Written by Rod Moore

Making better health decisions could come down to a well-timed nudge — a gentle encouragement or coaxing often done through text messages and other mobile notifications. Today, there are nudges for everything from making better supermarket choices to saving energy.

This subtle way of influencing human behavior and choices has emerged from the field of behavioral economics, defined as the study of psychology on the decision-making process. Ultimately, people are influenced by many factors that inhibit rational decision-making on a consistent basis, which can be particularly impactful when it comes to health. However, because humans are somewhat predictably irrational, what is promising about behavioral economics is how decision-making can be counteracted with nudges and incentives, according to “The Behavioral Economics of Health and Health Care,” an article in Annual Review of Public Health, 2013. We see the marketplace attempting to get into this area every day. From Apple Watches to FitBits, the effort of the nudge to affect human behavior in a positive way is trying desperately to cling to a foothold.

Behavioral Economics: A Brief Primer


Volpp
Behavioral economics has basically marked out ways in which people make decisions that deviate from perfect rationality,” said Kevin Volpp, M.D., Ph.D., founding director of the Center for Health Incentives and Behavioral Economics and vice chairman of health policy in the department of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania.

“When it comes to most decisions that people make about everyday health behaviors, risks ranging from what they eat to smoking, they're making decisions based on how they feel as opposed to, say, a deliberate cognitive process,” Volpp said. “They're also making decisions based on how their choices are framed for them and what people around them are doing.”

Applying incentives to improve decision making is only part of the application of behavioral economics. Other aspects include changing defaults to remove friction from a desired behavior and changing the context in which someone takes action.


OBrien
“Behavioral science is broader than just applying incentives,” said Julie O’Brien, Ph.D., principal of Better Living & Health, Center for Advanced Hindsight at Duke University.

“Sometimes an incentive may be the thing to change behavior — especially if the behavior is relatively easy and not intrinsically motivating.”

“Hospitals have an ethical obligation to improve patient outcomes, which means they continuously should be learning which strategies work best,” O’Brien said. “Hospitals also have the expertise and authority that many patients do not have — they are viewed as an expert source for health. In many cases, it may be appropriate for hospitals to test behavioral strategies aimed at improving health.”

“Behavioral science is a useful strategy for improving health behaviors because we approach these problems with the assumption that people are not acting rationally and that the context can play a large role in shaping behavior,” O’Brien said. “We look for scalable interventions that can improve health for everyone and we use experimental designs to test the effectiveness of our interventions so we know for sure what works and what doesn't.

“Health care providers, insurers, employers and consumers interested in better health outcomes have spurred technology companies and startups to enter the behavioral economics arena. Using understanding of behavioral economics, applications are being developed to positively influence patient behavior.

“I think there's recognition in some sense implicitly from these startups that the incumbents, the health care delivery systems, that are providing all the treatments today, are probably not going to be the nimble leaders in developing these new care approaches,” Volpp said.

While these innovations may not take place at a hospital or health care enterprise, they most certainly have the opportunity to incubate them or otherwise serve as the testing ground where innovations will eventually have significant impact.

Care Message, a San Francisco-based digital health company, offers an application designed to improve health literacy and self-health management, which chiefly makes use of messaging systems on mobile phones and primarily targets underserved populations.


Singal
Vineet Singal, co-founder and CEO of Care Message, said applications like his are finding some receptivity from providers because social determinants have such a significant influence. “Hospitals and providers in general I think are starting to realize that the majority of impact that they could have on somebody’s health, particularly in a value-based environment, is not in the clinic — it’s actually outside the clinic where (patients) spend 99 percent of their time,” Singal said.

This sought-after impact increasingly could come through proactive options like behavioral modification techniques and applications. Although it is still relatively early in the life cycle of behavioral economics and its related applications, the merits of using strategies to improve patient outcomes are beginning to show progress.

Behavioral Economics Applications in Action


Shah
Niki Shah, system vice president of care redesign and equitable care, and senior vice president of digital health at Baylor Scott & White Health, said after almost two years of using a messaging system, they’ve seen dramatic impacts among their underserved population.

“What we've learned from using a messaging platform is that there's power in the ability to connect with patients in the way that they want to connect with us and finding that methodology has shown that behavioral modification is possible,” Shah said. “Empowering patients with information and education at their fingertips does result in positive clinical outcomes.”

Shah said more than 30,000 patients are enrolled in one or more text messaging programs (including Baylor Scott & White employees) with an 80 percent retention rate for those who have opted in. “From a clinical outcomes perspective, we’ve seen a significant reduction in systolic blood pressure in patients enrolled in the diabetes education or hypertension program,” Shah said. “It was ‘p’ values of less than .05. We also saw an 18 percent increase in childhood immunizations from patients who received messages and reminders.”

Shah said another reason Baylor Scott & White chose to use a messaging platform is the ability to deliver messages in patients’ primary language, usually Spanish, to help serve their Hispanic patient community. “We’ve had a lot of positive feedback,” Shah said.

Health care innovations in behavior management are not limited to consumer-facing solutions. The Texas Hospital Association, in partnership with Illumicare, launched the THA SmartRibbon in late 2015 with the intention of presenting high-quality, highly relevant patient data at the point of care to engage physicians and help them make better care decisions. By scraping content and data from the electronic medical record, a ribbon of relevant patient data appears at the top of the patient's record. The physician can immediately determine the frequency of the specific patient’s radiation exposure before ordering a MRI, for example, reducing patient harm while also reducing excessive costs. The ribbon also features key data on alternatives on prescription drugs in order to select lower-cost options for patients. “These kinds of tools were incubated with our team’s engagement and tested in our member hospital facilities with the idea that we could more adequate affect physician decision-making by making key patient information more readily available” said Ted Shaw, THA president/ CEO. “Texas hospitals using the tool are already seeing major benefits.”

Given the potential impact applications could have on behavior and outcomes, the outlook for investments and more potential partnerships with hospitals and health systems looks promising. However, Volpp said while there isn’t sufficient evidence yet that behavioral economics approaches are effective, there are still many things done in medicine for which there is yet to be very good evidence.

“I think where behavioral economics has a lot to contribute is around trying to develop strategies that help keep people healthy and also recognize the very significant role of health behavior in influencing people,” Volpp said.

As behavioral economics continues to grow and more startups build applications to address human behavior, perhaps it won’t be long before there is a nudge for virtually all of our daily decisions.

“When it comes to most decisions that people make about everyday health behaviors, risks ranging from what they eat to smoking, they're making decisions based on how they feel as opposed to, say, a deliberate cognitive process,” Volpp said. “They're also making decisions based on how their choices are framed for them and what people around them are doing.”

KEVIN VOLPP, M.D., PH.D., FOUNDING DIRECTOR OF THE CENTER FOR HEALTH INCENTIVES & BEHAVIORAL ECONOMICS HEALTH ECONOMICS AND VICE CHAIRMAN OF HEALTH POLICY IN THE DEPARTMENT OF MEDICAL ETHICS AND HEALTH POLICY AT THE PERELMAN SCHOOL OF MEDICINE AT THE UNIVERSITY OF PENNSYLVANIA