Physician burnout in the US is reaching epidemic proportions as we seek for health care system solutions that optimizes people’s health and is yet affordable. Fundamentally, if we could better influence the health-related decisions that take place between a clinician and a patient, we would be making significant strides towards the triple aim. This is where behavioral economics can come into play.
Our behavior is powerfully influenced by our emotions, identity and environment, as well as by how options are presented to us. Traditional economics is rooted in the assumption that people make rational, self-interested decisions based on a strict cost/benefit analysis of their options. By contrast, the sub-field of behavioral economics acknowledges that common psychological factors, such as aversion to loss or the desire for fairness, also influence people’s decisions.
In order to find gentle but effective ways to change the behavior of both clinicians and patients towards optimal outcomes, providing a healthy nudge, has shown to be effective in randomized trials. By creating more favorable decision-making environments, we can take advantage of cognitive biases to encourage high-value care.
For physicians, a nudge for example could be used to increase referrals to cardiac rehabilitation for patients who have had a heart attack. This has been established as a best practice but typically requires various steps on the part of the referring physician. Conversely, a nudge might be deployed to dissuade a physician from utilizing unnecessary diagnostic testing.
For patients, nudges can promote adherence to exercise programs or medication regimens, or visits to a physician. There are many elements of healthcare that are dependent on the patient’s behavior and though patients are highly motivated to improve their behavior, this can be hard. The key solution therefore is to design the right incentives for both patients and physicians.
One fundamental example of a nudge that is based in behavioral economics is the power of defaults. Defaults take advantage of the status quo bias — a preference for continuing the current state of affairs. Health systems can employ defaults in myriad ways to promote high- value care. For example, when electronic order-entry programs default to generic drugs instead of brand-name ones, clinicians are more likely to prescribe generics.
Another example of a nudge is lottery based rewards. State lotteries capitalize on the innate regret aversion of the human mind. Providers can use the same trick on patients in tandem with pill-bottle technology that allows medication adherence to be monitored remotely. A lottery can be held each week, with, a given dollar amount prize going to the patient whose number is drawn at random. But patients are ineligible to win if they did not take their medication. The fear of getting a message that their number was drawn but they were ineligible to win because of non-compliance is a powerful motivator.
Again, the phenomenon of loss aversion offers an avenue for changing clinicians’ behavior. Research suggests that losses have about twice the psychological impact of commensurate gains — and the fear of a monetary loss can therefore produce a greater behavioral response than the opportunity to gain the same amount of money. Massachusetts General Hospital, for example, used a strategy of up-front incentive payments in an effort to improve hand hygiene, increase electronic prescribing, and reduce emergency department use. Physicians were given incentive payments in advance of the measurement period, separately from regular paychecks.
Further, people have a strong psychological need to maintain a positive self-image. Pairing performance incentives with appeals to self-image and professional identity provides an additional lever for meeting quality and efficiency goals. Making public some component of physicians’ performance, atleast within organizations, may enhance the effect of monetary incentives.
The New York Times also says – “Health insurers are betting that behavioral economics can improve quality and lower costs. Blue Cross Blue Shield (B.C.B.S.) of Massachusetts is using a variety of behavioral economics concepts to pay its doctors — including delivering incentives at the organizational level; peer comparisons and bonus payments for continuous improvement instead of absolute thresholds. In Hawaii, Blue Cross Blue Shield is experimenting with joint incentives for doctors and patients to meet diabetes care goals” (Khullar, D.; 2017; para.17).
Start-ups like the Brooklyn based company Wellth, for example are also jumping into the nudge game by having developed an app to reward patients for taking their medications.
So then is behavioral economics better directed towards patients or toward clinicians? The evidence suggests that the answer is both. Dr. David Asch, executive director of the Penn Medicine Center for Health Care Innovation led a study that consisted of four groups, each of which was seeking to achieve LDL cholesterol reduction in patients: Physician incentives ($1,024 per patient who achieved his or her cholesterol target after 12 months), patient incentives ($1,024 for achieving the target), shared incentives ($512 each to the physician and patient for achieving the target), and a control group. The results showed that patient incentives or physician incentives alone did not produce significantly greater cholesterol reduction than the control group. But shared incentives did boost results. According to him- “It takes two to tango. It takes a physician to prescribe and a patient to take it, and in a lot of strategies to improve health care, we target one or the other. We don’t think about using them together. We’ve all been taught about the clinician-patient relationship and how important it is. Why aren’t we using this effectively?” (Hutt, N.; 2018, para. 29).
To conclude, a more complete view of human behavior seems necessary for more effective medicine. Health is fundamentally the product of myriad daily decisions made by doctors and patients, and by uncovering what truly motivates us, we may be able to nudge one another toward wiser decisions and healthier lives.
Citations
Kullar, D. (2017). How Behavioral Economics Can Produce Better Healthcare. New York Times. Retrieved from https://www.nytimes.com/2017/04/13/upshot/answer-to-better-health-care-behavioral-economics.html
Khullar, D., Chokshi, D., Kocher, R., Reddy, A., Basu, K., Conway, P., & Rajkumar, R. (2015). Behavioral Economics and Physician Compensation — Promise and Challenges. The New England Journal of Medicine, 372(24), 2281-2283.
Life Is Like That! 