Rebecca Gourevitch, MS

Driven by the growth of high deductibles and price transparency initiatives, patients are being encouraged to search for prices before seeking care, yet few do so. To understand why this is the case, we interviewed individuals who were offered access to a widely used price transparency website through their employer.

We interviewed individuals enrolled in a preferred provider organization product through their health plan about their experience using the price transparency tool (if they had done so), their past medical experiences, and their opinions on shopping for care. All interviews were transcribed and manually coded using a thematic coding guide.

 In general, respondents expressed frustration with healthcare costs and had a positive opinion of the idea of price shopping in theory, but 2 sets of barriers limited their ability to do so in reality. The first was the salience of searching for price information. For example, respondents recognized that due to their health plan benefits design, they would not save money by switching to a lower-cost provider. Second, other factors were more important than price for respondents when choosing a provider, including quality and loyalty to current providers.

We found a disconnect between respondents’ enthusiasm for price shopping and their reported use of a price transparency tool to shop for care. However, many did find the tool useful for other purposes, including checking their claims history. Addressing the barriers to price shopping identified by respondents can help inform ongoing and future price transparency initiatives.

Our findings provide insight on why patients are not price shopping for care despite numerous efforts to promote price transparency. These findings suggest that key barriers must be addressed in order to promote ongoing and future price transparency initiatives:

		The idea of price shopping is not familiar to most patients. Price transparency initiatives should remind patients, at relevant times, to shop for care and services

		The structure of current health plan benefits inhibits price shopping. Other forms of health plan benefits, such as tiered networks or reference-based pricing, may be more conducive to shopping for care.

		Price transparency initiatives may provide value to patients beyond price shopping, including tracking claims and deductibles status. Encouraging this type of usage may increase patient engagement with price data.

Growing interest in healthcare consumerism is built on the premise that individuals should make healthcare decisions by using a combination of quality data, price information, and personal preference, just as they would when making other purchases.

 Prior work has studied how individuals (ie, consumers) use quality data to inform their healthcare decisions,

 but little qualitative research has examined how people do or do not use price data. This lack of evidence is notable in light of the recent proliferation of price transparency initiatives. Over 60 publically accessible websites hosted by state-based agencies and hospital associations are now available.

Numerous employers have introduced price transparency tools to their employees,

 which aim to engage individuals with easily accessible price data so they can shop for low-cost providers. Estimates suggest that increased competition from such a shift in demand would drive down overall healthcare spending

Despite the prevalence of healthcare price transparency tools and their potential associated savings, few appear to use such tools or price shop for care.

Recent research on healthcare decision making by those in high-deductible health plans (HDHPs) found that enrollees do not use price information despite the fact that their choice of lower-cost providers could reduce their out-of-pocket costs.

 When they do shop for care, it is often by calling their insurer or provider directly,

 which can make it difficult to compare across providers.

 In theory, online price transparency tools facilitate comparative shopping, but they have had mixed effects in practice. Some study results have shown either a modest reduction in price per service or enrollees switching to lower-cost providers, but many others have shown no effects on the prices of services that patients receive and on outpatient spending.

 One key finding throughout prior research is that individuals have not used price transparency tools as much as anticipated.

The reasons for the lack of price shopping remain unclear. It is possible that individuals view healthcare decisions differently than other consumer decisions and, correspondingly, do not seek out price information. Conversely, they might be interested in using price transparency tools but face barriers to their use. To fill this gap in knowledge, we conducted a series of qualitative interviews with individuals who were offered a popular price transparency tool by their employer. Our goal was to understand respondents’ general views on price shopping, and motivations for shopping, experiences with the price transparency tool, and potential barriers to price shopping for healthcare.

The California Public Employees’ Retirement System (CalPERS) manages the health benefits of over 1.4 million members, including teachers, state employees, retirees, and their dependents. Of these members, roughly 200,000 are enrolled in one of its preferred provider organization (PPO) products. Those enrolled in a PPO product were given the option to enroll in an online price transparency tool starting July 1, 2014. In 2015, we interviewed a sample of the PPO members; these members had a $500 individual or $1000 family deductible, a $20 co-payment for office visits, and 20% coinsurance for outpatient facilities and surgery services for in-network providers.

 Members also faced cost sharing through a reference-based pricing benefits program that began in 2011. Under this program, the health plan paid a fixed contribution toward hip or knee replacement surgeries and select outpatient services (eg, colonoscopy) and members did not pay additional costs above their normal cost sharing if they elected to have their procedure at a preferred facility.

