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Blunt Policy Instruments Deliver Blunt Policy Outcomes: Why Cost Sharing is Not Effective at Controlling Utilization and Improving Health System Efficiency.

Cost sharing in health care systems has long been used as a policy instrument with the aim of addressing fiscal constraints and controlling the utilization of health care services. Cost sharing can take the form of user fees implemented as full payments for health care services, copayments that cover a fraction of the cost of the episode of care, and within an insurance model, as a set deductible, above which all eligible costs are paid by the insurance policy. Despite the widespread use of cost sharing, its potential value as a targeted “policy-stick” to improve system efficiency has yet to be realized. In this issue, Zheng et al contribute new evidence on the impact of high deductible health insurance programs (HDHPs) on the use of diagnostic services—an area identified as a potential source of overutilization in the United States. They found that HDHPs were associated with lower overall service use: HDHP enrollees used 10.2% fewer imaging studies and had 7.5% less imaging payments compared with nonenrollees. The greatest difference in the use of diagnostic services was among HDHP enrollees with the lowest risk scores (ie, higher-risk enrollees had the same pattern of service use as nonenrollees). However, the authors found no evidence that higher cost sharing due to enrollment in HDHP was associated with a different mix of these services. There was no difference in the use of “low-value” and “high-value” services between HDHP enrollees and nonenrollees, and there was no evidence that HDHP enrollees used proportionately more low-cost modalities and proportionally less high-cost modalities compared with nonenrollees (ie, x-rays vs. magnetic resonance imaging). Rightly, the authors conclude that “HDHP may be a blunt instrument that reduces all diagnostic imaging, rather than helping physicians and patients choose high-value imaging.” Although these results are unsurprising, they do offer further empirical support that improved health system efficiency, by way of reductions in utilization, is rarely achieved with cost sharing. Cost sharing is an ineffective means of improving system efficiency because it relies on a patient-focused policy tool (ie, user fees or insurance deductibles) to motivate changes that are highly influenced and regulated by provider behavior (ie, access to diagnostic tests generally requires a referral from a health care provider). The implicit assumption underlying cost-sharing policies, including HDHP, is that providers are passive participants in utilization decisions—their behavior does not change in response to patient-initiated reductions in utilization due to the price. The income-expenditure identity for health care indicates the opposite—overall utilization is unlikely to fall with cost sharing as providers tend to alter the way health care is delivered in response to patient-initiated reductions in utilization, either by delivering more services to the patients who are insensitive to the higher costs of care or by changing the mix of