Making sound choices as a healthcare consumer might be even harder than we thought, a new study suggests. That's discouraging news for hospitals and doctors as high-deductible health plans grow more common. Consumers appear to prefer skipping care to shopping around.
The study, published by the National Bureau of Economic Research, looked at what happened to demand for medical care after a large employer with generous health benefits (“completely free care”) forced its workforce into high-deductible health plans.
Employees did have access to an online tool to help them comparison shop. Their employer also completely covered the $3,750 deductible by depositing the amount into employees' health saving accounts. What happened? “We find no evidence of consumers learning to price shop after two years in high-deductible coverage,” said researchers Zarek Brot-Goldberg, Amitabh Chandra, Benjamin Handel and Jonathan Kolstad.
Instead, healthcare spending dropped about $100 million per year (2013 and 2014) because the employees sought less care of every kind: hospitals, prescriptions, ambulatory care and preventive services.
More worrying was the finding that the biggest spending reductions were made by the sickest employees, said Kolstad, an assistant professor at the University of California Berkeley.
For hospitals and doctors, the results underscore the potential that price-sensitive patients will delay needed tests or forgo referrals or prescriptions. Deductibles have climbed steadily during the past decade.
Employers have embraced high deductibles as a strategy for holding down costs by exposing workers to more of the cost of their medical care. Previous studies have shown that health spending drops as patients' deductibles rise. Health systems report less demand, or more unpaid bills, when patients are covered by high-deductible plans.
“It shows that people are going to make decisions based on costs,” said Dr. Christopher Moriates, an assistant clinical professor at the University of California San Francisco and an advocate for more frank cost discussions between patients and doctors. In JAMA in 2013, Moriates called for physicians to screen patients for their financial worries. “As physicians, we need to understand those decisions. Whether we like it or not. It's reality,” he wrote.
The overall spending drop reported in the study did not surprise Moriates, but the lack of price shopping did, he said. That suggests patients need far more help finding and using the information they need, he said.
Pricing data may not be enough to determine the complex decisions patients are asked to make, both medically and financially, Kolstad said. There is also not currently much quality data to help inform patients' decisions, he said.
States including California and New Hampshire have launched online price-comparison tools, and some health systems have started to post prices or contact patients ahead of their scheduled procedures with bill estimates. Commercial insurance plans also offer price tools and bill estimators.
But health plans are complex, Kolstad said, and comparison shopping also requires patients to make decisions about the value of recommended medical care. “Why are we sending people to medical school if we think that the average consumer can shop for high- and low-value healthcare?” he said.
Moriartes said the results suggest it would be valuable to ask patients about their financial concerns. But physicians, too, have more work to do. Patients might be less likely to forgo care if doctors did a better job of clearly explaining their recommendations, he said. ”We can't get away with just saying you need this drug or you need this test,” he said.
