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he U.S. healthcare system spends far more per capita than the healthcare systems of other industrialized nations. Yet the U.S. is notorious for having some of the worst outcomes when measuring health on a population basis. Those outcomes are, in part, a reflection of the country’s failure to address a plethora of unmet social and economic needs — unmet needs that wind up having consequences for people’s health, says Mitchell A. Kaminski, M.D., MBA, director of population health at the Jefferson College of Population Health in Philadelphia.

The out-of-whack ratio between high U.S. healthcare spending and bottom-rung health statistics hasn’t gone unnoticed. All the current attention on addressing the social determinants of health (SDOH) — food pantries, housing programs, transportation vouchers — is a response. Kaminski says the much-talked-about shift from fee-for-service to value-based payment is another adjustment that U.S. healthcare is making. The track record of value-based care is mixed, but Kaminski says the Patient Protection and Affordable Care Act accelerated the shift to it with accountable care organizations and other value-based models.

Partly because of the COVID-19 pandemic, interest in population health has surged. What follows are four trends to keep an eye on.

Telehealth, telemedicine and remote patient monitoring have transformed access to care and how care is delivered, particularly since the COVID-19 pandemic began, says Allen Miller, M.P.H., principal and CEO of COPE Health Solutions, a healthcare consulting firm in Los Angeles. These trends are here to stay as foundational components of the care model and will continue to disrupt payment models, according to Miller.

Michael Gleeson, chief innovation and strategy officer at Arcadia, a healthcare data and software company in Burlington, Massachusetts, expects telehealth to continue to positively impact healthcare outcomes as it accelerates the shift toward value-based care. This will happen in three stages, he says. First, a combination of technologies and remote monitoring will be used to reduce hospital stays. This will make inpatient hospital stays more effective and improve care coordination between inpatients, outpatients and primary care providers. It will also make patients happier and decrease the cost of care through reduced length of stays, in Gleeson’s view. Second, telehealth visits will catch on, although Gleeson says their popularity will hinge on long-term reimbursement changes, increased levels of patient acceptance and widespread access to technology and internet bandwidth. Gleeson notes that telehealth visits offer a opportunity to engage patients for whom transportation, limited time off or mobility may impede access to care. Finally, wearable technology will be used for health monitoring. That will require equipment, but Gleeson says wearables will also require a change in workflows if physicians and other healthcare professionals are to make use of data they produce and for appropriate interventions to be triggered — all while addressing concerns from patients about privacy, surveillance and data use.

As the use of telehealth has grown, so has concern about its overuse. But as larger contracts and more forces in the healthcare system move to value-based models, concerns about overuse are minimized, says Doron Schneider, M.D., FACP, vice president of population health services at Tandigm Health, a value-based population health company in suburban Philadelphia. Schneider says the incentive structure of value-based care has the effect of curtailing overuse.

It has become a somewhat tired truism of the COVID-19 pandemic that it has laid bare U.S. healthcare disparities. The pandemic has disproportionately affected Black Americans, and Whites have been disproportionately vaccinated so far. Healthcare providers understand the need to identify social factors that threaten health and wellness and to partner with community agencies to help get patients’ needs met, observes Kaminski.

Lesley Curtis, Ph.D., chair of the Department of Population Health Sciences at Duke University School of Medicine says that helping people emerge from poverty is a current focus of SDOH initiatives. “Poverty inhibits a person’s access to affordable housing, food, employment, education and other social factors that are all inextricably linked to health,” Curtis says. “Poor health contributes to reduced income, perpetuating
income-related health disparities. If we focus on addressing poverty through policy and practices that supplement income, (build) educational opportunities, (increase) access to housing and more, there is good evidence that we’ll see big improvements in population health.”

For payers and providers working to create value-based care models and align financial incentives, the highest value is achieved when SDOH data and initiatives are integrated with medical care and premium dollar budgeting, says Miller of COPE Health Solutions.

The deaths of George Floyd and Breonna Taylor last year led to protests, some rioting and a great deal of discussion about racial disparities and inequities in the U. S. Although racist-driven healthcare disparities have been known in public health and population health for years, Kaminski has recently seen a greater appreciation of how healthcare systems promote inequity through implicit bias and structural racism.

