Americans Support Price Shopping For Health Care, But Few Actually Seek Out Price Information

Out-of-pocket spending for patients in the United States is rising rapidly, ¹ with a 41 percent increase from 2010 to 2014. ² The growth of high-deductible health plans has been a key driver of this increase. Over a third of Americans with employer-based insurance are in such plans, ³ and the most popular bronze plans in the federal Marketplaces have an average deductible of over $5,000. ⁴

One assumption underlying the shift of costs to patients is that greater financial responsibility (“skin in the game”) will drive people to seek lower-cost care. The potential for patients to save money by identifying lower-cost providers is clear given the large variation in prices across providers—even within a single health plan within a geographic area. ⁵

To help patients identify lower-cost providers, price transparency tools are now available through health plans; employers (via a third-party vendor such as Castlight); or public, state-level sites such as NH HealthCost. ⁶ Over half of the states have passed laws or regulations encouraging either payers or providers to disclose pricing information to patients. ⁷ Despite the increase in access to price transparency tools, the degree to which Americans are actually shopping for care is unknown. There is some basis for skepticism that price shopping is common. Previous studies have demonstrated that enrollment in high-deductible health plans decreases spending, ^8,9 but this appears to be driven by decreases in utilization ¹⁰ and not by the selection of lower-cost providers. ^11,12 Enrollment in high-deductible plans is not associated with substantially greater price shopping. ¹³ While users of price transparency tools do use lower-price laboratory and imaging facilities, ¹⁴ overall rates of tool use among those offered a price transparency tool are low. ^6,15–17 Furthermore, patients generally express great satisfaction with their physicians ¹⁸ and therefore may be unlikely to want to switch physicians based on price.

To our knowledge, no national estimates have been published in the peer-reviewed literature on the extent to which Americans shop for health care and their perspectives on shopping for care. To measure rates of shopping for care and describe general attitudes on price shopping and barriers to shopping for care, we conducted a nationally representative survey of nonelderly adults who had some out-of-pocket spending for medical care in the past year.

Study Data And Methods

Study Sample

We surveyed a nationally representative sample of noninstitutionalized adults, ages 18–64, drawn from the KnowledgePanel—an online survey panel of adults—of the market research firm GfK. This data source has been used in numerous studies of topics such as rates of tobacco use and care-seeking patterns. ^19–24 Panel members are recruited using address-based sampling, and the raw sociodemographic and geographic distribution of the members fairly closely reflects that of the US adult population. The panel is then weighted to ensure that samples are representative of the US adult population. GfK includes households without Internet access in the panel by providing members who had no access with a free netbook computer and Internet service.

From the GfK panel, we sampled respondents who answered “Yes” to the question, “Please think of the most recent time you received medical care. Did you receive care within the past 12 months?” We excluded adults ages sixty-five and older who were insured by Medicare, because 85 percent of Medicare beneficiaries have supplemental insurance that limits their cost sharing and therefore reduces the financial pressure they feel to shop for care. ²⁵ Furthermore, because prices in traditional Medicare do not vary within a health care market, most efforts to increase price transparency and price shopping focus on the commercially insured population younger than age sixty-five, whose members face both out-of-pocket spending and price variation.

Because of the importance of insurance and patient cost-sharing design in price shopping, we oversampled adults who were uninsured and those in high-deductible health plans (with deductibles exceeding $1,250 for individuals and exceeding $2,500 for a family) ²⁶ to ensure a robust sample size for these populations. Our goal was to have 3,000 respondents divided equally among people who were uninsured, insured with a high deductible, and insured without a high deductible. We invited a random sample of 30,863 GfK panel members to complete the survey; 20,853 (67.6 percent) invitees responded. Of these 20,853 people, 16,562 (79.4 percent) had received care in the past twelve months. We collected responses to our survey from the members of this group until we reached our prespecified number of respondents. Details of the panel survey and response rate are provided in the online Appendix. ²⁷

Among the 3,022 completed surveys, 23 (0.8 percent) were dropped because of concerns about the validity of the responses; the respondent answered fewer than one-third of the questions or completed the survey in less than one-quarter of the median response time. After these exclusions, there were 2,996 final respondents, of whom 826 were uninsured, 1,073 were in a high-deductible plan, and 1,097 were insured without a high deductible. Surveys were completed in February and March of 2015.

