Taking control of healthcare costs while optimizing care – a view from the consumer side of the equation

May 24, 2016

Taking control of healthcare costs while optimizing care – a view from the consumer side of the equation

The Institute for Healthcare Policy and Innovation

In an era of ever-rising healthcare costs, high-deductible health plans (HDHPs) continue to grow in popularity in both group and individual markets.

HDHPs have higher deductibles and higher out-of-pocket expenses than other plans, and are designed in part to control unnecessary healthcare use as a way of curbing health care costs.

More than 1 in 3 Americans with private insurance now face high out-of-pocket expenditures for their care because they are enrolled in HDHPs. These plans are an increasingly appealing option for employers as a cost-saving measure, and in federal and state insurance exchanges for their lower premiums.

Because consumers enrolled in HDHPs must pay more for their care before insurance kicks in to pay for benefits, they must be more discerning about the healthcare services they seek, and a growing body of evidence points to these plans’ success in reducing both care use and medical spending.

What is less clear from the research to date, however, is the health impact of the hard choices about healthcare that individuals are often forced to make under HDHPs, as some studies have indicated they often reduce necessary as well as unnecessary care.

More than 1 in 3 Americans with private insurance now face high out-of-pocket expenditures for their care

An HDHP enrollee’s decisions may be influenced more by the cost burden of a recommended treatment than by its perceived benefit, and the decision of whether or not to have an MRI, for example, becomes much more complicated once the reality of having to pay $1,000 in out-of-pocket cost is introduced to the decision-making process.

People living with chronic illnesses such as diabetes, mental health conditions, or high blood pressure, which require ongoing care or medications to manage, are even more likely to waive or put off necessary care when enrolled in an HDHP, research by the RAND Corporation and National Bureau of Economic Research (NBER), among others has shown.  

Many consumers are not aware they could use a number of potential strategies to help mitigate the toll of high cost-sharing. If patients could realize greater value from their healthcare dollars, wouldn’t this allow them to both spend more wisely and also choose care more appropriately?

Through a Robert Wood Johnson Foundation grant, a team of IHPI researchers led by Jeff Kullgren, M.D., M.P.H., M.S., an assistant professor of internal medicine at the University of Michigan (U-M) and research scientist with the VA Center for Clinical Management Research, will conduct a nationally representative survey to examine the extent to which consumers enrolled in HDHPs have engaged in certain behaviors to help optimize the value of their out-of-pocket payments.

Strategies like budgeting for necessary care, accessing tools to select providers and venues of care based on their prices and quality, engaging clinicians in shared decision making which considers cost of care, and even negotiating prices for services are all potential methods of value optimization available to patients.

Until this point, little research has examined how frequently these strategies are utilized, their perceived effectiveness among consumers, or opportunities to promote and increase their use.

“In this current era, we are asking consumers to take a more active role in their personal health decisions. Ideally, clinicians should still ultimately serve as agents for their patients – advising which care should be sought after, and which care should be foregone,” Kullgren explains. “Especially because patients may not always be well-positioned to make fully-informed decisions about their health care.”

Jeff Kullgren, M.D., M.P.H., M.S., assistant professor of internal medicine, U-M Medical School

The researchers at U-M aim to discover what types of innovations health plans, government agencies and employers could deploy to help consumers who are facing substantial challenges with affording their care. They also aim to identify which types of consumers are more or less likely to engage in these potentially value-promoting behaviors. The survey will oversample adults with common chronic conditions, since these individuals often forego or delay needed care at high rates when facing high cost-sharing, and thus could potentially benefit most from engaging in such behaviors.

The team hopes to discover what consumers are doing to optimize the value of their current plan, as well as gauge why consumers choose to engage or not engage in these behaviors, and to what extent these behaviors actually help consumers obtain and afford the care they need.

Since enrollment in high deductible plans is likely to continue to grow over time, figuring out how to help consumers make better and more cost-effective decisions within the constraints of their insurance coverage is a major goal of the study.

The researchers expect to have results from their survey by fall 2016. At that time, an analysis of the data should help determine how decision-making can be most improved among patients in HDHPs.

The project is funded as part of RWJF’s solicitation “Optimizing Value in Health Care: Consumer-focused Trends from the Field,” which supports studies that address consumer perceptions of value in the new and emerging healthcare landscape. Co-investigators on the project are Mark Fendrick, Helen Levy, Brady West, and Angie Fagerlin (University of Utah).