   |  | | Blending economics and psychology on behalf of health | By Mike Magee, MD
A great deal has been accomplished in health care in my life time. As a young boy, over a half a century ago, watching my father practice medicine in an office attached to our home, both he and his patients held great hope for the future. So much was unknown -- including the causes of acute and chronic diseases, from heart attacks to bleeding ulcers -- that all eyes were focused on Science as Savior.
Now as I hit 60, we’re facing an odd reversal, with the general acknowledgement that human behavior has been unable to maintain pace with scientific understanding.1,2 When it first became obvious that we as a population were not seizing the opportunities for health that were right in front of our noses -- like not smoking, staying on medication for high blood pressure to avoid stroke, and maintaining healthy weights and exercise to avoid diabetes -- economists felt more information and mild financial incentives would do the trick.3,4 When that didn't work, a sub-group of economists who had formed a new field called behavioral economics -- the marriage of conventional economics and psychology -- became more vocal.5
Behavioral economists say we are difficult to motivate not because we are bad persons or terminally obstinate, but because our brains are programmed in such a way that we are biased to make bad decisions.6 For example, we prefer to "stay put" rather than change. So our minds, presented with a change option, will over-weight the value of the "status quo," and under-weight the advantages of what is new.3,4 A second human tendency is to overweight the here and now, and under-weight the future. This impacts our interpretation of relative risks and benefits.7 For example we over-value the benefits of satisfying our appetite now, and under-value the danger of obesity later. In so doing, we inadvertently support an increased burden of certain diseases like hypertension, diabetes, cardiovascular disease and some cancers. In reverse, we often over-weight a present day inconvenience or risk -- like the discomfort of a bowel-prep for colonoscopy -- and under-weight the benefit of a future free of colon cancer.6 Such procrastination sets us up for disaster.
Finally, our human natures show distinct preferences for things measurable. We're quite conscious of the measurable minutes necessary to stop and take medications as prescribed, but far less conscious of the less measurable avoidance of future disease. Minutes necessary to stop and take statins makes a greater impression on us than the fuzzy notion of avoidance of formation of theoretical future coronary artery plaques.
Dr. George Loewenstein, and his colleagues from Carneige Mellon University’s Social and Decision Sciences Center, says that most of us "are likely to adhere to the path of least resistance, doing what is automatic, or what they have done in the past. Because of present-biased preferences and intangibility, informing patients about delayed consequences of their behavior is unlikely to have much effect because the costs of adhering to recommendations are often immediate and thus heavily weighted whereas the benefits are often remote in time and amorphous..."6
The solution? Experts say we should design the systems to play to our preference. Examples? Set up the food in the cafeteria so that items that are most nutritionally sound appear first. Or how about amending unhealthy status-quo options? For example, fast food combo-meals currently have a large soda as their opt-out option for individuals making the combo choice. It is presumed that if you order a combo meal, you will get a large soda. If you would prefer water, and speak up, it will be substituted. Well what if water was the first option, and the large soda was the substitute? This flip would positively impact consumers because the unhealthy option would have to be requested. And how about automatic rescheduling for screening exams, such as colonoscopy or mammography, advantaging the here and now, rather then relying on action in the fuzzy future?
Behavioral economists believe that "institutions and incentives should be structured and aligned in such a way to maximize the likelihood that individuals will engage in behaviors that are beneficial..."6 To me, that makes a great deal of sense.
For Health Commentary, I'm Mike Magee
References:
1. Mokdad AH et al. Actual causes of death in the United States 2000. JAMA 2004: 291 (10), 1238-1245.
2. Kripalani S et al. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch. Int. Med. 2007: 167 (6), 540-549.
3. Johnson EJ et al. Framing, probability, distortions and insurance decisions. J. Risk Uncertainty. 1993: 7, 35-53.
4. Madrian BC., Shea BF. The power of suggestion: inertia in 401(k) participation and saving behavior. Q.J. Econ: 2001: 116 (4), 1149-1187.
5. Cameer C., Loewenstein G., eds. Behavioral Economics: past, present, future. Advances in Behavioral Economics. NY, NY. Russell Sage Foundation Press, Princeton University Press.
6. Lowenstein G., Brennan T., Volpp KG. Asymmetric Paternalism to Improve Health Behaviors. NEJM, Nov. 28,2007: 298 (20) , 2415-2417.
7. O'Donoghue T., Rabin, M. Doing it now or later. Am. Econ. Rev. 1999: (89) 1, 103-124.
8. Weber BJ., Chapman BG. Playing for peanuts: Why is risk seeking more common in low stakes gambles? Organ. Behav. Hum. Decis. Process, 2005: 97, 31-46.
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