Researchers seek to tap economics, psychology to promote health

In Florida, one wellness program that offered smokers a financial incentive to get help to quit drew just two participants in five years. And in Pennsylvania, patients in a cash lottery were eligible for prizes when they took medication as scheduled. Patients reported a sharp drop—to a mean of 2.3% from 22%—of days when they failed to correctly take their pills.

Incentives are an increasingly popular option for policymakers, employers and others looking to exert influence over choices individuals make that can undermine health and drive up healthcare spending. But incentives, so far, have achieved limited results, raising questions about what makes an incentive effective.

Now, a growing body of research that uses economics and psychology, known as behavioral economics, is seeking to identify how emotions, perceptions and biases may derail healthy decisions and how those same irrational qualities can be deployed to help people “make better and more cost-effective choices,” four researchers from the Imperial College London wrote in the latest issue of Health Affairs.

Behavioral economics tries to take into account that even with prompting, individuals cannot always overcome unconscious, emotional and intuitive thoughts that influence choice, sometimes detrimentally, they wrote. So instead, researchers are searching for ways to make these automatic judgments “work in favor of the decisionmaker to achieve results consistent with desired goals.”

The authors listed multiple common ways that choice can be influenced by such automatic biases. The source of information matters; patients and providers will dismiss accurate information from a source they deem less credible, they wrote. Incentives may be more effective when individuals seek to avoid a loss rather than earn a reward.

The Pennsylvania lottery relied on desire to avoid the regret of a lost prize as one factor to motivate patients to take blood-thinner medication as directed, according to results published in the journal BMC Health Services Research. Patients who won the lottery were ineligible for a prize if they failed to take their medication correctly.

Perceived norms can also influence choice, authors wrote in Health Affairs. Individuals also frequently select the default setting. “Decisionmaking is predictably affected by the tendency people have to prefer that things remain the same,” they said.

Individuals can also be blind to all but the most novel and relevant information that holds our limited attention, what the authors describe as salience.

In Florida, researchers suggested that small financial awards to enroll in smoking cessation were not salient and so Medicaid enrollees did not participate. “In the end, the program's lack of effectiveness in improving behavioral outcomes may have been because it paid enrollees far less ($15) than the rewards ($500-$750) that have typically been effective in changing behavior such as smoking,” according to a study, also published in Health Affairs.

Environmental cues, known as priming, can influence choices and so can emotional reactions, the London researchers said. Commitments, or a pledge that can be tied to an incentive, may also help sway behavior. And the desire to “maintain a positive self-image” could be motivating when people are offered rankings or other public performance measures.

At Horizon Blue Cross and Blue Shield of New Jersey, officials are broadly examining behavioral economics, said Jay Driggers, director of customer insight and experience. The insurer is interested in research that suggests that the way information and incentives are conveyed matters, he said. One pilot underway will test whether rewards (vacation time) offered through a lottery will increase preventive screening.

Driggers said the New Jersey Blues is also interested in how individuals' desire to avoid loss can be a motivating tool. The insurer is testing a weight-loss incentive among its own employees that uses the desire to avoid loss among the incentives, he said.

“We know human nature is what it is,” Driggers said. “We know we should exercise regularly. We know we should not smoke, and drink in moderation only” but rational thought does not always lead to action.

The insurer is looking for “extrinsic motivators” that will sway people to healthy choices, he said.