Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
Thanksgiving is generally a rear-view mirror exercise: we reflect on the past year and focus on what we have rather than what we’ve lost. It’s an excellent exercise, proven to improve our subjective well being. It’s unnatural, and so we do it far less often than we should.
But this Thanksgiving I want you to consider looking forward as well. Please consider investing in a difficult conversation that will pay dividends for you and those you love. Here’s an important word from a one-of-a-kind healthcare innovator and passionate thought leader, Alexandra Drane.
Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace –- a movement aimed at having all of us understand and communicate our end-of-life wishes.
It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.
Our original mission – to get more and more people talking about their end of life wishes –- hasn’t changed. But it’s been quite a year, so we thought this holiday, we’d try something different.
A bit of levity.
At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.
To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:
Silly? Maybe. But it underscores how having a template like this –- just five questions in plain, simple language –- can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.
So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.
Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.
One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.
Wishing you and yours a holiday that’s fulfilling in all the right ways.
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
I met Don when he was a fellow at Stanford and I was a grad student. He is one of the most intelligent, funny, and interesting people I know.
When he was in high school, he made movies… a couple of which were shown on Saturday Night Live. As a young academic physician, he determined that memories of uncomfortable events (e.g., colonoscopy) are mostly related to peak level of discomfort and how the event ended. (This involved asking patients undergoing a colonoscopy every 30 seconds or so how they were feeling. And if there’s nothing more uncomfortable than having a colonoscopy, it’s got to be having a colonoscopy while an overeager researcher is asking you how it feels twice a minute.) The implication of that study is that you can make a colonoscopy more attractive by — get this — leaving the colonoscope just barely in place at the end (of the procedure, that is) and lengthening the procedure. He then went on to prove this to be the case with a randomized controlled trial. (Isn’t science fun?)
But Don’s work goes beyond discomfort and invasive procedures. He’s shown that winning an Academy Award increases life expectancy if you’re an actor, but shortens it if you’re a writer. He’s discovered that medical school class presidents are more successful professionally than their non-presidential peers, but that they live 2.4 years less on average. He’s cracked the code on why the other lane of traffic always appears to be moving more quickly than the one you’re in. He’s shown that presidential elections kill about two dozen people (due to driving, not arguments over dinner), but that marathons on the whole save lives (i.e., the sudden cardiac deaths caused by the event are more than offset by the reduction in traffic deaths due to roads being closed).
Importantly, Don has also studied the use of cell phones on traffic accidents. (I am a fan of my cell phone — especially when I am driving — and I have to begrudgingly admit that the study was very well done. You might reasonably decide that the benefits of using the cell phone outweigh the risks, but it’s hard to argue that those risks are nonexistent.) Interestingly, the issue seems to be one of distraction rather than mechanics. The human brain has a limited bandwidth, so the whole “hands free” thing may not solve the fundamental problem: Regardless of whether you do the dialing or it’s voice activated, our minds seem to be somewhere else when we’re engaged in a conversation.
So it was with interest that I read the same New York Times piece that Julie highlighted in the previous blog. The original article noted that a handful of companies have services that use GPS and other methods to determine when you’re in a moving car, and turn off your phone for you. (This means you can sign up for an anti-service service, I suppose.)
As I read the piece, I noted several features relating to the application of behavioral economics:
Intuition has significant limits, especially when it comes to intuition about thinking. In thinking through a solution to the cell phone problem, we conclude that the risk associated with cell phone use is one of coordination, and that a hands-free approach will solve the problem. When we think about thinking, we engage the part of our brain that’s rarely in use when we’re actually behaving. Driving and engaging in a conversation apparently draw on a common cognitive resource, and one that’s not obvious when we think about it.
Self-control is inherently challenging. During planning, the benefits (e.g., getting through a boring commute by talking to a colleague) and costs (e.g., risk of slamming into that car in front of you) are both in the future and therefore weigh equally. While driving, however, the benefits are certain and loom large.
Precommitment may help. During the planning phase, new technology (i.e., the companies cited in the article) make it possible to alter set of available options (or the payoffs associated with them) in the future. That is, you can tie yourself to the mast (metaphorically) to avoid bad behavior in the future.
Sticks (losses) are more powerful than carrots (gains). The article noted that some insurance companies are offering discounts for people who use the precommitment devices. My guess is that they would get more people to enroll in the services if they imposed a premium increase on those that didn’t sign up for the services than a discount for those who did.
