Some health insurance websites show improved efforts to support patient decision making

The marketplaces, also called health exchanges, were established by the Patient Protection and Affordable Care Act to allow consumers to compare and choose health insurance plans.

"Selecting a plan is a complex task for just about anyone, regardless of your knowledge of the marketplaces or health insurance, and the way plans are presented on the exchanges and the tools available there can influence consumers' choices," said the study's lead author Charlene A. Wong, MD, a Robert Wood Johnson Foundation Clinical Scholar and fellow in Penn's Leonard Davis Institute of Health Economics. "Performance of the health insurance marketplaces will significantly depend on such features as the order in which plans are displayed, the plan features listed, and the availability of decision-support tools created for consumers. While we generally found improvement in the second versus the first open enrollment period, additional measures can and should be added in the future to further improve the selection process for consumers."

The Penn investigators examined HealthCare.gov, the national marketplace used by the majority of states, and 12 state-based marketplaces during the first and second open enrollment periods (October 1, 2013 to March 31, 2014 and November 15, 2014 to February 15, 2015, respectively). They collected data that consumers would see while browsing before creating an account ("window shopping") and after creating an account and having their identities verified ("real shopping").

In continuing research extending from findings published online this past June in the Journal of Adolescent Health, Wong and her colleagues found that decision tools most likely to be helpful to consumers were more common in the second versus the first period but still not universally available. For example, while most sites allowed consumers to sort or filter plans by premium and deductible amounts, only three states had out-of-pocket cost estimators that "did the math" for consumers by adding together their premium and expected costs (e.g., deductible and copays) based on consumers' predicted use (e.g., number of physician visits or prescription medications). California (www.coveredca.com) listed plans in order of this estimated out-of-pocket cost from cheapest to most expensive. This is in contrast to most sites that simply used the premium amount as their default plan order, which may cause consumers' to be overly influenced by the premium amount while not paying enough attention to other potential out-of-pocket expenses, such as meeting a high deductible.

Only six sites included an integrated tool that allowed consumers to search plans on the basis of provider network. Pop-up definitions for common and important terms like "deductible" or "coinsurance" were available on only nine sites, despite being easier for websites to implement. Only four sites had health plan quality rankings, albeit a step-up from two in the first open enrollment period. "By including more of these tools in both real and 'window' shopping stages, marketplaces can help de-mystify what for many is a complex, opaque process," said Wong.