CalPERS’ PPO members were offered Castlight, an online price transparency tool that provides users with information about their out-of-pocket costs for healthcare services, including office visits, procedures, imaging, and labs, at different local providers.

All prices are specific to the user’s benefits design and provide real-time estimates that account for their deductible and out-of-pocket spending during the year. Members can also use the price transparency tool to review their claims history. For some searches, Castlight displays quality data on each provider.

CalPERS launched a consumer engagement campaign to encourage Castlight usage. Members were sent an e-mail from Castlight that invited them to open an online account and to invite other covered family members to access the tool as well. Other promotional efforts included home mailers, a 30-day lottery of iPad giveaways for employee members who created an account, live demonstrations, and additional incentives leading up to open enrollment in 2014. Continued communication with tool users included e-mail alerts when new claims information became available and monthly product updates. Four months after the introduction of the tool, 23% of eligible households had registered for the tool.

Of the roughly 200,000 PPO members who had access to the price transparency tool, CalPERS sent introductory letters to a sample of 200. We chose 200 based on an anticipated response rate with the plan to recruit more respondents if we did not saturate themes. Individuals were invited to participate in a 20-minute phone interview to discuss how they choose where to get healthcare and how price affects these decisions. If they were interested, they were asked to call or e-mail to set up an interview. We provided a $50 gift card on completion of the interview.

We were interested in talking to 3 groups of respondents: 1) those who had never used the price transparency tool, 2) those who had used it infrequently, and 3) those who had used it frequently for a sustained amount of time (defined as more than 5 log-ins over a 6-month period, with each log-in separated by at least 1 month) since the tool was introduced. CalPERS had access to administrative data on who had used the tool and how frequently, but for privacy reasons, these data were not available to the Harvard research team. In order to compensate for low rates of tool usage, CalPERS preferentially sampled and sent letters to those individuals who had used it frequently for a sustained amount of time. Interviews were conducted by 4 study team members (HS, RG, AS, AM) between May and October 2015. All interviews were transcribed.

Phone interviews used a semistructured interview guide that focused on 4 areas: the respondent’s use of the price transparency tool (if any), previous use of healthcare and how he or she selects a provider, opinions about healthcare consumerism, and demographic information. Consistent with qualitative research methods, interviewers had the flexibility to engage respondents in relevant discussion outside of the structured questions.

Interviews were coded using Dedoose (SocioCultural Research Consultants, LLC, Los Angeles, CA), an online platform for analyzing qualitative research. Research team members developed a thematic coding guide around use of the price transparency tool, opinions on shopping for care, and general views of the cost of healthcare. Using Dedoose, a study team member (HS) analyzed the transcribed interviews in conjunction with respondents’ descriptive information using the coded themes. Other study team members (RG, AS, AM) also coded a random sample of interviews to confirm consistency of coding and themes.

This study and its materials were approved by the Harvard University Institutional Review Board.

We contacted 200 CalPERS members who were enrolled in a PPO product and given access to the Castlight price transparency tool through their employer. We interviewed 39 members (20% response rate); 67% were female, 65% were older than 50 years, and 73% had completed an associate’s degree or higher (

). Among respondents, 17 reported using the price transparency tool frequently (defined as 4 or more reported log-ins), 13 reported using it infrequently (defined as 1-3 reported log-ins), and 9 reported never having used it. Our findings did not vary substantively across users versus nonusers or by frequency of use of the tool. Thus, we present our results by themes and highlight the few circumstances where there are notable differences.

Views on the Cost of Healthcare and Price Shopping

Most respondents expressed frustration with the high cost of their healthcare, price variations across providers, and receiving an unexpected, costly bill after receiving care. Many felt like they did not have control over their or their family’s healthcare spending beyond taking the initial step to seek medical care. One respondent said, “‘Control,’ I mean you can decide not to go and get the care, so in that respect, you have control. But at the same time, if you want to be healthy, you really do need to [get needed care], and sometimes that means you have to go do something that’s going to cost you money. And you don’t have any control over what they’re going to charge you.”

Despite this general frustration with costs and a lack of control, a number of respondents were very conscious of their healthcare spending and carefully monitored their family’s spending and deductible status. This tracking of spending was reported both by respondents who had used the price transparency tool and those who had not.

