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Our annual national survey measures the level of trust between hospitals and health plans. We’ve been conducting this research for years1, and 2020 brought the most dramatic erosion of trust in health plans we’ve witnessed yet. Our findings are particularly notable within the context of the global COVID-19 pandemic and the lengths that providers went to in order to keep taking care of their patients, risking not just their safety, but their financial solvency.

1 The survey was not conducted in 2018 due to resource constraints.

Analysis and insights

In October 2020, we collected data from 127 health system executives, managed care professionals, and financial officers. Our survey participants represent almost 40 percent of the hospitals in the United States.

This year, analysis and insights are brought to you by Un-covered, a space that is dedicated solely to examining trends in the insurance industry—and their impact on providers and patients alike.

Executive Summary [PDF]

Survey Audience Breakdown

Finding #1: Trust in payors is the lowest it’s been in years

In 2020, we saw a set of increasingly aggressive payor policies and business strategies that had the effect of blocking providers’ ability to deliver care. The 2020 Trust Index shows that this wasn’t the only negative impact. When we calculated the composite overall trust score for each payor—factoring in health plans’ reliability, honesty, and fairness scores—we saw a clear trend of declining trust. UnitedHealthcare, which has consistently ranked last, dropped a full 33 percent from last year, creating the most dramatic single-year drop in trust among any payor in the history of the survey.

Trust in Health Plans, 2015–2020

Finding #2: Payor ratings for honesty, reliability, and fairness are the worst they’ve ever been

United saw the biggest drops in scores across the board, but they weren’t the only payor to take hits in 2020.

  • Honesty: All payors except Humana saw notable drops in this important area, but United stood out with the lowest honesty score of any insurer.
  • Reliability: United, Cigna, and BlueCross BlueShield all had dramatic drops this year, while other insurers managed to roughly hold steady with 2019 ratings.
  • Fairness: United and Anthem were tied for the biggest drop this year. However, United ranked far lower than any of its peers.

Finding #3: Three new payor trends threaten to erode trust even further

Gone are the days when the only thing providers had to watch for were rate increases. Today payors engage in all kinds of untrustworthy behaviors that have hospitals and health systems on the defensive. And it’s no surprise to us to hear that United is leading the pack here as well.

Policy Changes

Q: In the past twelve to eighteen months, have any of the following health plans unilaterally changed a policy relevant to your hospital or health system without explicit notification?

Altered Language

Q: In the past twelve to eighteen months, have any of the following health plans unilaterally altered language in its provider manual without explicit notification?

Denied Claims

Q: In the past twelve to eighteen months, have any of the following health plans denied excessive amounts of claims with little explanation, even when claims were made correctly?

Dive Deeper on Trust with the No Normal Show

Listen to Wendell Potter, healthcare influencer, and Brandon Edwards, talk about how this year’s findings stack up against previous years.


Providers take notice—payor behavior is only getting worse. You need a plan to deal with them, or you’ll get clobbered.

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