Journal of General Internal Medicine

, Volume 25, Issue 3, pp 249–254 | Cite as

Consumer Awareness and Strategies Among Families with High-deductible Health Plans

  • Tracy A. LieuEmail author
  • Jeffrey L. Solomon
  • James E. Sabin
  • Jeffrey T. Kullgren
  • Virginia L. Hinrichsen
  • Alison A. Galbraith
Original Article



High-deductible health plans (HDHPs) are a new and controversial approach to increasing the share of health care costs paid by patients. Our study had the following aims: (1) to describe the experiences of families with HDHPs who had incurred high out-of-pocket costs and (2) to identify areas where clinicians could support more effective health care decisions by such families.


We conducted four focus groups with adults whose families had HDHPs in a New England-based health plan and had experienced high or unexpected out-of-pocket health care costs during the past 12 months. Transcripts of audio recordings were independently coded by three investigators using modified grounded theory techniques.


The 21 focus group participants had a good general understanding of how their HDHP worked, but reported confusion about specific processes due to the plans' complexity. They described heightened awareness of health care costs, and identified important barriers to their ability to control costs. These included needing to seek care for urgent problems without having the time to assess potential costs; having mistaken expectations about what services the HDHP covered; and being reluctant to discuss costs with doctors. They attempted to control costs by delaying or avoiding visits to doctors, but felt they had little control over costs once a clinical encounter had begun.


Patients with HDHPs reported heightened sensitivity to health care costs, and described important barriers to their ability to make effective choices. Helping such patients make optimal decisions will likely require systems-level changes that involve clinicians and health insurers.


health policy health insurance health care reform costs decision-making 



We are grateful to Bruce Landon, MD, MBA, Meredith Rosenthal, PhD, and Christopher Forrest, MD, PhD, who offered very helpful advice as consultants. We thank Stephen Soumerai, ScD, and Dennis Ross-Degnan, ScD, for support and guidance in this project. We thank Pamela Butler for assistance with the manuscript.

This study was supported by an R21 grant from the National Institute of Child Health and Human Development (HD053440). Dr. Lieu's effort was supported in part by a K24 Mid-Career Development Award from NICHD (HD047667). Dr. Galbraith's effort was supported in part by a K23 Mentored Career Development Award from NICHD (HD052742).

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Tracy A. Lieu
    • 1
    • 2
    • 3
    Email author
  • Jeffrey L. Solomon
    • 4
  • James E. Sabin
    • 2
  • Jeffrey T. Kullgren
    • 5
  • Virginia L. Hinrichsen
    • 2
  • Alison A. Galbraith
    • 1
    • 2
  1. 1.Center for Child Health Care StudiesBostonUSA
  2. 2.Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonUSA
  3. 3.Division of General PediatricsChildren’s Hospital BostonBostonUSA
  4. 4.Center for Health Quality, Outcomes and Economic ResearchENRM Veterans Affairs Medical CenterBostonUSA
  5. 5.Primary Care Internal Medicine Residency Program, Brigham & Women’s Hospital and Department of Ambulatory Care and PreventionHarvard Medical SchoolBostonUSA

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