Although relatively few had done so, most respondents had a positive opinion of the idea of price shopping and believed it could improve the value of the care they receive. One respondent said, “I don’t think that it hurts to get an idea [of price] if you’re going to get…comparable quality care at a location that’s gonna cost you a little bit less; then I think it is helpful information.” Some respondents drew parallels between healthcare and other types of purchases: “It’s just like going to get a car: [if] people are out looking around, trying to get the best price, [dealers] are going to drop the price for you because they want your business. I don’t think health care will be any different.” However, this sentiment was not universal. Several respondents did not support shopping for care based on price because they felt that money does not matter when it comes to taking care of their health.

Among those who reported prior price shopping, most attributed it to having gone through a major health event themselves or with a family member. One respondent commented, “I have a very good idea [of how much I spend on medical care]…because a couple of years ago I had a big surprise, and suddenly I started keeping track.”

Perceived and Actual Barriers to Shopping for Care

Despite frustration with the cost of care and optimism about price transparency among most respondents, many cited multiple barriers to shopping for care and using the price transparency tool (

Salience of searching for price information. 

The first set of barriers related to when and for what reason respondents reported they should search for price information. As previously noted, most supported the idea in theory; however, many respondents described price shopping as a foreign concept, as they had never considered using price to choose a doctor or going against a referral from their provider. Among those who had not used the tool, several respondents mentioned they simply forgot to use the price transparency tool when they were searching for a new provider. In particular, it was common for respondents to express disappointment during the interview if they had forgotten to use the tool after being reminded of it. Among those who had used the tool, it was common to have logged on to the tool once or twice out of curiosity but to not have returned to the website since then.

Another theme in the interviews was the belief that proactively searching for price would not impact what respondents would pay out-of-pocket for their care. For example, several respondents noted that it was unimportant to shop for care because they were already beyond their deductible or because their co-payment for an office visit was always the same. Many—in particular, those in rural areas&mdash;felt it was not useful to shop for care because there was a limited set of providers they could see within their health plan’s provider network. Others were skeptical of the usefulness of the price information on the website because it did not account for the tests or referrals the physician might order during a visit.

Perception that other factors are more important for provider choice than price. 

The second set of barriers consisted of factors that respondents judged as more important than their out-of-pocket costs when selecting a provider. Overwhelmingly, respondents did not want to shop for care because of loyalty to their current providers. This was true of those who used the tool and those who had not. Many respondents commented that differences in price were relatively unimportant when it came to their primary care physicians (PCPs) and specialists with whom they had an established relationship. Respondents also judged referrals and input from their own physicians as key reasons for making a given provider decision. 

Most respondents believed that seeking quality care was more important than the location of the facility and far more important than their out-of-pocket costs. However, there was disagreement among respondents on how to choose care based on quality. Some respondents took the provider’s location or the cost of their care to indicate quality: “[For] the more quality [care you receive], you should expect to pay a little bit higher cost as opposed to those [providers] that are discounted and may not have the attention to detail to find out exactly what you’re going in for, what’s wrong with [you]…I don’t have a problem with that.” Yet, many respondents reported that price had little to do with quality. 

Of the notion that higher-priced providers offer higher-quality care, one respondent said, “I don’t agree with that. I’ve had doctors that…provide incredible care and I’ve had other doctors that, you know, they charge huge amounts and you get 5 minutes of their time, and you’re out of there. No, I don’t see a correlation at all [between price and quality].” Respondents also reported overlooking price when it ultimately came to making a medical decision to improve their health and well-being.

Among those who used the price transparency tool, few made a decision based solely on the tool and instead used it as a supplement to other resources to make provider choices, such as online reviews and referrals from friends and family. One respondent described, “I spend quite a long time because what I do is I take the info from Castlight, and…[I try to] find the right match between what Yelp says about the office that Castlight is saying has quality.”

Situations amenable (or not) to shopping for care. 

Respondents reported that shopping for care, using either the price transparency tool or other resources, was reasonable for nonemergent services. Of the respondents who had shopped for care, particularly those who had used the price transparency tool, they most frequently reported doing so for imaging and labs. One respondent described, “I routinely have [an] MRI because…of the [

] gene…and I was concerned about how much it was going to cost…That’s why I went to Castlight.” A few respondents also described using the price transparency tool to find cheaper labs than they were currently using: “I have a condition that requires I have lab work 3 or 4 times a year…The blood work through the particular laboratory [I found on Castlight] was like 15%-16% of what I was paying for the last 5 years at the hospital labs…It’s a huge difference for me.”

Respondents also described situations in which they would not use the price transparency tool. They rarely reported using the price transparency tool to search for a new PCP. A few searched for their own PCP out of curiosity rather than with the intention of making a switch.

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