P.S. Don: if you’re out there, give me a call. I’ll be in my car with my cell phone handy.
Julie Adelsberger — Senior Manager; Express Scripts — As senior manager of knowledge management, Julie Adelsberger is responsible for translating scientific research into accessible communications for plan sponsors and other healthcare stakeholders.
Of course, there is a simpler, no-cost solution to limiting phone use while driving: the off button. But going cold turkey is hard for many Americans who have become addicted to their gadgets. And so technology companies are trying to solve a problem caused by technology with more technology.
An interesting aspect of this technology is the notion of committing to blocking calls during a moment of lucidity — say, after a commute where you nearly had an accident or missed a turn due to distracted driving. You set up the service then, when the danger of dialing and driving is fresh, and it prevents you from making calls later, when the lure of talking or texting might outweigh the risk.
According to the Times, auto insurance companies are investigating this technology, with one offering customers a discount for implementing it.
A side note: The hands-free systems that are so popular among drivers? A growing number of studies show they aren’t much, if any, better than talking on a handset. They won’t get you any discounts from your auto insurer, and they might not make you any safer behind the wheel.
Julie Adelsberger — Senior Manager; Express Scripts — As senior manager of knowledge management, Julie Adelsberger is responsible for translating scientific research into accessible communications for plan sponsors and other healthcare stakeholders.
A friend and colleague provides an example of hyperbolic discounting with her search for the H1N1 vaccine. She has two children, one under 5, and so is among the group the government recommends for first-line vaccination. After taking her children to their pediatrician for the vaccine, she sought the shot out for herself, anxious about the discomfort of the flu and the complete disarray it would bring to her family and work life — that is, until she discovered that the closest clinic that will vaccinate her is miles away.
That upfront cost — a drive from our office on the campus of the University of Missouri - St. Louis to the city — is enough to deter her. The hassle of the drive (and the wait at the clinic, and the shot itself) in the now is enough that it outweighs the possibility of the flu later. Remember that we discount future events by half, so she’s not giving it the full weight of its misery.
No doubt, there’s plenty of latent demand there for the flu shot, and it’s a drive she’ll wish she’d made if she gets H1N1.
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
Tim Harford takes us on a tour of trust, which turns out to be one of the most valuable side effects of social norms. Some economists believe that trust – defined broadly – fully explains the difference between per capita income across countries. The implication is that 99.5% of our economic output is due to trust, with the remaining 0.5% due to hard work. (I don’t know where alimony fits into that equation.)
Trust operates in all sorts of ways, from saving money that would have to be spent on security to improving the functioning of the political system. But above all, trust enables people to do business with each other. Doing business is what creates wealth.
Center for Cost-Effective Consumerism board member David Laibson makes an appearance as well, describing a laboratory experiment in which trust increases based on some simple social cues (e.g., having a partner).
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
The New York Times reports on the effect of choice architecture on tips for taxi drivers:
The increase in tips, however, may have less to do with New Yorkers’ generosity than with the preset amounts suggested to passengers on the taxi’s software systems. In many of the city’s cabs, riders are offered options for their tip depending on the length of the ride. For fares under $15, a screen prompts tips of $2, $3 or $4; the numbers can range from 15 percent to 30 percent for higher fares. The presets are used about 70 percent of the time, according to industry estimates.
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
Behavioral economics tells us that people get hung up over upfront costs for downstream benefits. Exercise, weight loss, switching to Home Delivery… all these behaviors offer benefits that outweigh the costs, but only after getting through the immediate costs.
But “downstream” apparently doesn’t have to mean months or years in the future. Cutler and colleagues, for example, assert that the reduction in meal preparation time (due to better food processing and storage) has caused people to add additional meals to their days. As the cost of preparation (upfront cost) diminishes, people engage in the behavior (making a meal) to achieve the downstream benefit (yummy goodness). This occurs even though the costs and benefits are separated by minutes rather than months.
And so it is with typing in a URL, apparently. I noticed that GoDaddy.com’s renewal pricing varies by domain extension. My first reaction is that this must be due to the popularity of the extension, but closer examination suggested a negative correlation between the length of the extension.