No one is expecting such problems to be remedied overnight, but Kaminski says some changes have occurred. For example, billing codes have been created to capture SDOH issues such as hunger, homelessness and transportation barriers, and in some cases, those SDOH issues are more prevalent among Black and other discriminated groups. Some payers are beginning to provide additional support for those patients. This makes financial sense because by addressing these basic needs, patients can be healthier. In the long run, healthcare costs are reduced when prevention can decrease the amount and severity of chronic diseases in a population, Kaminski says.

Miller believes that one key aspect to closing racial and ethnic disparities and inequities is to ensure that providers for diverse populations reflect the linguistic, cultural and racial profile of the communities they serve. He says this requires education and support to help them achieve professional goals, such as experiential education, mentoring, professional development support and access to entry-level jobs in the field that provide both financial support and experience to support career aspirations.

The pandemic has also underscored the importance of healthcare and science messages, particularly because whatever messages healthcare officials care to emphasize may be in information combat with conspiracy theories and other misinformation circulating through social media. “During the pandemic, we have seen how misinformation, sometimes promoted for political purposes and capitalizing on public fears, travels at the speed of light and confuses the public,” Kaminski says.

As a result, masks and vaccines have become controversial. Media and social media habits can plant and propagate beliefs that are difficult to disabuse people of. Because of the overwhelming amount of information promoted in media and on social platforms, population health messages need to be conveyed quickly and effectively through the same channels, Kaminski says.

5. Population health itself is having a moment

Knowing where population health trends are headed, most of Miller’s customers are focused on ensuring that they are equipped to manage population health with value-based payment arrangements. This includes potential downside risks and capitation, particularly as CMS’ Direct Contracting Model begins the delayed 2021 performance year. Some industry observers see that program as being a bona fide break from fee-for-service payments.

With value-based payment arrangements becoming more common and the growth in Medicaid managed care and Medicare Advantage, population health has become a business — and a competitive one at that. “Private equity and venture capital money is flowing into the population health space while acquisitions of various key components of population health functionality and networks continue at a rapid pace,” Miller says. Meanwhile, a number of firms called verticals have emerged, focusing narrowly on a particular disease or condition, such as diabetes or high blood pressure, to bring a set of tools to a defined population, Schneider says. Using tools that monitor patients over time, these verticals can help ensure treatment adherence and encourage positive patient progress against a disease.

Academic institutions are also getting on board as awareness in population health grows. “We’re seeing more interest in our masters and Ph.D. programs because students are seeking more rigorous data analytic skills than what a traditional school of public health might offer,” Curtis says. “Employers are looking for students with deep research analytics experience. More students are seeking out academic programs that work directly with health systems like Duke to get real-world experience. I anticipate the COVID-19 pandemic will have lasting effects in so many ways, including a new global focus on population health science.”

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania. 

Articles

Some of the usual suspects are on the list. And population health itself is trending as a competitive business and an area of study.

5 Population Health Trends to Watch

COVID-19 wreaked havoc last year and seems destined to trample through 2021, causing illness, death and healthcare disruption. But cancer experts and clinicians fear a subtler, slow-motion effect of the pandemic: more cancer-related illness and death for years to come as a consequence of people not being screened and treatment being delayed.

Some of those missed screenings and diagnostic tests may have been unnecessary, even harmful. American healthcare — including cancer care — has plenty of low-value care. And it’s too soon for evidence of increased illness and death (and expense) from deferred screenings and care to emerge. However, there is enough experience with the pandemic for researchers to start combing through data that show how much cancer screening and care decreased in 2020.

is a prime example. A research team led by Debra Patt, M.D., Ph.D., MBA, FASCO, had access to data that included about 6.2 million Medicare fee-for-service claims. They sifted through the data to identify billing patterns for cancer screening services, evaluation and management, biopsies, certain cancer-related surgeries (mastectomy, colectomy, prostatectomy) and chemotherapy. They examined data from the first five months of the pandemic, March through July, and compared the claims with the same months in 2019.

Predictably, the sharpest drop-off in every cancer-related service, as reflected in claims, was in April. Patt and her co-investigators found an 85% decrease in mammography claims in April 2020 compared with April 2019. By July, the difference had decreased to 9%. Other services also bounced back a bit, but not all of them, and their results show that many categories of cancer care stayed well below 2019 levels from March through July. For example, claims for administration of chemotherapy drugs were approximately one-third lower in July 2020 than in July 2019. Overall, the study results paint a picture of a widespread, pandemic-related retreat from normal cancer screening and treatment.

