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What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics

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  • Brot-Goldberg, Zarek C.

    (University of CA, Berkeley)

  • Chandra, Amitabh

    (Harvard University)

  • Handel, Benjamin R.

    (University of CA, Berkeley)

  • Kolstad, Jonathan T.

    (University of CA, Berkeley)

Abstract

Measuring consumer responsiveness to medical care prices is a central issue in health economics and a key ingredient in the optimal design and regulation of health insurance markets. We study consumer responsiveness to medical care prices, leveraging a natural experiment that occurred at a large self-insured firm which forced all of its employees to switch from an insurance plan that provided free health care to a non-linear, high deductible plan. The switch caused a spending reduction between 11.79%-13.80% of total firm-wide health spending ($100 million lower spending per year). We decompose this spending reduction into the components of (i) consumer price shopping (ii) quantity reductions (iii) quantity substitutions, finding that spending reductions are entirely due to outright reductions in quantity. We find no evidence of consumers learning to price shop after two years in high-deductible coverage. Consumers reduce quantities across the spectrum of health care services, including potentially valuable care (e.g. preventive services) and potentially wasteful care (e.g. imaging services). We then leverage the unique data environment to study how consumers respond to the complex structure of the high-deductible contract. We find that consumers respond heavily to spot prices at the time of care, and reduce their spending by 42% when under the deductible, conditional on their true expected end-of-year shadow price and their prior year end-of-year marginal price. In the first-year post plan change, 90% of all spending reductions occur in months that consumers began under the deductible, with 49% of all reductions coming for the ex ante sickest half of consumers under the deductible, despite the fact that these consumers have quite low shadow prices. There is no evidence of learning to respond to the true shadow price in the second year post-switch.

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  • Brot-Goldberg, Zarek C. & Chandra, Amitabh & Handel, Benjamin R. & Kolstad, Jonathan T., 2015. "What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics," Working Paper Series 15-060, Harvard University, John F. Kennedy School of Government.
  • Handle: RePEc:ecl:harjfk:15-060
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    References listed on IDEAS

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    1. repec:aea:aejpol:v:9:y:2017:i:2:p:91-123 is not listed on IDEAS
    2. Liran Einav & Amy Finkelstein, 2017. "Moral Hazard in Health Insurance: What We Know and How We Know It," NBER Working Papers 24055, National Bureau of Economic Research, Inc.
    3. Ulrike Malmendier, 2016. "The Bidder's Curse: Reply," American Economic Review, American Economic Association, vol. 106(4), pages 1195-1213, April.
    4. repec:aea:jecper:v:31:y:2017:i:4:p:51-72 is not listed on IDEAS
    5. repec:eee:jhecon:v:55:y:2017:i:c:p:61-75 is not listed on IDEAS
    6. Tzu-Ting Yang & Hsing-Wen Han & Hsien-Ming Lien, 2014. "Patient Cost-Sharing and Healthcare Utilization in Early Childhood: Evidence from a Regression Discontinuity Design," Working Papers 14C003, Canadian Centre for Health Economics.
    7. Chenyuan Liu & Justin R. Sydnor, 2018. "Dominated Options in Health-Insurance Plans," NBER Working Papers 24392, National Bureau of Economic Research, Inc.
    8. Minke Remmerswaal & Jan Boone & Michiel Bijlsma & Rudy Douven, 2017. "Cost-Sharing Design Matters: A Comparison of the Rebate and Deductible in Healthcare," CPB Discussion Paper 367, CPB Netherlands Bureau for Economic Policy Analysis.
    9. Ethan M. J. Lieber, 2017. "Does It Pay to Know Prices in Health Care?," American Economic Journal: Economic Policy, American Economic Association, vol. 9(1), pages 154-179, February.
    10. Benjamin R. Handel & Jonathan T. Kolstad & Johannes Spinnewijn, 2015. "Information Frictions and Adverse Selection: Policy Interventions in Health Insurance Markets," CESifo Working Paper Series 5623, CESifo Group Munich.
    11. Jonathan Gruber & Johanna Catherine Maclean & Bill J. Wright & Eric S. Wilkinson & Kevin Volpp, 2016. "The Impact of Increased Cost-sharing on Utilization of Low Value Services: Evidence from the State of Oregon," NBER Working Papers 22875, National Bureau of Economic Research, Inc.
    12. Hayen, Arthur & Klein, Tobias & Salm, Martin, 2018. "Does the framing of patient cost-sharing incentives matter? The effects of deductibles vs. no-claim refunds," CEPR Discussion Papers 12908, C.E.P.R. Discussion Papers.
    13. Leemore Dafny & Christopher Ody & Matthew Schmitt, 2016. "When Discounts Raise Costs: The Effect of Copay Coupons on Generic Utilization," NBER Working Papers 22745, National Bureau of Economic Research, Inc.
    14. Cooper, Zack & Craig, Stuart & Gaynor, Martin & Van Reenen, John, 2015. "The price ain’t right? hospital prices and healthspending on the privately insured," LSE Research Online Documents on Economics 66059, London School of Economics and Political Science, LSE Library.
    15. Remmerswaal, Minke & Boone, Jan & Bijlsma, Michiel & Douven, R.C.M.H., 2017. "Cost-Sharing Design Matters : A Comparison of the Rebate and Deductible in Healthcare," Discussion Paper 2017-039, Tilburg University, Tilburg Law and Economic Center.
    16. Atwood, Alicia & Lo Sasso, Anthony T., 2016. "The effect of narrow provider networks on health care use," Journal of Health Economics, Elsevier, vol. 50(C), pages 86-98.
    17. Handel, Benjamin R. & Kolstad, Jonathan T. & Spinnewijn, Johannes, 2015. "Information frictions and adverse selection: policyinterventions in health insurance markets," LSE Research Online Documents on Economics 65011, London School of Economics and Political Science, LSE Library.
    18. Benjamin R. Handel & Jonathan T. Kolstad & Johannes Spinnewijn, 2015. "Information Frictions and Adverse Selection: Policy Interventions in Health Insurance Markets," NBER Working Papers 21759, National Bureau of Economic Research, Inc.
    19. Benjamin R. Handel & Jonathan T. Kolstad & Johannes Spinnewijn, 2015. "Information Frictions and Adverse Selection: Policy Interventions in Health Insurance Markets," CEP Discussion Papers dp1390, Centre for Economic Performance, LSE.
    20. repec:eee:jhecon:v:55:y:2017:i:c:p:232-243 is not listed on IDEAS
    21. Haizhen Lin & Daniel W. Sacks, 2016. "Intertemporal Substitution in Health Care Demand: Evidence from the RAND Health Insurance Experiment," NBER Working Papers 22802, National Bureau of Economic Research, Inc.
    22. Handel, Benjamin R. & Kolstad, Jonathan & Spinnewijn, Johannes, 2015. "Information Frictions and Adverse Selection: Policy Interventions in Health Insurance Markets," CEPR Discussion Papers 10953, C.E.P.R. Discussion Papers.
    23. Fels, Markus Peter, 2017. "Incentivizing efficient utilization without reducing access: The case against cost-sharing in insurance," Working Paper Series in Economics 105, Karlsruhe Institute of Technology (KIT), Department of Economics and Business Engineering.

    More about this item

    JEL classification:

    • D12 - Microeconomics - - Household Behavior - - - Consumer Economics: Empirical Analysis
    • G22 - Financial Economics - - Financial Institutions and Services - - - Insurance; Insurance Companies; Actuarial Studies
    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private

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