Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans

This survey study assesses which patients who may be eligible for a health savings account do not have one and what decisions patients with these accounts make about contributing to them in a representative sample of US adults.

This supplementary material has been provided by the authors to give readers additional information about their work.

KnowledgePanel Methodology
KnowledgePanel (KP) is the largest U.S. online panel that relies on probability-based sampling techniques for recruitment; hence, the largest national sampling frame from which fully representative samples can be generated to produce statistically valid inferences for study populations. This panel provides samples with the highest level of representativeness available in online research for measurement of public opinions, attitudes, and behaviors. The panel was first developed in 1999 by Knowledge Networks, a GfK company. Panel members are randomly selected so that survey results can properly represent the US population with a measurable level of accuracy, features that are not obtainable from nonprobability panels.
The recruitment process for KP was originally based exclusively on a national Random Digit Dialing (RDD) sampling methodology. In order to improve the representation of the panel, GfK migrated to using an Address Based Sampling (ABS) methodology via the Delivery Sequence File (DSF) of the USPS for recruiting panel members in 2009. This probabilitybased sampling methodology improves population coverage, and provides a more effective sampling infrastructure for recruitment of hard-to-reach individuals, such as young adults and those from various minority groups. Under the ABS recruitment, households without Internet connection are provided with a web-enabled device and free Internet service.
After initially accepting the invitation to join the panel, participants are asked to complete a short demographic survey (the initial Core Profile Survey), answers to which allow efficient panel sampling and weighting for future surveys. Completion of the Core Profile Survey allows participants to become active panel members.

Survey Sampling from KnowledgePanel
Once KP members are recruited and profiled by taking the Core Profile Survey, they become eligible for selection for client surveys. Typically, survey samples are based on an equal probability of selection method (EPSEM) sample from the panel for general population surveys. Customized stratified random sampling based on profile data can also be carried out as required by the study design to reduce screening costs for rare subgroups.
For this particular survey, a nationally representative sample of U.S. adults (18 to 64) with private health insurance was selected. The sample was also selected so that half the respondents had previously reported one of the following chronic conditions on the Core Profile Survey, and half had not: • Anxiety Disorder • Asthma/Bronchitis/COPD • Depression • Heart Attack • Heart Disease • High Blood Pressure • Type 1 or Type 2 Diabetes

Survey Administration
Once assigned to a survey, KP members receive a notification email letting them know there is a new survey available for them to take. This email notification contains a link that sends them to the survey questionnaire. No login name or password is required. The field period depends on the client's needs and can range anywhere from a few hours to several weeks. After three days, automatic email reminders are sent to all non-responding panel members in the sample. If email reminders do not generate a sufficient response, an automated telephone reminder call can be initiated. The usual protocol is to wait at least three to four days after the email reminder before calling. To assist panel members with their survey taking, each individual has a personalized "home page" that lists all the surveys that were assigned to that member and have yet to be completed.
GfK also operates an ongoing modest incentive program to encourage participation and create member loyalty. Members can enter special raffles or can be entered into special sweepstakes with both cash rewards and other prizes to be won. The typical survey commitment for panel members is one survey per week or four per month with duration of 10 to 15 minutes per survey. In the case of longer surveys, an additional incentive is typically provided.

Sample Weighting
Significant resources and infrastructure are devoted to the recruitment process for KP so that active panel members can properly represent the U.S. adult population. This representation is not only achieved with respect to a broad set of geodemographic indicators, but also harder-to-reach adults such as those without Internet access or who speak only Spanish. Consequently, the distribution of KP participants closely mirrors the distribution of the U.S. population, barring occasional differences that may emerge for certain subgroups due to differential attrition.
For selection of general population samples from KP a patented methodology has been developed that ensures all samples behave as EPSEM. Briefly, this methodology starts by weighting the pool of active members to the geodemographic benchmarks secured from the latest March supplement of the Current Population Survey (CPS) along several dimensions. Using the resulting weights as measure of size, in the next step a PPS (probability proportional to size) procedure is used to select study specific samples. It is the application of this PPS methodology with the imposed size measures that produces fully self-weighting samples from KP, for which each sample member can carry a design weight of unity. Moreover, in instances where a study design requires any form of oversampling of certain subgroups, such departures from an EPSEM design are accounted for by adjusting the design weights in reference to the CPS benchmarks for the population of interest.

