qotd: High deductibles do not increase patient price shopping

JAMA Internal Medicine
January 19, 2016

Cost-Sharing Obligations, High-Deductible Health Plan Growth, and
Shopping for Health Care
By Anna D. Sinaiko, PhD; Ateev Mehrotra, MD; Neeraj Sood, PhD

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. The wide variation in costs across physicians and hospitals
implies considerable opportunity for enrollees to save money by
switching to lower-cost providers. High-deductible health plan
enrollment is associated with lower health care spending. 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. Limited prior work has assessed
attitudes toward price shopping among HDHP enrollees and whether they
were more likely to consider costs when seeking care.

From Methods

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 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.

From Results

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).

From Discussion

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.

http://archinte.jamanetwork.com/article.aspx?articleid=2482348


Editor's Note
High-Deductible Health Plans and Higher-Value Decisions
By Joseph S. Ross, MD, MHS

High-deductible health plans — insurance plans that have lower premiums
but higher deductibles than traditional health plans — have been
increasingly promoted as a means to incentivize higher-value health care
decision making. However, we have little information on how individuals
take accessibility, cost, and quality information into account when
making health care decisions. Moreover, there remains uncertainty about
whether individuals will obtain recommended health care services while
at risk for greater out-of-pocket costs.

In this issue of JAMA Internal Medicine, Sinaiko and colleagues conduct
an internet-based survey of enrollees in high-deductible health plans
and traditional health plans to better understand how they think about
health care decisions. Individuals enrolled in plans with different
financial incentives actually share many of the same beliefs about
health care pricing and how to obtain high-quality care. Both rarely
consider obtaining care from a different health care professional and
even less often compare costs among health care professionals. Despite
the limitations of an internet-based sample and few questions to
disentangle the nuance of decision making, an interpretation of this
study could be that high-deductible health plans are rationally designed
for individuals who do not yet have access to sufficient information to
make higher-value decisions in today's market, suggesting that these
plans have not yet succeeded at making cost and quality information more
available and more actionable for their enrollees. However, a more
likely interpretation is that getting enrollees to make higher-value
decisions remains a mirage. High-deductible health plans take advantage
of an irrationally designed health care system. In fact, information
about our health care system is asymmetric in that it is better
understood by physicians and less so by patients, which means patients
obtaining care are not truly informed decision makers.

It is true that high-deductible health plan enrollees have "skin in the
game." However, these enrollees are exposed to substantial out-of-pocket
cost risk with little evidence that this risk exposure will incentivize
higher-value health care decisions, meaning they are essentially playing
the game blindfolded with one hand tied behind their back.

http://archinte.jamanetwork.com/article.aspx?articleid=2482346

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Comment by Don McCanne

This study shows that individuals with high-deductible health plans
(HDHP) are no more likely to select their care based on their
out-of-pocket costs than do individuals enrolled in traditional health
plans without high deductibles. As the editorial states, it is likely
that "getting enrollees to make higher-value decisions remains a mirage."

So high deductibles do not cause patients to be smart shoppers, but they
do cause patients to decline beneficial health care services. They also
create financial hardships for some patients. Thus high deductibles have
a net negative impact. We should get rid of them. A single payer system
is a much more efficient and patient-friendly method of controlling
health care spending.