How do high-deductible health plans affect patient experience?

HDHPs impact care access, affordability

The question of cost and affordability is perhaps most important to the HDHP discussion. Because these plans charge a lower premium, enrollees have a higher deductible and are on the hook for more of a medical bill.

And enrollees certainly feel this financial pinch. As noted above, HDHPs are largely designed with generally healthy patients in mind. However, healthcare problems can arise at any time, and even generally healthy patients might have a costly healthcare encounter.

Additionally, patients with more complex health needs might be swayed into an HDHP, lured in by that lower monthly premium. They might also have fewer plan options, leading to enrollment in an HDHP.

When faced with a high cost, patients feel the stress. According to a 2022 report from pharmaceutical industry lobby PhRMA, 40% of Americans blame their deductibles for the high out-of-pocket healthcare costs they face.

The potential for a high medical bill can be discouraging for patients, with study after study showing that high healthcare costs dissuade patient care access.

HDHP proponents state that health savings accounts (HSAs) are a key tool enrollees should use to manage potentially high medical bills. HSAs are pretaxed accounts that HDHP enrollees can use to pay for various medical expenses, ranging from prescription drugs to co-pays. Individuals in low-deductible plans typically do not have access to an HSA.

Data has shown that HSAs aren't enough to offset the problems that high deductibles and high costs can cause. This is because there is little beneficiary education about HSAs, leading few to open the accounts and even fewer to use them.

Cost comparison shopping left wanting

HDHPs were designed to create more cost-conscious patients, bringing to market price comparison strategies to help enrollees shop around for care. Theoretically, patients who are responsible for more of their healthcare costs will utilize price transparency tools that let them select the best provider for the most reasonable cost.

But that hasn't exactly happened, with one study showing that HDHPs were only modestly effective at encouraging price shopping.

After assessing claims data for 1.8 million health plan enrollees from 2004 to 2010, researchers found that about a quarter (28%) changed physicians for their office visits after enrolling in an HDHP. Those changes did not result in a statistically significant reduction in price for office visits.

Another quarter of enrollees changed providers for lab testing, which resulted in savings of around $2.09. That shakes out to a 12.8% reduction in price per laboratory test.

Meanwhile, a separate study from Michigan Medicine found that HDHP enrollment does not result in savvier shoppers. The researchers conducted a national poll of 1,637 adults under age 65 who had an HDHP for at least one year, finding that only 14% of people compared prices for the same service or product or looked at quality ratings.

Folks who comparison shop for other major lifestyle purchases, like a car or appliance, were twice as likely to say they do this for healthcare. Among those who did comparison shop for healthcare, 80% said they used an online website. Only 25% of respondents said they talked to a healthcare provider about the cost of a service; of those, only about half said they actually got help.

HDHPs give rise to healthcare consumerism

Among the most far-reaching effects of HDHPs is the rise of healthcare consumerism.

Healthcare consumerism acknowledges the shift of financial responsibility onto patients. With the rise in HDHPs, and therefore greater cost-sharing at the point of care, comes the rise of patients as healthcare payers. Patients are ponying up more of their own money, transforming medical care into a commodity the patient might consume like other service sector products.

This has transformed how healthcare organizations interact with patients, according to the American College of Healthcare Executives (ACHE).

"Increasingly, patients are becoming active, empowered healthcare consumers, shopping for care just like they do for any other good or service," ACHE says. "They're looking for quality and value. As an industry, we have the opportunity to adapt and help enhance the patient experience by providing the tools and information to help empower the consumer, leading to better outcomes for patients, providers and payers."

When patients do price shop and are more selective with their provider choices, it puts pressure on hospitals and health systems to deliver care that meets patients where they are.

Patients expect healthcare to operate similarly to the retail, banking or travel sectors, which has pressured hospitals and health systems to invest in the digital front door and other solutions to create a frictionless patient experience.

This approach has changed how healthcare organizations do business with patients. Services like online self-scheduling, self-check-in, online bill pay and other aspects of the digital front door have been built to streamline the patient experience and make it easier for them to interact with their medical care. These patient engagement technologies have also cropped up to mirror the tools used in other service sectors.

ACHE says healthcare organizations need to adapt to healthcare consumerism trends in order to remain competitive in a market defined by slim margins.

After all, patient loyalty is on the line. Patients are willing to leave their providers for ones who fit their needs and preferences now more than ever, according to an Accenture report. In 2021 alone, a quarter of patients left their doctors for one that fit their needs. That's up from just 18% who did the same in 2017.

Patients aren't necessarily leaving because of a bad clinical experience, Accenture found. Rather, they are leaving providers that have not set up patient engagement technologies to adapt to consumer-driven needs.

Consumer satisfaction with HDHPs moderate

In terms of consumer satisfaction, HDHP enrollment can yield a mixed bag. While many assessments show people like their health insurance, those enrolled in a high-deductible plan are more likely to be dissatisfied. This trend is mostly due to the costs members incur and the complexity of their plans.

For example, one EBRI study showed that while 11% of all health plan enrollees were dissatisfied, 18% of those in HDHPs were dissatisfied. The inverse was also true; 62% of all health plan enrollees were very satisfied with their insurance, but only 46% of HDHP members reported as much.

The EBRI study showed that HDHP enrollees were particularly dissatisfied with their out-of-pocket expenses (42% dissatisfied) for prescription drugs and other healthcare expenses. Moreover, around one in 10 expressed dissatisfaction with their provider choice, indicating that they had a hard time finding a doctor who accepted their insurance.

This dissatisfaction comes as HDHP enrollees are choosier about selecting their health plan: HDHP members were more likely to spend anywhere from five minutes to an hour studying their health plan options.

Effect on clinical outcomes

Like consumer satisfaction, clinical outcomes tend to suffer under HDHPs. In most cases, this is because of high patient financial responsibility and how it can discourage patient care access. When patients do not access the preventive or acute care they need, they run the risk of becoming even sicker down the line.

One study in JAMA Network Open found that individuals with diabetes who were enrolled in HDHPs were at higher risk for all diabetes complications than their peers in non-HDHPs.

The team looked at around 42,000 adults who switched to an HDHP because their employer no longer offered a non-HDHP plan. Those individuals ended up being at higher risk for diabetes complications, including myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy and blindness.

This study is notable because it looked at patients forced to switch to an HDHP because of limitations on their employer benefit offerings. Many patient education resources discussing HDHPs advise folks with chronic illnesses to opt for more comprehensive health plans. However, little guidance exists for chronically ill patients who are left with no other plan options from their employers.

A separate study, which also looked at individuals with diabetes, found that HDHPs were able to reduce healthcare spending and overall utilization, but that it came at the cost of medication adherence and access to high-value care.

In particular, the researchers said HDHPs were linked to less access to diabetes monitoring, routine care and medication adherence. This led to an uptick in acute care access, which can tend to be more costly and more invasive for the patient.

HDHPs in and of themselves are not harmful. After all, they are part of healthcare's shift toward consumerism, heralding an era of digital patient experiences designed to make healthcare more convenient and easy to access.

However, enrollees need enough information about how these health plans work, the risk for high out-of-pocket costs and how plan add-ons like HSAs can mitigate costs. Armed with that information, consumers can make better decisions about the health plans they enroll in and how to manage potential medical bills should they arise.

Sara Heath has been covering news related to patient engagement and health equity since 2015.