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The Importance of Behavioral Economics for Patient Engagement

by Douglas E. Hough, Ph.D.

As health care organizations enter the brave new world of value-based reimbursements, understanding how to influence human behavior is swiftly becoming a core competency.

No longer rewarded for simply treating the sick, providers will increasingly be paid to keep people healthy – and that takes more than procedures and prescriptions. That shift in care requires that patients and providers alike make good decisions that spur wellness.

Our sister blog, The Health Leadership Forum, recently sat down with Douglas Hough, Ph.D., an associate scientist at The Johns Hopkins Bloomberg School of Public Health, to discuss how insights from behavioral scientists are already being applied to health care.

HEALTH LEADERSHIP FORUM: Can you tell me a little bit about your areas of interest and research?

HOUGH: I was a standard mainstream economist and an underlying assumption of that discipline is that people are always rational. But in healthcare I found that the traditional economic models weren’t working: patients weren’t acting rationally, and physicians weren’t acting rationally. In the US for example, we’ve had enormous problems with physicians washing their hands. For 160 years physicians have known that they should wash their hands. They know it, but they still don’t do it as much as they should. Why is that? Are there ways we can change their behavior so they do both what they need to do and what they want to do? In this way patients can improve their own health and physicians can improve the health of their patients. That’s what I’m about.

HLF: If humans aren’t always rational that makes patient engagement particularly difficult, doesn’t it?

HOUGH: It’s not that patients are stupid, they just haven’t internalized the importance of following the treatment regimen as their physician has determined. The presumption is that all we have to do is educate the patient and then they’ll say “Oh, now I see why I have to take my Lipitor everyday! Sure, I’ll do it.” Well, one of the things we’ve found is that education may help, but that’s not going to be the driver. There are other things that are standing in the way of patient’s decisions, even if they have perfect information.

HLF: What are the behavioral tricks or “nudges” being used by leading care managers that you think all providers could start doing right now?

HOUGH: I’ve floated the potentially heretical notion that we ought to get patients less engaged. Or rather, we need to get them selectively engaged. People are not engaged not because they don’t want to be. They’re not engaged because they’ve got all these other things that they’re worried about: their job, their family, their marriage, trying to figure out if they can pay their mortgage that month. They will not be engaged in their health until their concern rises to the level of these other issues.

Behavioral science research has indicated that getting people to do something multiple times is difficult. There are going to be other pressures on them and the salience to them of doing those things is going to do down over time. But if you can have them do it only once – one change, one time – then they’ll do it.

The second approach is to have patients engaged when they’re doing something else. Let’s take medication: if you need a patient to take a medication in the morning, then set it up so that the only way they can get their car key is if they take their medication. Or the only way they can turn on the TV at 6pm is if they take their meds (the technology for that is getting pretty available). Get them to do something when you know they have to do something else.

HLF: What lessons have been learned about motivating providers – for example, around pay for performance and other incentives?

HOUGH: This may sound strange coming from an economist, but for the most part money doesn’t work. Money will motivate people in the short term, but not the long term. From a physician’s standpoint, in the short term they’ll say “Gosh, I’ve got 90% of my diabetic patients with their HBA1C levels exactly where they need to be, so I’m going to get an extra $5000.” Well, that’s fine. But if they get $5000 every year, the money becomes wallpaper – part of the background. So money won’t motivate them.

What motivates physicians is: autonomy, being able to do interesting work, being able to treat their patients. The most valuable resources for physicians are their minds and their time. Doing their work takes a lot of energy and thought, and if we could find ways of saving them time or enabling them to do their job more easily, that’s what’s going to motivate them.

So give physicians time. If you help them save time, they can spend it with their patients, or with their family. That’s going to be a big motivator.

HLF: How do you do that?

HOUGH: Here’s an example: here at Hopkins, we’ve implemented a new electronic health record system, and for this to work you need the clinician to input different variables. But Hopkins (as well as others) has had difficulty getting physicians to input the data. Why would a physician want to take more time inputting variables into the electronic health record, when it’s not necessarily going to improve this patient’s health, or the process of care?

So have somebody else input the record! Or find another way the number makes it in. Why are you using a physician to do that? There’s no direct benefit to them. It’s not that physicians are selfish – or lazy. It’s just that if you distract them from doing their job, then you’re going to get, well…. who knows what kind of behavior!

HLF: What are some things you’d like to see government do to harness some of the insights from behavioral sciences?

HOUGH: Make it easier for people to make decisions. In the US we have Obamacare and insurance exchanges and sometimes they’re difficult to maneuver. People give up and get frustrated. You have to find ways of creating what Cass Sunstein and Richard Thaler call a “choice architecture.” That is, set up a structure so that it’s easy for people to make the decisions they need to make.

As an example, I want to give a shout out to a beautiful, elegant article by Peter Ubel and his colleagues in the New England Journal of Medicine back in February, titled, “Healthcare.Gov 3.0: Behavioral Economics and Insurance Exchanges.” What they describe are fairly easy changes that could be made to the website for the insurance exchanges that would make it much easier for people to make decisions.

That’s what you need to do. It’s not that you need to get the patients more engaged or give them more information. You need to make it easy for them to make decisions.

Douglas E. Hough, Ph.D., is associate scientist and associate director of the master in healthcare management program in the Department of Health Policy and Management at the Bloomberg School of Public Health, Johns Hopkins University. 
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