In health care, trust is foundational. We trust our physicians to recommend treatments based solely on their effectiveness and appropriateness to the diagnosis. We trust that the drugs and technologies used are solely because they work best. We trust that our hospitals are safe and our insurance will help pay the bills. When we learn otherwise, we rationalize that they’re the exceptions until recurring doubt leads to distrust.

Stories about fraud, price gouging, denials of coverage and excessive profit cast doubt and compromise trust in our health care system. Polling by Harris and Gallup show trust in the medical system slipping — falling below technology, manufacturing and other industries. And within the system itself, surveys show that trust in hospitals, nursing and physicians is slipping somewhat, but it is significantly higher than views about insurers and drug companies.

Webster’s defines trust as a “firm belief in the reliability, truth, ability, or strength of someone or something.” In health care, it’s often discussed in terms of how patients and consumers think about the performance of the system. A new study offers a unique view: how key players in health care — physicians, hospitals and private insurers — assess the trustworthiness of the others. Arguably, these three trading partners are the cornerstone of how health care works in each community: Distrusting relationships among the three leads to suboptimal performance and poses risks to patient care.

ReviveHealth, a national health care marketing communications firm, released its 2016 Trust Index Survey — an analysis of the level of trust among the managers of hospitals, insurers and physicians.

The study compared views along three dimensions of trust: “This organization makes every effort to honor its commitments”; “This organization is accurate and honest in representing itself and its intentions”; and “This organization balances its interest with ours and doesn’t routinely take advantage of us.”

Its findings are enlightening. They underscore the distrust that’s pervasive in relationships between providers and payers. Highlights:

  • The major trading partners in health care — physicians, hospitals and insurers — do not hold strong feelings of trust toward the others. In general, insurers tend to trust providers more than providers trust insurers.
  • On a scale of 1 to 100 and averaging scores in the three areas, health system executives’ average level of trust of insurers stood at 54.1, while physicians' trust level was 55. At the same time, insurers’ trust score of hospitals and physicians was 67.6.

What’s the key takeaway from the ReviveHealth survey? Distrust between providers and payers is a systemic challenge in our system. That physicians and hospitals trust insurers less than insurers trust providers is a finding that’s been reflected in other studies. The intensity of distrust varies somewhat by local circumstances, but it’s fair to say that relationships are generally distrusting and unhealthy. That means contract negotiations can be difficult, as each believes the other wants unfair advantage.

Can it be remedied? Theoretically, yes. It requires transparency in all business dealings. It means insurers must provide access to data on which their premiums are calculated and networks designed. It means cost and quality goals must be the result of collaborative planning and valid and reliable measurement. It means the three parties must understand the needs of the others and seek to find win-win scenarios where possible.

The trust chasm between insurers and providers is deep and long-standing. It did not evolve overnight nor will it be solved quickly. In the new world order of health care, shared risk arrangements between the parties is necessary but problematic when insurers want the upper hand in key areas like data ownership, plan design, medical management and shared savings. Unless and until distrust between payers and providers is addressed, these efforts will disappoint and results will be negative.

Trust between trading partners is key as the transition from volume to value takes shape. It’s perhaps our biggest challenge in health care.

Paul H. Keckley, Ph.D., does independent health research and policy analysis and is managing editor of The Keckley Report, a weekly blog free to subscribers at He is a member of Health Forum’s Speakers Express. For speaking opportunities, please contact Laura Woodburn.