The health care industry maintains that the best way to cut health care costs is to force consumers to have more “skin in the game,” yet studies keep piling up that point to this conclusion: Americans, including those in high-deductible plans who have the most at stake financially, are not comparison shopping for health care based on price.

This phenomenon is well described in a recent study by Anna Sinaiko, Ateev Mehrotra, and Neeraj Sood, which appears as a research letter in JAMA Internal Medicine. They compared the price-shopping behavior of consumers in high-deductible plans (deductible greater than $1,250) to those in more traditional plans. The researchers found only one percentage point difference in the likelihood of members of either group to comparison shop for medical care. This was the case despite the fact that 60% of those in high-deductible plans reported that they knew price and quality varied across health care providers, or that 71% said out-of-pocket cost differences were important.

What Is Causing the Big Disconnect?

The Health Care Cost Institute (HCCI) took an interesting look at how much health care is actually “shoppable.” They defined a shoppable service as having the following key elements:

• It must be a common service that can be researched (shopped) in advance.
• Multiple providers of that service must be available in a market (i.e., competition).
• Sufficient data about the prices and quality of service must be available.

By their definition, only 7% of total health care spending in 2011 was on shoppable services. Yet even within that small window, examples of shopping behavior are hard to find.

Price-Shopping Hits a Wall

With Americans now accustomed to online price comparison for everything from cars to lunch boxes, surely, you might think, some of this behavior must have spread to the health care sphere. Our research says it has not. In March 2015, CHCF released results from a survey of Californians. When asked whether they had ever looked in advance for information about the cost of a test, treatment, or other type of health care, only 26% replied that they had. The percentage is identical to a similar survey conducted three years earlier (PDF).

Delving a bit deeper into the 2015 research, we found statistically significant differences for only a few types of consumers.

• By health status: 30% of those reporting to be in excellent health said they had price shopped versus only 21% among those reporting to be in poor health.
• By age: Older Californians had a lower rate of price comparison. Only 13% of those over age 65 said they had price shopped. In contrast, those in the 35-to-44 age bracket reported the highest rate of price shopping, though still only 33%.
• By education level: Of those who had more than a college degree, 38% had looked for price information.
• By parenting status: Having children correlated with a higher price-shopping rate (31%).

Unfortunately, it appears that those in the most perilous financial condition (sicker, older, less well-educated) are the least likely to take advantage of current tools.

Understanding more about the barriers facing this audience seems like a reasonable first step. Looking back at the CHCF survey, we asked a follow-up question of those who reported that they had not looked for pricing information: “Why not?”

If we exclude those who report having rich benefit plans (“Costs mostly covered by my insurance…”), the second and third most frequently cited reasons are feeling locked into current providers (“I don’t feel like I have a choice…”) and difficulty finding useable tools (“It’s too hard to find information…”).

Stymied by a Triple Threat

The problem appears to be threefold.

First, as demonstrated in the HCCI research, most services are not inherently shoppable, including those that are urgent or emergent in nature.

Second, many of the same plans that have high cost-sharing also have limited provider networks. Consumers are put in the driver’s seat and then face one-way streets, cul-de-sacs, and dead ends.

Third, consumers lack good maps. What are the elements of good navigation? Clarity, comprehensiveness, and availability of up-to-date information. Though there has been extensive research on best practices for web display of quality and price information, plans do not always take these lessons into account in designing their shopping tools.

Are there alternatives to increase consumer engagement for the subset of services that are shoppable? New research shows doctors and patients talk about cost during one in three office visits. Since patients often rely on their providers to recommend the most cost-effective approach, why not create apps for patients to use while speaking with their doctor?

Even better, we need apps for medical comparison-shopping that compare prices for in- and out-of-network providers and allows price comparison across plans. A public tool would cut down on the need for many separate, incomplete, and hard-to-use tools.

For now, the inability or unwillingness of health plans to work together to create effective price comparison tools casts significant doubt on the industry’s elegant theories about consumers putting skin in the game.