Consumer Behaviors Among Individuals Enrolled in High-Deductible Health Plans in the United States

Increasing enrollment in high-deductible health plans (HDHPs),¹ which have deductibles of at least $1300 for individuals or at least $2600 for families, is creating challenges for patients and providers, such as health care services that are needed but foregone² or received but uncompensated.³ To confront these challenges, patients enrolled in HDHPs are encouraged to be discerning health care consumers by saving for future services, using information about the price or quality of services, talking with providers about costs, or negotiating prices.^4,5 Our study examined the prevalence and reported results of these consumer behaviors among individuals enrolled in HDHPs in the United States.

In this study conducted from August 26, 2016, through September 19, 2016, we surveyed 1637 participants in GfK’s nationally representative online KnowledgePanel⁶ who were 18 to 64 years of age and enrolled in an HDHP for at least 12 months. We oversampled individuals with chronic conditions. The response rate was 54.8%. The study was deemed to be exempt from review by the University of Michigan Medical School Institutional Review Board, Ann Arbor, Michigan. Participants provided online consent before beginning the survey.

The survey asked participants whether in the past 12 months they had saved for future health services, compared prices or quality ratings for a service, talked with a provider about the cost of a service, or tried to negotiate a price for a service. When participants reported engaging in one of these behaviors, they were asked about the types of services and what they perceived as the results.

For each measure, we generated nationally representative estimates by applying survey weights that accounted for the sampling design and nonresponse and were calibrated to the Current Population Survey and the National Health Interview Survey.

Most individuals were employed (1363 [84%]) and had employer-sponsored insurance (1331 [85%]). Nearly half (806 [42%]) had a chronic condition, and most (932 [58%]) had an account to pay for medical expenses, such as a health savings account.

The most common consumer behavior was saving for future health services (685 individuals [40%]), followed by talking with a provider about the cost of a service (445 [25%]), comparing prices (248 [14%]), comparing quality (204 [14%]), and trying to negotiate a price for a service (98 [6%]) (Table 1). Prescription drugs and outpatient visits were the most common services for which individuals engaged in a consumer behavior.

The most common reported result of saving for health services (351 individuals [53%]), comparing quality (114 [52%]), and discussing cost with a provider (203 [45%]) was help with getting a needed service (Table 2). The most common reported result of comparing prices (111 individuals [45%]) and trying to negotiate a lower price (51 [52%]) was paying less for a service.

We found that few individuals enrolled in HDHPs in the United States are engaging in consumer behaviors, and those that are could be realizing more benefits.

Our study used self-reported, cross-sectional data without a comparison group of individuals enrolled in traditional plans. To identify HDHP enrollees, we relied on participants’ knowledge of their deductible, because verification of insurance benefits was infeasible. Respondents were sampled from an internet survey panel and may have had different consumer characteristics than nonrespondents.

There are a number of ways in which consumer behaviors could be encouraged among and made more helpful to individuals enrolled in HDHPs. Providers could help patients anticipate services that they may need in the future so that patients can try to save for them. Health systems could make prices for services available at the point of care to facilitate patient and clinician conversations about cost. Employers and insurers could go beyond disseminating price information to help patients learn how to use this information in health care decisions. Such efforts will become increasingly important as enrollment in HDHPs continues to increase and could become essential if modifications to the structure or implementation of the Affordable Care Act accelerate patients’ exposure to high cost sharing.

Corresponding Author: Jeffrey T. Kullgren, MD, MS, MPH, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113-0170 (jkullgre@med.umich.edu).

Accepted for Publication: September 24, 2017.

Published Online: November 27, 2017. doi:10.1001/jamainternmed.2017.6622

Author Contributions: Kullgren and Cliff had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kullgren, Krenz, West, Levy, Fendrick, Fagerlin.

Acquisition, analysis, or interpretation of data: Kullgren, Cliff, Krenz, West, Levy, Fendrick.

Drafting of the manuscript: Kullgren, Krenz, West.

Critical revision of the manuscript for important intellectual content: Kullgren, Cliff, West, Levy, Fendrick, Fagerlin.

Statistical analysis: Kullgren, Cliff, Krenz, West, Levy.

Obtained funding: Kullgren, West.

Administrative, technical, or material support: Kullgren, Cliff, Krenz, Fendrick.

Study supervision: Kullgren, West.

Conflict of Interest Disclosures: Dr Kullgren is a Veterans Affairs Health Services Research and Development Career Development awardee at the VA Ann Arbor Healthcare System.

Funding/Support: Support for this research was provided by the Robert Wood Johnson Foundation (grant 73054).

Role of the Funder/Sponsor: The views expressed here do not necessarily reflect the views of the Foundation. Support was also provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.