of a trust deficit.

Put simply, distrust drives additional spending, which is precisely what physicians are being asked to reduce.

The increased spend may come with unnecessary tests. It may come from fragmented care as patients struggle to find a clinician willing to see things from their point of view.

Patients may turn to online sources, virtual care, urgent care, or emergency departments in search of answers to their underlying questions. Demands for specialty referrals may also increase.

Patients may become increasingly insistent on advanced imaging without realizing that the additional care may not be clinically necessary and may add cost and complexity to an already overly complex system.

Consider this scenario:

A woman in her early 50s comes to her PCP asking for a DEXA scan.

Her PCP responds, “You don’t meet the criteria.” From the clinician’s perspective, the recommendation is sound: a DEXA scan is not supported by the applicable evidence or guidelines and would represent unnecessary testing and cost.

Her reasoning is innately human: Her mother broke a hip, the fracture revealed osteoporosis, and the consequences were devastating. She does not want the same future for herself, so a DEXA scan feels necessary.

The trust issue is not whether a DEXA scan is medically indicated or not. The trust issue comes into focus when you realize the woman and her PCP are having two different conversations in the same moment.

The woman is not simply asking whether she qualifies for a test. She is asking whether she is receiving the right care and what she can do to avoid her mother’s fate. Those are reasonable concerns.

The issue isn’t that patients are wrong. It’s that healthcare often answers the clinical question while missing the emotional question.

The clinical response may be: A DEXA scan isn’t indicated.

But the underlying question is: What is my risk and what can I do about it?

These are very different conversations.

When those conversations fail to connect, distrust grows. And as distrust grows, so do many of the cost, quality, and utilization challenges healthcare leaders work so hard to solve.

Imagine What Could Be

But what if this isn't inevitable?

What if many of healthcare's most persistent challenges are not simply clinical or operational problems, but communication and relationship problems?

What if the future of healthcare depends less on convincing patients to trust us and more on designing systems that are worthy of their trust?

Consider our woman asking for a DEXA scan. Imagine if the conversation shifted away from whether she met criteria for a DEXA scan and toward the question she was really asking. What are my risks? What happened to my mother? What can I do now to protect my future health?

The test itself may not change. The clinical recommendation may remain exactly the same. But the patient's experience changes entirely. She leaves with understanding instead of uncertainty.

Too often, healthcare interprets these moments as resistance. Patients are labeled non-compliant, difficult, or unwilling to follow recommendations.

In healthcare, what looks like resistance may also be a lack of understanding, a lack of trust, or an unanswered question. Patients are often trying to make sense of risks, tradeoffs, and decisions that carry profound consequences for their lives.

Imagine shifting the conversation so it addresses both clinical appropriateness and the patient’s emotional questions.

The trust factor changes. It grows.

What would change if trust became a deliberate design principle in healthcare? Could decisions happen faster, complaints decrease, outcomes improve, and the total cost of care fall?

Can we unlock affordable healthcare through trust?

The Path Forward

Patients do not need to agree with every recommendation. They need confidence that the recommendation is being made in their best interest.

Trust forms when patients believe healthcare is acting for them, not on them.

Trust is not accidental. It must be designed.

Just as we design clinical pathways, patient journeys, and quality processes, we should design experiences to grow trust.

Patients need to be heard. This signals that their concern matters.

Patients need to be understood. Understanding is not the same as agreement. It means recognizing where patients are, seeing the situation from their vantage point, acknowledging their reasoning, and considering their individual circumstances.

Patients need to feel guided. When trust is present, they can receive recommendations as they were intended: as genuine efforts to help them.

When one of these elements disappears, distrust will fill the gap.

Design systems that consistently deliver all three elements, and trust becomes a measurable strategic asset rather than an accidental byproduct.

Clinical conversations move from transactions to partnerships when they address both clinical relevance and the patient’s emotional needs.

The real shift occurs when we recognize that:

We need to earn trust differently in a value-based environment.

The Business We Are Really In

Healthcare leaders obsess over access, quality, and affordability. All three matter. But none of them work without trust.

Before we can improve health outcomes, reduce costs, or succeed in value-based care, we may need to confront a more fundamental reality:

We are not merely in the healthcare business.

We are in the trust business.

Helping People See What Is Possible.

Healthcare’s Most Expensive Problem Isn’t Disease.

It’s Distrust

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Donna M. Bergman is an author, speaker, and healthcare leader exploring caregiving, leadership, resilience, and healthcare transformation.