Study-Specific Post-Stratification Weights
Once the study sample has been selected and the survey administered, and all the survey data are edited and made final, design weights are adjusted to account for any differential nonresponse that may have resulted during the field period. Depending on the specific target population for a given study, geodemographic distributions for the corresponding population are obtained from the CPS, the American Community Survey (ACS), or in certain instances from the weighted KP profile data. For this purpose an iterative proportional fitting (raking) procedure is used to produce the final weights. In the final step, calculated weights are examined to identify and, if necessary, trim outliers at the extreme upper and lower tails of the weight distribution. The resulting weights are then scaled to aggregate to the total sample size of all eligible respondents.
For this study, the following benchmark distributions from the most recent data from the CPS and NHIS were used for the raking adjustment:

CPS
• Age (18-24; 25-34; 35-44,45-54,55-64)  Thank you for your interest in our survey on health care decisions. This survey will take about 20 minutes to complete. Filling out the survey is your choice. You can skip any questions that you don't want to answer. In order to protect your privacy, we will not connect your name or email address to your survey. Clicking "Next" below means that you agree to take the survey. Next we would like to ask you some questions about shopping and money.
Please tell us how much you disagree or agree with the following statements.

Down:
SHOP1. In whatever I buy, I shop a lot for specials. SHOP2. I find myself checking prices in the grocery store even for small items. SHOP3. I like to use coupons as much as possible. SHOP4. I generally shop a lot to compare products. SHOP5. I divide my shopping between 2 or 3 stores to get the best deal. The next questions are about your use of health care services in the past 12 months. As you answer these questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

Use_Num[Banked Grid, S across]
During the past 12 months… Down: Use_NumOutpatient How many times have you seen a doctor or other health care professional about your own health at a doctor's office, a clinic, or some other place? Do not include times you were hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits, or telephone calls. Your best estimate is fine.
Use_NumInpatient How many different times did you stay in any hospital overnight or longer? Do not include any overnight stays in the emergency room. Your best estimate is fine.
Use_NumED How many times have you gone to a hospital emergency room about your own health? Please include emergency room visits that resulted in a hospital admission. Your best estimate is fine.

Unmet [Grid, S across]
During the past 12 months… Down:

Unmet_Delay
Have you delayed seeking medical care because of worry about the cost?

Unmet_Foregone
Was there any time when you needed medical care, but did not get it because you couldn't afford it?

Unmet_Medbills
Did you have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.

F. Behaviors Intro
The next set of questions is about things that some people do and some people do not do when thinking about and getting health care services (e.g., a doctor visit, procedure, test, or medication). For these questions, please tell us whether you have done these while thinking about and getting health care services in the past 12 months. There are no right answers and we just want to understand your experiences so that we can help other patients make decisions about health care services. For this next set of questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

B_Engage [S]
In the past 12 months, did you put aside money to pay for any health care services (e.g., a doctor visit, procedure, test, or medication) before you needed them (e.g., in a Health Savings Account or Flexible Spending Account, bank account, or somewhere else)?

BY_Account [S]
In the past 12 months, did you put aside money to pay for health care services, before you needed them, in any of the following? If needed, you can scroll over 'Health Savings Account (HSA)' and 'Flexible Spending Account (FSA)' for more detail. Scripter: mouseover text for BY_HSA: Health Savings Account (HSA): An HSA is a tax-advantaged account where money can be put aside to pay for qualifying medical expenses. In order to quality for an HSA, you must have a high-deductible health plan (HDHP). Either individuals or employers can contribute pre-tax dollars to the account, and money withdrawn for qualified medical expenses is never taxed. Unlike a Flexible Spending Account, contributions roll over from year to year. mouseover text for BY_FSA: Flexible Spending Account (FSA): An FSA is a tax-advantaged account where money can be put aside to pay for qualifying medical expenses. An FSA is established by an employer and is funded through pre-tax payroll deductions or employer contributions. Unlike a Health Savings Account, funds in an FSA must be used by the end of the year (or the end of the next grace period) or they will be lost.

BY_Other_Specify [O]
Where else did you put aside money in the past 12 months to pay for health care services before you needed them?

BY_Effects/Facilitators [Grid,S across]
Did putting aside money in the past 12 months to pay for health care services before you needed them result in any of the following things for you?

