Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health Care: Enrollees With Skin in the Game

The rapid growth of high-deductible health plans (HDHP) has been driven in part owing to a belief that cost-sharing obligations (ie, having skin in the game) will encourage health insurance enrollees to shop for health care.¹ The wide variation in costs across physicians and hospitals implies considerable opportunity for enrollees to save money by switching to lower-cost providers.² High-deductible health plan enrollment is associated with lower health care spending.^3,4 However, prior studies using health insurance claims data indicate these savings are primarily owing to decreased use of care and not because HDHP enrollees are switching to lower-cost providers.⁵ Limited prior work has assessed attitudes toward price shopping among HDHP enrollees and whether they were more likely to consider costs when seeking care.

We surveyed a nationally representative sample of insured US adults between 18 and 64 years of age who used medical care in the last year and compared HDHP enrollees with people in traditional plans on rates of shopping for care. The sample was drawn from GfK’s online KnowledgePanel (http://www.knowledgenetworks.com/ganp/), generated through a probability-based random sampling of adults and teens recruited via address-based sampling. Those enrolled in the study were then provided Internet access at no cost. The definition of an HDHP was established as a health plan having an individual deductible greater than $1250 or a family deductible greater than $2500⁶ or a health plan that included a health savings account. All analyses were weighted by poststratification weights to be representative of US enrollees in HDHP and non-HDHP plans.

We surveyed enrollees for their attitudes about price shopping, and whether, when they most recently received medical care, enrollees considered going to see another health care professional or if out-of-pocket costs were compared between different health care providers. We used logistic regression to compare enrollees in HDHPs and non-HDHPs, accounting for sociodemographic characteristics.

The response rate was 67.6%, and the study sample included 1951 respondents: 1099 in the HDHP group and 852 in the non-HDHP group. High-deductible health plan enrollment was higher among whites, those employed, those with more education, and those with higher income (Table 1). Overall, 659 of 1099 HDHP enrollees (60%) believe there are large differences in prices and in quality across health care providers, only 185 (17%) think higher price physicians provide higher quality care, and 774 (71%) report that out-of-pocket costs are important when choosing a doctor (Table 2). These perceptions are not significantly different from those held by enrollees in traditional plans. We found that HDHP enrollees are less likely to believe that higher price facilities provide higher quality care than non-HDHP enrollees (n = 179 [16%] vs n = 206 [25%]; P = .001) and more likely to report out-of-pocket costs are important in choice of radiology facility (n = 882 [81%] vs n = 598 [74%]; P = .003) than enrollees in traditional plan. A total of 611 HDHP enrollees (56%) say they would use additional sources of health care price information if available.

During their last use of medical care, HDHP enrollees were no more likely than enrollees in traditional plans to consider going to another health care professional for their care (n = 120 [10.9%] vs n = 85 [10.0%]; P = .67), or to compare out-of-pocket cost differences across health care professionals (n = 42 [3.8%] vs n = 23 [2.7%]; P = .37).

Simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping. Members of HDHP and traditional plans are equally likely to price shop for medical care, and they hold similar attitudes about health care prices and quality. Despite considerable focus on increasing price transparency,¹ HDHP enrollees express interest in greater access to health care price information.

Key limitations of our study are that we did not survey the uninsured or enrollees who did not use medical care. Because respondents report care-seeking behavior up to 12 months prior, recall bias may be an issue. We lack information about enrollee use of quality information. Despite a high level of response, there may be potential bias owing to differences between respondents and nonrespondents.

If encouraging price shopping is a viewed as an important policy goal, then there is a need for greater availability of price information and innovative approaches to enrollee engagement with this information.

Corresponding Author: Neeraj Sood, PhD, Schaeffer Center for Health Policy & Economics, University of Southern California, Verna and Peter Dauterive Hall 210, Los Angeles, CA 90089-3333 (nsood@healthpolicy.usc.edu).

Published Online: January 19, 2016. doi:10.1001/jamainternmed.2015.7554.

Funding/Support: This study was supported by internal intuitional funding from Harvard and University of Southern California. Drs Sood and Mehrotra received additional funding from the National Institutes of Health (grant No. 5R01AG043850).

Additional Contributions: We would like to acknowledge Kayleigh Barnes, BA; Katie Dean, BA; and Harlan Pittell, BA, for their excellent research assistance. They were not compensated for their contributions.