Summary

Concern about Affording Hospital Services

A majority of Tennessee respondents report being concerned about their ability to afford care. In fact, 76% of Tennessee respondents reported being worried about affording health care, both now and in the future, and nearly three in every five (57% of) respondents reported being “worried” or “very worried” about affording medical costs in the event of a serious illness or accident.

• Fifty-nine percent (59%) of respondents reported being “worried” or “very worried” about affording medical cost when elderly.
• Sixty-two (62%) percent of respondents reported being ‘worried” or “very worried” about being able to afford home health care services.

Some respondents also reported cost burdens following care. In total, 45% reported experiencing a financial burden due to medical bills and 59% of respondents reported receiving an unexpected medical bill in the past year. Among the 59% of respondents who reported receiving an unexpected medical bill in the past year, over half (54%) said at least one of those bills came from a hospital.

Confidence Seeking Hospital Care, Quality, Billing Information

Limited knowledge of health care quality or costs can hinder consumers’ ability to budget for care, which can be especially detrimental to the under- and uninsured.⁴ Tennessee respondents are fairly confident in their ability to recognize when to seek emergency care, follow directions provided by their doctor, and their ability to fill a prescription. Sixty-two percent (62%) of respondents are very or extremely confident that they know when to visit the emergency department as opposed to an urgent care center or a primary care provider (see Figure 1).

However, respondents are less confident in their ability to find hospital costs and quality information before a service. They are also less confident in their ability to resolve concerns related to financial obligations, such as disputing a medical bill. Out of all respondents:

• Sixty-four percent (64%) of respondents reported they were not confident in their ability to afford home health care services;
• Sixty percent (60%) of respondents reported they were not confident in their ability to have enough money to cover major unexpected illnesses or injuries;
• Fifty-one percent (51%) of respondents feel very or extremely confident they could resolve an issue if their health plan was not being responsive;
• Forty-six percent (46%) of respondents reported they were not confident in their ability to have enough money to cover their usual necessary medical cost;
• Forty-one percent (41%) of respondents reported they were not confident in their ability to determine the cost of a medical procedure in advance;
• Thirty-nine percent (39%) are not confident in their ability to find quality ratings for hospitals; and
• Thirty-eight percent (38%) are not confident in their ability to find quality ratings for doctors.

This lack of confidence may be reflected in the low rates of searching for hospital price and quality information. Only 40% of respondents reported trying to find the cost of a hospital stay ahead of time, while 14% of the respondents that reported needing a hospital service did not search for cost information at all. Among the respondents that did search for cost information or who required a hospital service:

• 25% were able to find the information they needed, and
• 15% attempted to find hospital cost information but were unsuccessful.

Similarly, nearly half (48% of) Tennessee respondents reported searching for hospital quality information, 41% found the information they needed, 16% did not find what they needed, and 16% reported needing a hospital stay but not searching for quality information (see Figure 2). Among those that did search for hospital quality information or needed a hospital stay, 35% were successful in their search, while 13% searched for hospital quality information but were unsuccessful.

Few respondents indicated that cost and quality information was not important to them (10 and 5%, respectively). Additionally, despite federal price transparency mandates for hospitals, hospital costs and quality ratings are still not always accessible.⁵ The most frequently cited reasons respondents did not attempt to find cost or quality information include:

• 29% followed their doctors’ recommendations or referrals;
• 28% did not know where to look;
• 28% reported that searching for information felt too confusing or overwhelming;
• 18% did not have time to look; and
• 16% reported that it did not occur to them to look for quality or price information.

The respondents who did attempt to find hospital cost information, but were unsuccessful, described several challenges:

• 35% reported that their provider or hospital would not provide a price estimate;
• 34% reported that their insurer would not provide a price estimate;
• 27% reported that the available cost information was confusing; and
• 27% reported that the price information was insufficient.

Similarly, among the respondents who were unsuccessful in their search for hospital quality information, 31% reported that the resources were confusing and 15% reported that the quality information was not sufficient.

Comparing Cost and Quality Information

Among the respondents who were able to successfully locate sufficient cost or quality information, 89% reported they were able to find enough information to successfully compare the costs of a hospital stay between two or more options, and 85% reported finding enough information to compare quality ratings across hospitals (see Figure 3).

Respondents who were able to successfully compare cost or quality information between multiple providers reported that the comparison ultimately influenced their choice of which provider to seek care from:

• 87% of respondents who compared costs for a primary care or specialist visit;
• 92% of those who compared the cost of medical test providers;
• 87% of those who compared the cost of a hospital stay; and
• 85% of respondents who searched for hospital quality information reported that the comparison influenced their decision.

Difficulty Understanding Common Health Terms

Research indicates that nearly half of insured adults find at least one aspect of their insurance difficult to understand.⁶ When given multiple choices, over two out of three (69% of) Tennessee respondents were able to correctly define “premium,” and a similar amount (68%) were able to correctly define “deductible.” However, fewer than half (43%) were able to accurately define “coinsurance”(see Figure 4).  Of note, more educated respondents generally performed better when asked to define these terms (see Table 1).