Down:
BYE_GetCare. Getting a health care service you felt you needed. BYE_PutOff. Deciding to put off getting a health care service until you could afford it. BYE_Forego. Deciding a health care service wasn't worth the cost. BYE_LessCost. Paying less for a health care service. BYE_LessDebt. Having less debt from health care bills. BYE_OtherCosts. Freeing up money you used to pay for other (non-health care) things.

BYE_Other[O]
Please describe anything else that resulted from putting aside money in the past 12 months to pay for health care services before you needed them (if nothing else resulted, just leave this blank):

BASE: if B_Engage=1 ("yes") [Grid,S across]
How much did each of the following things help you put aside money in the past 12 months to pay for health care services before you needed them?

Down:
BYF_Web. A website BYF_App. A smart phone app BYF_Friend. A family member, friend, or acquaintance BYF_Employer. An employer who contributed to an account for health care spending BYF_HealthPlan. Your health insurance plan BYF_Staff. Someone at your doctor's office BYF_Broker. An expert in money (e.g., financial adviser, broker, etc.)

Across:
1. Not at all 2. A little

BYF_Other [O]
Please describe anything else that helped you put aside money in the past 12 months to pay for health care services before you needed them (if nothing else helped you, just leave this blank):

BYF_App_Specify [O]
What smart phone app(s) helped you?

BYF_Staff_Specify [O]
Who in your doctor's office helped you?

BASE: if BYF_Broker =2 or 3 ("A little" or "A lot") BYF_Broker_Specify [O]
What type of expert in money helped you?

BN_Barriers/Facilitators[Grid,S across]
Were any of the following things reasons why you did not put aside money in the past 12 months to pay for health care services before you needed them?

BNB_Other [O]
Please describe any other reasons you did not put aside money to pay for health care services in the past 12 months before you needed them (if there were no other reasons, just leave this blank):

BASE: if B_Engage=2 ("No") [Grid,S across]
In the future, how much do you think each of the following things could help you put aside money to pay for health care services before you need them? Please describe anything else that you think could help you put aside money to pay for health care services before you need them (if you can't think of anything, just leave this blank):

G. PRICE_Comparison [Display]
For this next set of questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

P_Engage [S]
In the past 12 months, did you compare prices for any health care services (e.g., a doctor visit, procedure, test, or medication) at different places?

PY_Services[S]
For each of the following types of health care services, did you compare prices at different places in the past 12 months?

PY_Other_Specify [S]
For what other type(s) of health care services did you compare prices at different places?

PY_Effects/Facilitators [S]
Did comparing prices for health care services at different places in the past 12 months result in any of the following things for you? Down:

PNF_Other [O]
Please describe anything else that you think could help you compare prices for health care services at different places (if you can't think of anything, just leave this blank):

H. QUALITY_Comparison [Display]
For this next set of questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

Q_Engage [S]
In the past 12 months, did you compare quality ratings for any health care services (e.g., a doctor visit or procedure) at different places (e.g., different doctors or different hospitals)?

QY_Services [S]
For each of the following types of health care services, did you compare quality ratings at different places in the past 12 months?

QY_Other_Specify [O]
For what other type(s) of health care services did you compare quality ratings at different places?

QY_Effects/Facilitators [S]
Did comparing quality ratings for health care services at different places in the past 12 months result in any of the following things for you?

Down:
QYE_GetCare. Getting a health care service you felt you needed. QYE_PutOff. Deciding to put off getting a health care service until you could afford it. QYE_Forego. Deciding a health care service wasn't worth the cost. QYE_LessCost. Paying less for a health care service. QYE_LessDebt. Having less debt from health care bills. QYE_OtherCosts. Freeing up money you used to pay for other (non-health care) things.

QYE_Other [O]
Please describe anything else that resulted from comparing quality ratings for health care services at different places in the past 12 months (if nothing else resulted, just leave this blank)

BASE: ask if Q_Engage=1 ("yes") [Grid, S Across]
How much did each of the following things help you compare quality ratings for health care services at different places in the past 12 months?

QYF_App_Specify [O]
What smart phone app(s) helped you?

QYF_Staff_Specify [O]
Who in your doctor's office helped you?

QN_Barriers/Facilitators[Grid,S across]
Were any of the following things reasons why you did not compare quality ratings for health care services at different places in the past 12 months?

