User Interactions With Health Insurance Decision Aids: User Study With Retrospective Think-Aloud Interviews
Authors: Giang Wayne C W , Bland Emma , Chen Jeffrey , Colón-Morales Coralys M , Alvarado Michelle M 
Published: July 2021

Background
Two barriers to effective enrollment decisions are low health insurance literacy and lack of knowledge about how to choose a plan. To remedy these issues, digital decision aids have been used to increase the knowledge of plan options and to guide the decision process. Previous research has shown that the way information is presented in a decision aid can impact consumer choice, and existing health insurance decision aids vary in their design, content, and layout. Commercial virtual benefits counselors (VBCs) are digital decision aids that provide decision support by mimicking the guidance provided by an in-person human resources (HR) counselor, whereas more traditional HR websites provide information that requires self-directed navigation through the system. However, few studies have compared how decision processes are impacted by these different methods of providing information.

Objective
This study aims to examine how individuals interact with two different types of health insurance decision aids (guided VBCs that mimic conversations with a real HR counselor and self-directed HR websites that provide a broad range of detailed information) to make employer-provided health insurance decisions.

Methods
In total, 16 employees from a local state university completed a user study in which they made mock employer-provided health insurance decisions using 1 of 2 systems (VBC vs HR website). Participants took part in a retrospective think-aloud interview, cued using eye-tracking data to understand decision aid interactions. In addition, pre- and postexperiment measures of literacy and knowledge and decision conflict and usability of the system were also examined.

Results
Both the VBC and HR website had positive benefits for health insurance knowledge and literacy. Previous health insurance knowledge also impacted how individuals used decision aids. Individuals who scored lower on the pre-experiment knowledge test focused on different decision factors and were more conflicted about their final enrollment decisions than those with higher knowledge test scores. Although both decision aids resulted in similar changes in the Health Insurance Literacy Measure and knowledge test scores, perceived usability differed. Website navigation was not intuitive, and it took longer to locate information, although users appreciated that it had more details; the VBC website was easier to use but had limited information. Lower knowledge participants, in particular, found the website to be less useful and harder to use than those with higher health insurance knowledge. Finally, out-of-pocket cost estimation tools can lead to confusion when they do not highlight the factors that contribute to the cost estimate.

Conclusions
This study showed that health insurance decision aids help individuals improve their confidence in selecting and using health insurance plans. However, previous health insurance knowledge plays a significant role in how users interact with and benefit from decision aids, even when information is presented in different formats.