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Perspectives on a selected key
topic
February/March 2019 |
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Can Healthcare Behavioral Economics Be Used—Or Not— To Advance
Population Health And Quality Improvement?
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David Fairchild, MD,
MPH
Director
BDC
Advisors |
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Population Health is based on the notion of a dedicated
provider taking care of a defined population with a focus on
the whole person. So why is it frequently difficult to get
patients to take drugs as specified, or engage in chronic
disease self-management? For that matter, why do we
physicians not always take our own advice? Perhaps our
population health strategies would be more effective if we
incorporated more learnings regarding how and why humans
make the decisions they do.
Behavioral economics,
which relies on psychology as well as traditional economic
theory, may prove to be a useful new population health tool
by helping us understand why patients do what they do.
Behavioral economics argues that people don’t always make
decisions about their health rationally based on a careful
calculation of risks and benefits. Rather consumer and
patient decisions are strongly influenced by emotions and
the environment, as well as how healthcare choices are
presented. In their 2008 book Nudge: Improving Decisions
About Health Wellness and Happiness”, Nobel prize winning
economist Richard Thaler and co-author Cass Sunstein explain
how natural human biases can cause people to make poor
decisions, and how these choices negatively impact
population health. With knowledge of these biases it may be
possible to structure “choice environments” with “peer
supports” to better engage patients in their wellness
planning, make it more likely people will make healthy
choices, and develop “nudges” to improve adherence
medication compliance and wellness programs.
One of
the key principles of behavioral economists is “loss
aversion” or “present bias”---- our tendency to be more
sensitive to the potential impact of an immediate loss than
the possibility of a future gain. Employers have recognized
this and have assumed a more activist role in benefit plan
design introducing both rewards and penalties to “nudge”
employees to participate in a variety of wellness
activities. In our provider world these kind of behavioral
“nudges” may include use of telehealth to improve access of
patients to their providers; or new remote technology such
as Adhere Tech’s digital “smart pill bottles” reported in
the NY Times recently, which can alert patients when it’s
time for medication, and send an automatic reminder if they
miss a dose in real time. New technologies, that enable
providers to track behavior and connect with patients,
however, “are not in and of themselves going to change
behavior in high risk patients”, according to Kevin Volpp,
MD, PhD., founding director of the University of
Pennsylvania’s Center for Health Incentives and Behavioral
Economics: “You have to combine technology with an
engagement approach that is really going to provide ongoing
active participation”
Volpp has designed randomized
trials to “nudge” physicians to provide evidence-based care,
as well as testing how to help consumers choose better
health plans depending on how options are provided. And some
health plans are trying a variety of behavioral economic
concepts to reward physicians for quality, including peer
comparisons and bonuses for continuous improvement instead
of basing rewards on hitting one absolute target. My own
experience in designing population health programs confirms
the need to combine peer and social support to change
patient behaviors. The discipline of behavioral economics is
still young, and will need further testing to see if the
concepts are scalable. But it is already stretching our
thinking, and may help provide a more complete understanding
of patient and physician decision making, and how we can
design more sensible strategies for population health.
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Lindsay R. Resnick
Executive Vice President
Wunderman Health |
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It’s HUGE! Healthcare behavioral economics is the effect of
psychological, cognitive, emotional, and social factors on
the economic and health decisions of individuals. Not only
do consumers and patients face a mind-numbing array of
financial healthcare choices, there are also tough decisions
navigating the complexities of how, when and where medical
care is delivered. It's no surprise that most consumers say
health care is so complicated they don't know what's
covered, what it will cost or where’s the best place to go
to get it. The result often comes in the form of confusion,
apathy and disengagement.
The ability to engage
patients in follow-up treatments and adherence protocols is
central to the success of population health management
programs and ultimately, quality improvement. Today,
millions of dollars and countless hours are spent each year
to try to get health care consumers to do what’s good for
them. It’s a long, slow and expensive effort that sees only
modest behavior change. It’s the dilemma of ‘health
inertia’…getting people to face personal health challenges,
adhere to a plan of action, and stay motivated to
proactively deal with their health. It’s fighting human
nature to get results.
Changing behavior takes moving
away from educational-based efforts overloaded with complex
clinical and instructional messaging about conditions and
treatment options. There needs to be a shift from education
to inspiration, from features and functions to gut-level
emotional appeals that move people to action and sustain
engagement. It’s about connecting across the customer
lifecycle around personal, relevant motivations and deep,
sometimes even unconscious desires and values like freedom,
happiness, personal goals, self-esteem, or the ability to be
a better parent or partner. It’s the principles of
healthcare behavioral economics.
Effective population
health management is about inspiring individuals to make
smart, personalized choices in a health care ecosystem
defined by significant out-of-pocket responsibility and
complicated care delivery choices. Monotone, common
denominator off-the-shelf programs to improve patient health
around chronic conditions, prevention, early detection or
wellness isn't enough. Success only comes when you can get
individuals to respond, interact and engage in a meaningful
two-way relationship driven by emotion, psychological
drivers, and most importantly built on trust. Payers,
providers and employers need to step up and support the
underlying belief that connected, motivated and empowered
health care consumers will help drive better care, better
quality, better outcomes, and ultimately, better value.
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