Down:
QNB_NoNeed. You didn't need any health care services. QNB_NotConsider. You didn't think about it. QNB_TooHard. You felt it would be too difficult. QNB_NotKnowHow. You didn't know how to. QNB_NoImpact. It wouldn't change your decisions. QNB_NoTime. You didn't have time to. QNB_NoVary. Quality of health care services doesn't vary much.

QNB_Other [O]
Please describe any other reasons you did not compare quality ratings for health care services at different places in the past 12 months (if there were no other reasons, just leave this blank):

BASE: if Q_Engage=1 ("No") [Grid,S across]
In the future, how much do you think each of the following things could help you compare quality ratings for health care services at different places?

QNF_Other [O]
Please describe anything else that you think could help you compare quality ratings for health care services at different places (if you can't think of anything, just leave this blank):

I. DISCUSS [Display]
For this next set of questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

D_Engage [S]
In the past 12 months, did you talk with a health care provider (e.g., a doctor, nurse, or pharmacist) about how much any health care services (e.g., a doctor visit, procedure, test, or medication) would cost you personally?

DY_Services [GRID, S Across]
For each of the following types of health care services, did you talk with a health care provider about the cost in the past 12 months?

DY_Other_Specify [O]
For what other type(s) of health care services did you talk with a health care provider about the cost?

DY_Effects/Facilitators [S]
Did talking with a health care provider about the cost for health care services in the past 12 months result in any of the following things for you?

Down:
DYE_GetCare. Getting a health care service you felt you needed. DYE_PutOff. Deciding to put off getting a health care service until you could afford it. DYE_Forego. Deciding a health care service wasn't worth the cost. DYE_LessCost. Paying less for a health care service. DYE_LessDebt. Having less debt from health care bills. DYE_OtherCosts. Freeing up money you used to pay for other (non-health care) things.

DYE_Other [O]
Please describe anything else that resulted from talking with a health care provider about the cost for health care services in the past 12 months (if nothing else resulted, just leave this blank):

BASE: ask if D_Engage=1 ("yes") [Grid, S Across]
How much did each of the following things help you talk with a health care provider about the cost for health care services in the past 12 months?

Down:
DYF_Web. A website DYF_App. A smart phone app DYF_Friend. A family member, friend, or acquaintance DYF_HealthPlan. Your health insurance plan DYF_Staff. Someone at your doctor's office DYF_Broker. An expert in money (e.g., financial adviser, broker, etc.)

DYF_Other[O]
Please describe anything else that helped you talk with a health care provider about the cost for health care services (if nothing else helped you, just leave this blank):

DYF_App_Specify [O]
What smart phone app(s) helped you?

DYF_Staff_Specify [O]
Who in your doctor's office helped you?

DYF_Broker_Specify [O]
What type of expert in money helped you?

DN_Barriers/Facilitators[Grid,S across]
Were any of the following things reasons why you did not talk with a health care provider about the cost for health care services in the past 12 months?

DNF_Other [O]
Please describe anything else that you think could help you talk with a health care provider about the cost for health care services (if you can't think of anything, just leave this blank):

J. Negotiate [Display]
For this next set of questions, think only about your own individual health care and not health care that was for someone else (e.g., a child, parent, or friend).

N_Engage [S]
In the past 12 months, did you try to negotiate a lower price for any health care services (e.g., a doctor visit, procedure, test, or medication), either before or after you received them?

NY_Services [S]
For each of the following types of health care services, did you try to negotiate a lower price in the past 12 months?

NY_Other_Specify [O]
For what other types of health care services did you try to negotiate a lower price?

NY_Effects/Facilitators [S]
Did trying to negotiate a lower price for health care services in the past 12 months result in any of the following things for you?

Down:
NYE_GetCare. Getting a health care service you felt you needed. NYE_PutOff. Deciding to put off getting a health care service until you could afford it. NYE_Forego. Deciding a health care service wasn't worth the cost. NYE_LessCost. Paying less for a health care service. NYE_LessDebt. Having less debt from health care bills. NYE_OtherCosts. Freeing up money you used to pay for other (non-health care) things. Across:

NYE_Other [O]
Please describe anything else that resulted from trying to negotiate a lower price for health care services in the past 12 months (if nothing else resulted, just leave this blank):

BASE: ask if N_Engage=1 ("yes") [Grid, S Across]
How much did each of the following things help you try to negotiate a lower price for health care services in the past 12 months?

NYF_Other[O]
Please describe anything else that helped you try to negotiate a lower price for health care services in the past 12 months (if nothing else helped you, just leave this blank):

NYF_App_Specify [O]
What smart phone app(s) helped you?

