by Jessica Baker 12-04-2017
Healthbox Forum events bring together healthcare leaders and innovators in a small group setting to explore important industry topics and to think creatively about how to implement actionable change. This November, we invited a group of stakeholders from across the industry to explore innovating behavioral change in healthcare. Building off this momentum, we are excited to share insights from the Healthbox Forum to spur more discussion across the innovation community.
Motivating Patients to Change their Behavior: Leveraging Behavioral Design
A large part of changing individual behavior revolves around the idea of the “nudge.” The term was popularized by recent Nobel Prize winner Dr. Richard Thaler and Harvard Law Professor Cass Sunstein as the title of their book on improving decisions about health, wealth, and happiness. In the context of healthcare, nudging is the use of behavioral economics to positively alter behavior. Nudges have been used, both intentionally and incidentally, throughout history to guide individual and group behaviors. For example:
- Fatal car accidents have been significantly reduced by introducing beeping into vehicles to encourage drivers and front-seat passengers to fasten seat belts.
- The Illinois plastic bag tax decreased the use of plastic bags at grocery stores by 40% as patrons began bringing in their own reusable bags to avoid the tax.
In healthcare, nudges exist in the form of:
- Opt-out organ donation methods, wherein countries that have organ donation as a default with the ability to opt-out, exhibit higher rates of organ donation than countries where you are asked to opt-in to donate.
- The framing of less invasive prostate cancer treatment options, reducing the overtreatment of early stage patients by introducing active surveillance as an option before radiation and surgery.
- Using traffic light symbols to encourage healthy eating, with healthier foods classified as green, less healthy as yellow, and the least healthy as red, triggering the same response as seeing a red traffic light, making individuals pause before deciding to choose an unhealthy food option.
Nudging builds on the idea that people are guided by both conscious and unconscious forces. We are rarely aware of the subconscious aspects of our mind, which guide behavior based on outside influences such as commercials, tweets, or even the actions of those around us.
A number of methods exist to help in leveraging the power of the unconscious mind to affect human behavior. These methods play on a few key principles of behavioral economics:
- People tend to look at objects and ideas differently depending on the context;
- People tend to follow the perceived majority;
- People are more likely to give to others when others give to us first;
- Most people are, by nature, loss averse and tend to avoid choices that will make them incur a loss; and
- A sense of ownership increases our perceived value of an object.
Leveraging these principles in creating nudges can greatly impact the degree to which a nudge creates a meaningful change in an individual’s life.
During the Forum, Healthbox President Neil Patel guided participants through a spirited discussion about the pain points various stakeholders in healthcare feel and the behaviors they exhibit. An important insight that came up was the fact that patients who do change are already internally motivated to do so; those who do not change, lack internal motivation and are often not impacted by traditional extrinsic motivation. Thus, it is up to policymakers, payors, providers, integrators, suppliers, and everyone on the other side of the equation to create an environment for the patient to be a partner it their own successful healthcare journey, whether that be supporting those who are motivated or encouraging those who are not.
As a caveat to the potential benefits of nudging, and with any practice that affects patients, it is important to maintain integrity and respect for the individual. Nudges, through their covert nature, often have the potential to subvert patient autonomy. They can be seen as parentalistic, with a superior entity making choices for the individual. Parentalistic behavior can lead to the “right choices”, if you’re a good parent, but even good parents don’t always know what’s best for their children.
Consider organ donation in Iran. The country has effectively ended the kidney transplant waitlist by making it legal to purchase a kidney. A positive result, but at the same time, this transaction has the potential to take advantage of vulnerable individuals who may feel that they have no choice but to sell a kidney in order to receive a much-needed monetary incentive. This example raises the questions: Can we use the same nudges equally for all individuals? What nudges are ethical for the highest number of people impacted by them?
The Importance of Patient Advocacy
Oftentimes in trying to affect change, it is easy to forget that there is an individual with thoughts, emotions, and opinions on the other side of the equation. In healthcare, we spend great deal of time thinking and talking about how to improve population health, but the most important stakeholder needed to alter patient behavior is, of course, the patient. Keeping in mind that nudging leans towards parentalism, the “nudger” should consider the following questions:
- Is the tactic we are using to change behavior honest?
- Is the intention to help the patient in the long-run?
- What does this nudge look like from the patient’s perspective?
- What stakeholders are affected by the nudge and what part do they play in the patient experience?
These questions were echoed throughout the patient advocacy panel at the Healthbox Forum event. The panel consisted of five individuals from the American Diabetes Association, all of whom live with diabetes and thus serve in both the capacity to impact behavioral change tactics and experience them. In sharing their own personal health care journeys with the audience, the panelists unanimously expressed the need for a strong clinician-patient relationship. Panelists reflected on feeling like “a guinea pig” and being disheartened spending only a few minutes with a physician who never asked them for anything more than their glucose levels and moved on, without further explanation or expression of caring. Finding a clinician that was able to partner with them on a deeper and more involved level was a life-changing event for the panelists, who were finally able to make the behavioral changes they needed to in order to live their lives to the fullest and manage an, up to that point, unmanageable condition.
Putting it All Together
Nudges, like humans, are complex. There are many considerations that go into the development and implementation of a nudge. But a nudge can only be effective if it is viewed through the proper lens and takes into account the stakeholders that can affect or will be affected by it.
As an example, consider compliance with infection control and prevention regulations. The stakeholders here are patients, clinicians, administrators, and anyone else who comes in and out of the patient-care setting, particularly those in direct contact with patients. Barriers to full compliance include personal preferences, social norms, environmental cues, lack of proper training and education, and a diffusion of responsibility among the guilty parties. Potential nudges therefore include eliminating environmental barriers by putting sinks in every room in an accessible area, positive social reinforcement for handwashing, education and marketing, tracking of sink use against room entry and exit, and the development of a culture which praises compliance with prevention regulations.
These nudges take into account the principles of human nature viewed through the lens of behavioral health and span across the various stakeholders that have the potential to affect patient outcomes in the healthcare setting. It is easier said than done, but if we can take what we’ve learned from behavioral economics, take into account patient perspectives and goals, and synthesize them together into a nudge that is ethically sound and can create lasting, meaningful change in the future, leveraging behavioral health has the potential to significantly alter the course for population health in the United States and beyond.
- As the industry further explores the use of behavioral economics, the following considerations should be made:
- What are the frictions that prevent our ability to easily choose the right solution to enact behavioral change? Is it awareness, education, access, or something else?
- How can we create patient accountability for health? Can we use tracking, feedback, and reminders or should we go with soft and gentle encouragement?
- Can we use social proofing to our advantage? Can we reestablish social norms, rewarding behaviors that collectively show that we are good humans and do things for our own wellness and the wellness of others?