Because the focus of price shopping is to save money, we restricted our analysis of price-shopping rates to the 1,904 respondents who said that they had at least some out-of-pocket spending for their care.

Instrument Development

We drew on our previous research on price shopping, ^8,11,14 other survey instruments, ^28–32 and reviews by experts in survey methodology to develop our survey instrument. It was pilot-tested in January 2015 with eighty respondents, who were then interviewed for follow-up cognitive testing. Survey domains included general perceptions of price shopping for health care, descriptions of the last health care encounter, barriers to obtaining price information, reasons one might not use price to shop for a provider, type of insurance, and general demographic characteristics. The relevant questions are in the Appendix. ²⁷ None of these questions allowed multiple responses.

Measures Of Price Shopping

The concept behind price shopping for health care is that patients will seek information about their out-of-pocket spending and compare that spending across providers before choosing one. Operationalizing this concept into a single measure of price shopping was not possible. We therefore created several different measures that together captured the concept of price shopping. All survey questions asked respondents to answer based on the last time they had received care. The measures were the following: price awareness (did the respondent know his or her out-of-pocket spending amount before receiving care), active price searching (did the respondent obtain price information before receiving care, by contacting the doctor or health care provider directly, visiting a health plan or price transparency website, or calling his or her health insurance company), considering using another provider (did the respondent consider going to a different health care provider), and making price comparisons (did the respondent compare his or her out-of-pocket spending amount across different health care providers). Note that we did not include as active searchers those who were aware of their out-of-pocket spending amount because they had learned what it would be at a previous visit or because they simply looked at their insurance card. Because patients with no previous relationship with a provider might be more likely to search for prices, we separately examined shopping behavior for patients who visited a provider for the first time.

Characteristics Of Survey Respondents

We categorized survey respondents by sociodemographic characteristics, deductible amount ($0, $1–$500, $501–$1,250, $1,251–$2,500, or $2,501 or more), level of coverage (single or family plan), and type of care last received (selected from a list).

Potential Barriers To Shopping For Care

In the survey we evaluated three sets of potential barriers to shopping for care: Patients do not price-shop because they do not support the idea, people who would like to shop for care are unable to do so because they lack the time or information needed to identify a lower-cost provider, and patients do not shop for care because of existing relationships with a provider or the lack of alternatives.

Analyses

In this article we report the results of bivariate analyses and multivariate logistic regression models with the binary outcome of yes or no for the four price-shopping measures. We eliminated variables that were collinear with other variables. The model included respondents’ reported deductible amount. We classified the uninsured in the highest deductible category because they pay the full costs of their care, and we therefore expected that their price shopping would be most consistent with those paying the highest deductibles. We conducted a sensitivity analysis with the uninsured in a separate category (see Appendix Table S1). ²⁷ To adjust for multiple comparisons, we calculated the false discovery rate, and based on that calculation, we considered only p values of less than 0.015 to be significant. ^33,34 All p values were two-tailed. In all analyses, survey respondents were weighted by probability of selection into the sample to increase the national representativeness of our results.

Limitations

There were several limitations to our analyses. First, the respondents to this survey might not be representative of a random sample of people in the nation who received health care, although our sample was weighted to be similar to the US population (see Appendix Table S2). ²⁷

Second, although we operationalized price shopping using four different measures, each had limitations. For example, patients might not search for out-of-pocket spending amounts because they are going to visit a known provider or know that they always have the same copayment and do not need to search for cost information. Alternatively, a patient might not compare prices because he or she obtained the price at one provider, judged it to be sufficiently low, and thus did not compare it to the prices at other providers.

Third, some respondents might not accurately remember the details about what they did before their last episode of care, though we included only respondents who had received care in the past twelve months. In addition, because many patients are unsure of their deductibles, ³³ there might be some misclassification on this measure.

Fourth, because we focused on the adult population younger than age sixty-five, our results might not be generalizable to older adults with Medicare.

Finally, while the focus of this work was on shopping for care based on price, we acknowledge that price is only one consideration for patients when they choose a provider.

