Intervention: Online advertising campaign

The online advertisement campaign focused on three categories of services: imaging services, emergency department visits, and physical therapy services. We selected these three service categories because they are common and among the most frequently searched services on price transparency websites.^9,12 Also, these services are on average lower cost than a deductible in a high-deductible health plan and therefore, more likely to incur patient cost sharing obligations. Imaging and physical therapy services are also non-emergent, while many emergency department visits could be addressed in an alternative and cheaper setting such as an urgent care center.¹⁶

Advertisements were shown to people from the state of New Hampshire who were using Google’s search engine (“search ads” in Google parlance) or on a website with content considered relevant (“display ads”). Each user’s location was determined using the Internet Protocol address (IP address). The search terms that triggered a search ad were refined over the campaign both by an independent Google advertisements consultant and automatically by the Google advertisements algorithm. Once a search term is determined to be relevant to the advertisement content, the advertisement is entered into an automated auction with competing advertisements. The search advertisement was displayed if it won the automated auction (see Supplementary Appendix Section 1 for details¹⁷). The algorithm “learned” over time to better target search terms and users. Display advertisements appeared on websites with content related to the three service categories or on websites visited by individuals determined to have relevant search or web usage patterns.

The advertisements directed users to the price transparency website. See Appendix Exhibit A1 for screenshots of the advertisements.¹⁷ If an individual clicked on the advertisement, they would be directed to the NH Health Cost website where they could select their insurer (or uninsured status) and a health care service. They were then shown insurer-specific negotiated prices and their estimated out-of-pocket costs across providers in New Hampshire. A total of $39,060 was spent on the advertising campaign in the 6 months (January 1, 2019 to June 30, 2019) during which the campaign was fully implemented. In the 6 months prior to that (July 1, 2018 to December 31, 2018), we piloted the advertisements on a small scale.