Patient engagement's obstacle: human nature

Is patient engagement over-hyped?

The chief scientist for pharmacy benefits manager Express Scripts won't go that far, but years of experience from a career studying what makes patients tick makes Bob Nease at least consider the possibility.

“It's taken us decades to get fat,” Nease told an audience of healthcare industry leaders in Chicago on Wednesday for the 9th annual Health and Life Sciences Executive Forum hosted by Microsoft. “We're not going to get skinny for a while. We should not pretend that the issue is that people just aren't trying hard enough. I am a little more skeptical that patient engagement is some sort of magic wand.”

Patient engagement was the theme of the two-day conference.

A big problem, Nease said, is our focus—or the lack thereof—a recurrent human trait, hard-wired into us through evolution. Nease, with an undergraduate degree in electrical engineering, holds a doctorate from Stanford University in decision analysis.

“Your brains are absolutely miraculous,” Nease said. “They process 10 megabits per second,” about the same speed as the first Ethernet cable. Yet most of that activity is subliminal, such as operations of the limbic system, one of the oldest, most primitive parts of the brain.

The limbic system “tells you what feels good or bad,” Nease said, but it is concerned only with what happens now. Its cost-benefit calculations consider only the present, in contrast to those of the prefrontal cortex, where cost-benefit factors are calculated regardless of time.

“The part that you're aware of, your conscious mind, that part of your brain runs at 50 bits (a second),” Nease said. “Human attention is incredibly scarce. There may be more helium in the room than attention.”

As a result, humans focus on those subjects that command attention, either something interesting or essential, he said. What's not dealt with immediately fades from awareness.

“Anything that doesn't happen now gets discounted 50%,” Nease said. “It's like a perpetual motion machine of procrastination. This is what we're all fighting. People are wired for inattention and inertia.”

That said, groups of people—communities, even nations—can be moved to behavioral change. Seat belt usage is one example. Smoking cessation is another, brushing teeth, a third.

Each was achieved with a combination of factors, legal coercion as well as rational self-interests in the first two examples, the eventual development of pleasant-tasting tooth paste and self-interest in the third, according to Nease.

In years of work at behavior modification, from increasing health plan members' participation in mail order prescription drug programs, to driving increased use of lower-cost generics, Nease said he's developed a series of what he called “proven strategies for activating good intentions.”

One way is to design patient-engagement programs so that the desired behavior leverages the human propensity to procrastinate by making them opt out—that is, the default position is patients are participating in the program unless they take some affirmative action to leave. By placing pharmacy benefits plan members in an opt-out program for mail order pharmacy for maintenance drugs, 88% of patients stayed with mail order, Nease said. Another opt-out program, requiring members to take the low-cost generics first, had 93% to 97% compliance rates, he said.

Sweeteners help, too, he said. At his home, Nease said, the only television in the house is positioned in front of a tread mill, where the pleasure of TV entertainment can mitigate the discomfort of exercise.

Patient engagement program planners, take heed, Nease said.

“I do believe in my bones we're facing some very powerful parts of human nature,” Nease said. “The engagement is going to happen with their 50 bits, and that's pretty rare. If it isn't fun and can't be done in the here and now, I think we're going to find it difficult,” he said.