NYF_Staff_Specify [O]
Who in your doctor's office helped you?

NYF_Broker_Specify [O]
What type of expert in money helped you?

NN_Barriers/Facilitators[Grid,S across]
Were any of the following things reasons why you did not try to negotiate a lower price for health care services in the past 12 months?

Down:
DNB_NoNeed. You didn't need any health care services. DNB_NotConsider. You didn't think about it. DNB_TooHard. You felt it would be too difficult. DNB_NotKnowHow. You didn't know how to. NNB_NoWorry. You were worried what others would think. DNB_NoImpact. It wouldn't change your decisions. DNB_NoTime. You didn't have time to. DNB_CannotNeg. Patients can't negotiate prices for health care services.

NNB_Other [O]
Please describe any other reasons you did not try to negotiate a lower price for health care services in the past 12 months (if there were no other reasons, just leave this blank):

BASE: if N_Engage=2 ("no") [Grid,S across]
In the future, how much do you think each of the following things could help you try to negotiate a lower price for health care services? Select one answer from each row in the grid.

Down:
NNF_Web. A website NNF_App. A smart phone app NNF_Friend. A family member, friend, or acquaintance NNF_HealthPlan. Your health insurance plan NNF_Staff. Someone at your doctor's office NNF_Broker. An expert in money (e.g., financial adviser, broker, etc.)

Across:
1. Not at all 2. A little 3. A lot BASE: if N_Engage=2 ("no") show on same page as NN_facilitators

NNF_Other [O]
Please describe anything else that you think could help you try to negotiate a lower price for health care services (if you can't think of anything, just leave this blank):

OtherBehavior [S]
In the past 12 months, did you do anything else (that we did not ask about) to try to make health care services more affordable for you?

OtherBehavior_Specify [O]
Please describe what you did and how much it helped you: L. MRI BASE: Total Qualified respondents Scripter: Randomize Sections L. MRI and M. GASTROENTEROLOGIST [The first section should see: In this next set of questions, we will ask you to imagine yourself in two different situations. Please read about the first situation carefully and then answer the questions that follow.] [The Second section should see: In this next set of questions, we will ask you about the second situation. Please read carefully and then answer the questions that follow.]

[Display] [Insert display text]
Imagine you hurt your lower back after lifting some heavy objects around the house. When your back pain didn't get better you went to see your primary care provider. Your primary care provider is now recommending you get an MRI (magnetic resonance imaging) of your lower back.

MRI_1 [Grid, S Across]
Please tell us how much you disagree or agree with the following statements. Select one answer from each row in the grid.
Comparing the price of getting the MRI at different places…

Down:
MRI_P_Difficult. …would be difficult. MRI_P_Help. …would help me be able to get the MRI. MRI_P_Save. …would help me pay less for the MRI. MRI_P_Engage. …is something I would actually do.

MRI_2 [Grid, S Across]
Please tell us how much you disagree or agree with the following statements. Select one answer from each row in the grid.

Down:
MRI_D_Difficult. …would be difficult. MRI_D_Help. …would help me be able to get the MRI. MRI_D_Save. …would help me pay less for the MRI.
Spec_N_Difficult. …would be difficult. Spec_N_Help. …would help me be able to see the gastroenterologist. Spec_N_Save. …would help me pay less to see the gastroenterologist. Spec_N_Engage. …is something I would actually do. You are nearing the end of the survey! Thank you! For this next set of questions, please rate your feelings on a scale from 1 to 10.

Import_Costs [Grid, S Across]
As of right now, how important is it to you to control how much you spend on health care services? a HSA defined as in the National Health Interview Survey as "a special account or fund that can be used to pay for medical expenses" that are "sometimes referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), Personal Care accounts, Personal Medical funds, or Choice funds, and are different from Flexible Spending Accounts." Sample is the 1,547 respondents with non-missing covariates. b Ages grouped to represent distinct generations (Millennials, Generation X, and Baby Boomers respectively) according to Pew Research Center groupings. c "Other" includes American Indian or Alaska Native, Asian, Native Hawaiian/Pacific Islander, and those who selected more than one racial category. d Tertiles of participants' scores for the Altarum Consumer Engagement Measure™ which is a scale of questions representing three distinct subscales of patient engagement with their health and healthcare (informed choice, navigation, and ownership