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.
Researchers surveyed a nationally representative sample of insured 18-64 year olds. Yes, it was an Internet-based sample. They compared those with HDHP to those with traditional plans with respect to rates for shopping for care. Huge response rate, and almost 2000 respondees.
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 the accompanying editorial:
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.
So much for the benefits of increasing “skin in the game“. I hate that phrase. I also hate it here and here. You know what? I spend a lot of money on health care. I have a chronic illness. I have plenty of “skin in the game”, thank you very much.