Even though there are only eight extensions, the correlation is sizeable (68% of the price variation is explained by the length of the extension) and statistically significant (p = 0.007). Does typing one more letter into the URL box really matter? Apparently it does, at least enough for GoDaddy to charge a premium on the shorter extensions. (Perhaps they ought to promote GoDaddy.us instead of .com?)
As an editor for the Corporate Database team, Eric Ferguson is responsible for writing and editing strategic language for Express Scripts' Sales & Marketing department.
As the beef jerky wrappers in my car would indicate, I’m not a man with particularly high standards when it comes to food. Still, when my absolutely adorable nephews hit me up for their fundraiser, I couldn’t help but be disappointed that they were hocking assorted flavors of popcorn.
Of course, I couldn’t say no. Whichever evil entity lurks behind this fundraising racket (I suspect it’s the same organization that invented the Snuggie), it seems to have taken its cues from those cookie-pushing masters of behavioral economics known as the Girl Scouts.
Consider the order form: You can’t ignore the donations of others when they’re presented to you in a handy little spreadsheet. Imagine if such a system existed at Target or Best Buy – would you be more likely to spend $50 if you knew that the previous five customers had topped that amount? I know I would.
I couldn’t even use the old “I left my wallet in my other pants” routine – I could simply pay when they delivered the popcorn. With payment still way off in the future, the natural decision was to pledge a donation to the cause.
Which cause exactly? You know, I couldn’t tell you. When a couple kids ask you for a donation, you give one. As Robert Cialdini writes in Influence, “we most prefer to say yes to the requests of people we know and like,” which means that I will continue to fall prey to my nephews’ requests … at least until they hit that obnoxious teenager phase.
In the meantime, I’ll keep ordering stuff I don’t want to support causes that may or may not deserve my money. Either that, or I’ll figure out how to say “no.”
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
The pilot program reflects Express Scripts’ use of behavioral psychology to prompt patients to switch to lower-cost drugs and comply with their prescriptions by making the process convenient and delivering key information at “the right time,” said Dr. Steve Miller, Express Scripts’ chief medical officer.
What’s so special about the “right time?” One principle that continually reappears as we apply Express Scripts Consumerology to healthcare is that small upfront hassles frequently lead to procrastination. Procrastination in turn leads to pent-up, latent demand: interest in a behavior or option that lies dormant because members don’t get around to doing it.
The kiosks offer a powerful platform for tapping latent demand. By providing information “at the right time,” they offer an extremely easy mechanism for members to quickly and easily express their underlying preference as an outward behavior. In this case, the result will be the use of lower-cost, equally effective alternative medications, Home Delivery of maintenance medications, and support for improved therapy adherence.
Bob Nease, PhD — Chief Scientist; Express Scripts — is a leader in the convergence of behavioral economics and healthcare; at Express Scripts, he is responsible for advancing the understanding of consumer behavior. To this end, he closely follows emerging science around human behavior and decision making, then works to develop tools and communications that help plan sponsors enable better health and value.
When wrapping up a conversation the other day, my colleague said she had to run; she didn’t want to be late for Oil Change Lunch Day.
I was stumped. The first place my brain went was a new line of automotive-themed salad toppings: Thousand Mileage, 20W50 and vinegar, Ranch Wagon, and (dare I say it) Rushin’ dressing.
But I was off just a bit. Oil Change Lunch Day involves four or five people (I think in this case they were all women) who drive to a local oil-change shop, drop off their cars, and walk to lunch across the street. They do this on a regular basis… roughly every 3,000 miles, I suspect. The men at the oil change shop are reported to be very courteous, and give every indication that they look forward to Oil Change Lunch Day as well.
“This is genius,” I say, an assertion that my colleague affirms a bit too quickly.
Oil Change Lunch Day is a beautiful example of behavioral economics in action. It recognizes the danger of procrastination, and then whips it into submission. The left jab is the use of social norms – if you say no to the invitation of Oil Change Lunch Day, are you saying you’re too busy for the oil change, or too busy to enjoy your friends? And if that’s not enough, Oil Change Lunch Day offsets the upfront hassles of getting an oil change with the upfront fun of having lunch with friends.
But one question: How did five people all get synchronized to have the same oil change need at the same time? I didn’t ask, but my bet is that before OCL, there was a whole lot of procrastinatin’ going on… and there were plenty of people who needed that first Oil Change Lunch.