Impact, Concerns about Hospital Consolidation*

In some cases, health care consolidation — which occurs when hospitals and other health care facilities are joined together through a merger, acquisition, or other change of ownership — can magnify the challenges consumers face when seeking, comparing, and affording care.⁷ Although the number of survey respondents who reported they have been impacted by a consolidation transaction is too small to report reliable estimates, the survey results indicate that some encountered new challenges following consolidation.

*Note: The sample size of respondents who said they were affected by a merger was not large enough to report reliable estimates, so the values in this section should be interpreted with caution.

Six consolidation transactions involving hospitals have occurred in Tennessee between 2018 and 2024.⁸ Tennessee requires that the State Attorney General be notified of non-profit hospital transactions and does not have the authority to approve or deny these transactions.⁹  In total, 27% of Tennessee survey respondents reported that they are aware of a health care consolidation transaction in their community.

Out of the 27% of respondents who reported being aware of a health care consolidation transaction, nearly two out of five (39%) reported that they or a family member lost access to their preferred health care provider because the change led to their provider being moved out-of-network. Among respondents who lost access to their preferred provider:

• 46% skipped a recommended follow-up visit due to a merger;
• 45% delayed or avoided going to the doctor or having a procedure done because they could no longer access their preferred health care organization due to a merger;
• 40% switched to an in-network provider;
• 36% skipped filling a prescription;
• 28% changed their health insurance plan to keep their preferred provider;
• 23% turned to telehealth options to continue seeing their preferred provider;
• 20% continued seeing their provider but must now pay out-of-network prices; and
• 9% had to switch providers due to a service closure following a merger.

Some respondents reported additional challenges beyond losing access to their preferred health care provider. Out of those who reported that the merger caused an additional burden for them or their families, the most frequently reported consequences include:

• 30% reported that the merger created an added financial burden;
• 24% reported that the merger created an added transportation burden;
• 21% reported that the merger created an added wait time when searching for a new provider; and
• 17% reported that the merger created a gap in the continuity of my care.

Some respondents also provided examples of how they have been personally impacted following hospital consolidation. Examples include:

Although only a small number of respondents indicated that they have been personally impacted by a health care consolidation, far more respondents (61%) reported being “somewhat,” “moderately,” or “very” worried about the potential impacts of a consolidation transaction should it occur. When asked about their biggest concerns:

• 27% reported that they are worried they would have fewer choices for care;
• 25% are concerned that their doctor may no longer be covered by their insurance;
• 21% are concerned that they will have to pay more to see their doctor;
• 12% are concerned they will have to travel farther to receive care.
• 11% are concerned that the consolidation will result in lower quality of care; and

Respondent Perceptions of Health Care Systems, Policy Solutions

Hospitals, along with drug manufacturers and insurance companies, are viewed as a primary contributor to high health care costs. Out of fifteen possible options, Tennessee respondents most frequently reported believing that the reason for high health care costs due to powerful industry stakeholders, such as:

• 73%—Drug companies charging too much money
• 70%—Hospitals charging too much money
• 69%—Insurance companies charging too much money

Respondents endorsed a number of strategies to address high health care costs and transparency-oriented strategies, including:  

• 93%—Show what a fair price would be for a specific procedures;
• 92%—Require drug companies to provide advanced notice of price increases;
• 92%—Require insurers to provide up-front cost estimates to consumers;
• 91%—Require hospitals and doctors to provide up-front cost estimates to consumers;
• 91%—Lower cost of follow-up care and treatment for people with chronic conditions like diabetes, liver disease and cancer.
• 89%—Set standard payments to hospitals for specific procedures;
• 87%—Strengthen policies to drive more competition in health care markets;
• 87%—Require routine health services to cost the same no matter what facility those services are conducted at;
• 86%—Establish an independent entity to rate doctor and hospital quality, such as patient outcomes and bedside manner; and
• 86%—Establish limits on health care spending growth.

The survey findings indicate that while some Tennessee respondents are motivated to search for hospital cost and quality information to inform their decisions and plan for future medical expenses, over half did not seek this information at all. This suggests that price transparency initiatives alone may not effectively influence consumer behavior. The lack of knowledge of hospital quality and potential costs may impede Tennessee residents’ ability to plan for needed care and budget for the expense of a hospital stay, which can be costly, particularly for residents who are uninsured or under-insured.¹⁰

Tennessee respondents reported support for government-led solutions to make price and quality information more accessible and to help consumers navigate hospital care. Many favored solutions could reduce the burden on consumers, such as standardizing payments for specific procedures, requiring cost estimates from hospitals and doctors, and establishing an independent entity for quality reviews. Policymakers should consider these and other policy options to address the bipartisan call for government action.