Study Results

Characteristics Of Respondents

Of our weighted sample of respondents with any out-of-pocket spending for their last health care encounter ( $n=1,664$ ), 56 percent were women, 70 percent were non-Hispanic whites, 6 percent were uninsured, and 34 percent were enrolled in a health plan with a deductible of $1,251 or more ( Exhibit 1 ). Among the insured, 37 percent were in an individual plan, 63 percent were in a family plan, and 1 percent were unsure of their plan type (the percentages do not sum to 100 because of rounding) (data not shown). The demographic characteristics and insurance status of the weighted sample were similar to those of the US adult population overall and those of the US adult population with a health care expense in the past year, as shown in Appendix Table S2. ²⁷

Rates Of Price Shopping For Care

Fifty-two percent of the respondents were aware of the price before they received care, and 13 percent had searched for their expected out-of-pocket spending ( Exhibit 2 ). Ten percent reported that they had considered going to another provider, and 3 percent had compared costs across providers. Of the 13 percent who had actively searched for out-of-pocket spending, 63 percent had called their provider for information, 25 percent reported using a website sponsored by their health plan or employer or a website available to the public, and 9 percent had called their health plan directly (data not shown).

Theoretically, patients with a higher deductible and lower income would be more financially motivated to price-shop for care. While there was no clear trend in price shopping across strata of income, respondents with a deductible were less likely to be aware of their expected out-of-pocket spending before they received care, compared to those with no deductible ( Exhibit 2 ). This difference may be driven by the fact those with a deductible have to pay the full cost of care until the deductible is met, and the out-of-pocket amount they are responsible for under the deductible might be unknown until a bill is received. Non-Hispanic blacks (63 percent) were more likely to be aware of the price before receiving care, compared to non-Hispanic whites (54 percent) and Hispanics (49 percent).

Price shopping also varied by site of care. Respondents were most likely to have compared costs across providers for physical therapy (24 percent) and for lab tests or imaging services (11 percent) ( Exhibit 3 ). The results of our multivariate models—which adjusted for age, sex, household income, deductible, race/ethnicity, care location, and whether this was the first time seeking care—largely echoed our univariate results (see Appendix Table S3). ²⁷ Respondents who received a procedure in an ambulatory surgery center (odds ratio: 4.51; $p<0.01$ ) were most likely to have sought information on the cost of care before receiving care. Those who received physical therapy (OR: 24.5; $p<0.01$ ) or received a lab test or imaging service (OR: 6.36; $p<0.01$ ) were most likely to have compared costs across providers.

Potential Barriers To Price Shopping

As noted above, we examined three sets of potential barriers to price shopping for care. One set is patients’ attitudes about the concept: Patients might believe that out-of-pocket spending is relatively unimportant when choosing a provider, that shopping for care is not a good idea, that there is little price variation across providers, or that choosing a lower-cost provider results in lower-quality care. Our respondents did not generally hold these views.

Seventy-one percent of respondents said that out-of-pocket spending was either important or very important to them when choosing a doctor, and 72 percent of respondents agreed or strongly agreed that having more patients compare the cost, quality, or both of medical services when they choose their doctors would be good for the United States ( Exhibit 4 ). Ninety-three percent of respondents agreed or somewhat agreed that prices vary greatly among providers, and only 22 percent said that it was likely or very likely that more expensive providers had higher quality.

SOURCE Authors’ analysis. NOTES Results are reported based on a weighted sample of 1,664 people who received medical care in the previous twelve months with out-of-pocket costs. Percentages may not sum to 100 because of item nonresponse.

The second set of potential barriers to price shopping are a lack of time or knowledge about where to get information on out-of-pocket spending. Only 19 percent of respondents indicated that time was the reason they did not consider other providers, but 75 percent of respondents said that they did not know of a resource that would allow them to compare costs among providers (data not shown). Fifty-three percent of respondents reported that they would be likely or very likely to use a website to shop for care if one were made available to them.

The third set of potential barriers includes having a previous relationship with a provider. Among respondents who did not consider going to another physician the last time they received medical care, 77 percent reported that this was because they had gone to their provider in the past (data not shown). Respondents who reported that their most recent use of medical care was with a new provider were more likely to have compared costs of care across providers before receiving care, compared to respondents who returned to a provider (8 percent versus 2 percent) ( Exhibit 3 ), but the differences were modest.

A related barrier is a lack of alternatives. Among the respondents who did not consider other providers, 13 percent reported that they did not do so because their health plan limited their choice, and 2 percent reported that there were no alternative providers in their community (data not shown). Few respondents (1 percent) reported that they did not shop for care because they required emergency care.

