Nudging People Into Healthy Behaviors

During the second day of the Academy of Managed Care Pharmacy 2016 Nexus meeting in National Harbor, Maryland, 2 speakers from Humana outlined how merging economics with psychology and sociology has helped them improve medication adherence and nudge their members into making healthier choices.

People don’t have unlimited time, money, or cognitive capacity, and in healthcare that can mean getting confused, Tova Levin, MBA, a strategic consultant with Humana, said.

“We try to simply people’s decisions so we can nudge them and help them into healthier behaviors,” she said.

Doing so means understanding the incentives that can help nudge people in the right direction, whether it means getting them to walk more, eating healthier, or taking their medications as prescribed.

Behavioral economics has shown that people dislike losing something more than they like gaining something and that they value the present much more heavily over the future. Levin provided the example that someone may want to lose 8 pounds in the next month, but they also want to sit on the couch and watch television while eating a bag of chips.

“How do we make your future more salient to your present?” she asked.

Monetary incentives are one way, but that’s not enough to get people to change their lives. One thing is that does work is that people like to be part of the norm. “We can either shame or encourage people to be closed to the norm by providing people information on the norm,” Levin said.

Providing that information is also good because sometimes people don’t realize where they fall in the spectrum. They might believe they are doing a good job of taking care of themselves, but then find out that they missed picking up their medication 2 out of the last 7 months.

However, she admitted that tricks to influence behavior in other industries have not always worked in healthcare. The problem is that changing behaviors in healthcare is usually very demanding.

“We’re asking people to change their whole lives,” she said.

Michael Relish, MA, a consultant with Humana, explained that the problem with incentives is that if people don’t know the reward is there, they don’t work. He used the example of medication adherence.

One example was the authority effect, in which the potency of the message depends on the source. Humana tested having the same message delivered to members through different sources. They made phone calls and sent postcards all reminding people to take their medications but there were difference sources: the patient’s primary care physician; a pharmacist; and a celebrity (actress Florence Henderson, in this case).

Humana found that there was a genuine increase in members taking their medications and the message from the pharmacists had the largest effect. The message that had the second-largest impact was one with a call that Henderson had recorded, followed by the postcard from the pharmacist. Overall, there was a 4% increase in the proportion of days covered.

Another tactic was to synchronize members’ prescription refills.

“We have members who have scores of prescriptions,” Relish said, which can come out to 120 refills or more a year. “You can imagine with that many opportunities, there are a lot of opportunities to fail.”

Overall, syncing medication refills increased adherence by 3% to 5% for all members. And the results were even better for members who had poor adherence going into the study. Synchronizing refills increased adherence in that group by 9% to 13%.

There were skeptics who worried that synchronizing so many medications might be a problem because it would mean getting hit by copays all at once. But members who participated in the study said the preferred having all the medications delivered at once and having the copays due at the same time, because it meant fewer bills to keep track of.

Finally, Humana tried making decisions automatic. Healthcare doesn’t really have the option to automatically opt people into a program, but an active choice is a good possibility. Active choice makes people answer a question with a “yes” or a “no.” In this case, Humana asked if members when they were purchasing medications online if they wanted to enroll in the auto-refill program. There was an increase by about one-third.

The point of these programs is to make behaviors that the healthcare industry wants to encourage—like filling prescriptions and taking medications as prescribed—more automatic.

“Members face decisions all of the time … where can we help them?” Relish said.