Introducing Garner’s First-Dollar HSA Incentive: Rewarding Quality Care from Day One

Health Savings Account (HSA) enrollment has risen consistently for over a decade, now covering roughly 30% of the American workforce. The theory was simple: expose employees to some out-of-pocket costs, equip them with a tax-advantaged account to cover those costs, and they will become "smart shoppers".

The data, however, tells a different story. At Garner, our research finds that only 4% of HSA members have engaged in smart shopping - most have never tried, and of those who have tried, many do not have the right information they need to succeed. Accordingly, there is limited evidence that HSAs meaningfully lower total cost of care today.

Overcoming the Structural Engagement Gap

We’ve concluded that HSAs underperform because of two structural design flaws:

• Weak shopping incentives for high spenders: While only 45% of employees meet their deductible annually, those individuals account for 90% of total healthcare spend. When a member will hit their out-of-pocket maximum regardless of the surgeon that they choose, there is no real financial incentive to shop for higher-quality or lower-cost providers: the cost of individual variation is paid for by the employer.
• The black box of healthcare costs: Healthcare shopping is structurally difficult. Approximately 75% of Americans say it is very difficult to know what a procedure will cost upfront. Even a motivated patient who finds a "low" procedure fee can be blindsided by facility fees and anesthesia costs they had no way of predicting. A patient’s inability to predict what services they are going to need, which they cannot know without knowing their own diagnosis or the behavior of the individual physician that they choose, makes shopping for healthcare essentially impossible.

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The Solution: Garner’s First-Dollar HSA Incentive

To solve this, Garner has launched our First-Dollar HSA Incentive. Our approach repurposes the HSA mechanism by making employer HSA contributions contingent on seeing a Top Provider — doctors proven to deliver higher quality care at a lower total cost. Members and employers can rest easy knowing that Top Providers not only deliver the best care, but also deliver 27% lower total costs on average, across the entire episode of care by choosing more efficient sites of service, prescribing generic drugs, and avoiding unnecessary downstream tests and procedures.

The core mechanism is a conditional employer HSA contribution. When a member sees a Garner Top Provider, they receive a direct contribution to their HSA account—no deductible required. Because the reward is structured as an employer HSA contribution rather than an HRA reimbursement, it remains fully IRS-compliant. It is similar in nature to wellness incentives (like rewards for steps or dental cleanings), except with substantially larger incentives tied directly to provider decisions that drive outcomes and cost.

With a First-Dollar HSA incentive, members have a meaningful, day-one reason to engage with Top Providers. This results in 28% higher engagement compared to traditional post-deductible HSA models.

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Seamless Integration and Results

We built this incentive to be simple for members to understand and plug-and-play for employers, integrating with every major HSA provider without need for customization. 

The results are meaningful. The percentage of employees seeing top-performing providers nearly doubled after they implemented Garner’s incentive—rising from 23% to 43%.

Garner’s First-Dollar HSA Incentive is now available for all plans starting July 1, 2026. By giving all members a meaningful incentive and the right tools to actually act on that incentive, we are finally delivering on the promise of consumer-driven healthcare.

To learn more, watch our recent webinar The First Dollar Problem: What Employers Need to Know to Make HSAs Work or contact us today sales@garnerhealth.com.