Discussion

In a nationwide survey of nonelderly adults, we found that Americans are supportive of the concept of price shopping, but most do not price-shop themselves. Most respondents believed that patients should shop for care and perceived large differences in costs across providers. Contrary to concerns that patients equate lower costs with lower quality, ³⁵ the majority of respondents felt that there was little relationship between the two. However, relatively few respondents actively sought information about out-of-pocket spending amounts before receiving care, and even fewer compared prices across providers. This was true for respondents with insurance; those with higher deductibles; and those seeking care for the first time. Our findings that few Americans are shopping for care and most do not know where to get information on costs are consistent with those in a recent report by Public Agenda ³⁶ and a recent Kaiser Health Tracking Poll, in which most respondents reported difficulty finding information on price. ³⁷

While the concept of price shopping is clear, it was not possible to operationalize it into a single measure. We used several different measures of price shopping, and the overall rates we found appear low even for populations that clearly would benefit financially from price shopping. However, we acknowledge that there is no consensus on the “optimal” rate of price shopping in health care. This research offers insights into patients’ current perspectives and begins to answer the questions of why people don’t price-shop and what barriers stand in the way.

Policy Implications

The difference between Americans’ willingness to price-shop for care and the rates at which they do so is striking. Based on our findings, there appear to be two key barriers that explain why patients do not shop. First, people do not know how to obtain price information. Despite the many state and private interventions to improve price transparency, few respondents in our study were aware of external resources they could use to obtain prices for different providers. Of the respondents who searched for price information, most obtained it by contacting their provider or their health plan.

If price shopping is an important policy goal, it will be necessary to increase the availability of information on price and decrease the complexity of accessing the information. Patients often must know specific procedure or diagnosis codes to obtain prices, and differentiating between professional and facility fees makes the process even more difficult. ^38,39 Other complex issues are cost sharing and network design. There is evidence that most Americans do not have basic information on how their plan is structured, such as their coinsurance responsibility and whether or not a provider is in the plan network. ⁴⁰ This confusion likely makes it more difficult to price-shop effectively.

Possibly the most important barrier to price shopping is that many people either do not want to switch providers or are constrained by insurance networks or lack of provider availability. Collectively, these barriers highlight a disconnect between two policy trends in the United States, each of which is built on a different assumption. One trend is reflected in the growth of deductibles and price transparency and is built on the belief that in order to save money, patients should price-shop for each health care service (office visits, lab tests, imaging services, and procedures) that can be obtained independently across a variety of providers. The other trend is reflected in the use of incentives to provide and use coordinated care (such as what occurs in patient-centered medical homes and accountable care organizations), which is based on the belief that patient outcomes are improved when people receive coordinated care over time. Models that focus on coordination discourage price shopping, as the implicit expectation is that the vast majority of the care would be provided by a single provider or health system. The conflicts between these policy trends need to be resolved if price shopping is to become an effective tool for cost reduction.

In spite of the low rates of price shopping for care in general, we found that shopping was more common for some types of care. Not surprisingly, respondents were most likely to have sought cost information for higher-cost services such as outpatient procedures. Physical therapy care may be ideally suited to comparison shopping because it is nonurgent and is typically repeated several times, which allows people to benefit from cost savings over multiple visits.

Conclusion

Increased publicity about widely varying prices and steadily increasing rates of patient cost sharing has emphasized the importance of price shopping in health care. In a nationally representative survey of nonelderly adults, we found general support among the American public for the idea of price shopping for care, but little evidence that patients are shopping. Key barriers include the availability and awareness of price information and the desire to avoid switching providers and disrupting existing relationships.

Our results emphasize that simply passing price transparency laws or regulations (as over half of states have done) appears insufficient to facilitate price shopping. Price information must be more accessible and comprehensible to patients. However, our results show that even if the information were more easily accessible, patients’ preferences to maintain provider relationships and efforts to coordinate care would limit overall rates of shopping. Efforts to encourage price shopping may need to be targeted to selected clinical contexts that are suitable for shopping.

ACKNOWLEDGMENTS

An earlier version of this paper was presented at the Sixth Biennial Conference of the American Society for Health Economics, Philadelphia, Pennsylvania, June 14, 2016.

NOTES

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