Still, many cancer centers and oncologists responded to the pandemic by finding ways to maintain their level of service, especially when it came to treatment. At Virginia Commonwealth University (VCU) Massey Cancer Center in Richmond, cancer care was deemed an essential service. “We knew we needed to do everything possible to continue providing care,” says Khalid Matin, M.D., FACP, associate medical director of the Cancer Service Line at VCU Massey Cancer Center and interim chair of the Division of Hematology, Oncology and Palliative Care. “But, (as with) all other healthcare providers, we had to make a lot of decisions early in the pandemic about how to best provide care that kept patients and staff as safe as possible,”
Matin adds.

VCU Health delayed elective procedures in March, April and May. “While this did not include cancer care, it did include some preventive screenings such as colonoscopies and routine mammograms,” Matin says. “The services reopened as we gained experience providing care during the pandemic and established appropriate safety protocols.” VCU Massey Cancer Center continued clinical trials in which patients were in active treatment. The opening of new clinical trials and nontreatment trials paused, says Matin, but enrollment resumed in the spring “when we became more comfortable with safety procedures.”

Direct evidence of the consequences of reduced screenings and deferred care may not be apparent for some time, but there are projections and a track record of research to use for comparison.

The National Cancer Institute (NCI) predicts there will be as many as 10,000 additional deaths during the next 10 years related to the delayed diagnosis of breast and colorectal cancers. “Although we do not have data to show a direct correlation to screening delays, we experienced an influx of (patients with newly diagnosed breast cancer) in the summer after providers began offering mammography services,” says Kandace McGuire, M.D., chief, section of breast surgery, at VCU’s Massey Cancer Center.

There is plentiful research showing that delays in cancer care can lead to additional illness and a greater likelihood of death. For example, evidence shows an association between a longer time-to-treatment period — the interval between diagnosis and the start of treatment — and mortality risk. 

 added to the evidence. Using pre-pandemic data for patients with breast, prostate, non-small cell lung and colon cancers, the researchers found the effect of treatment delay especially pronounced for patients with colon cancer. In a review study published in 

 in November that combined data from 34 studies with 1.3 million patients, researchers found that that each four-week delay in surgical treatment for seven different cancers resulted in a higher mortality risk.

The more aggressive or fast-growing the cancer, the more dangerous the delays. Variability can occur among cancers that occur at the same site. “Slow-growing breast cancers may not change much within a year, but faster-growing breast cancers could have a more advanced stage and more limited prognosis with a year’s delay in diagnosis,” Patt notes.

The University of Michigan researchers developed the OncCovid model to weigh the risks and benefits of delayed treatment in a systematic way. They also folded in the risk of COVID-19 infection in healthcare settings. Their results, published in

 in December, showed the web-based tool may be useful in making judgments regarding cancer care delays based on the patient’s cancer and COVID-19 risk.

The NCI COVID-19 in Cancer Patients Study (NCCAPS) investigates how COVID-19 and cancer interact. Researchers are collecting blood samples, medical information and medical images from 2,000 people with cancer who also have COVID-19. They will be followed for up to two years. Researchers at Baylor College of Medicine in Houston are recruiting patients for NCCAPS. 

“I think this study is incredibly important to obtain data on these two major current causes of mortality,” says Claire Hoppenot, M.D., assistant professor of gynecologic oncology at Baylor’s Dan L Duncan Comprehensive Cancer Center. Some study results have shown that patients with cancer are more likely to have poor COVID-19 outcomes. The cancer center at Baylor is prioritizing vaccination of patients with cancer who are receiving treatment, Hoppenot says.

The pandemic has affected cancer care beyond medical treatments. Cancer centers and clinicians now work to situate patients in a supportive web of nonmedical services — a web that has been frayed by the pandemic. Although canceling in-person support groups and restricting visitors helps reduce the spread of COVID-19, these measures can also have serious negative impacts for patients with cancer, says Elizabeth Koelker, M.H.A., FACHE, a director of The BDO Center for Healthcare Excellence & Innovation, a healthcare consultancy in Beavercreek, Ohio. 

It is well documented and understood that the best practice in cancer care delivery is a treatment approach that addresses the mind, body and spirit of patients with cancer. Support groups address the loneliness and isolation associated with a cancer diagnosis, and exercise rehabilitation programs have scientifically proven positive effects on long-term survival. Although many efforts to resume screening and standardized treatment such as chemotherapy, radiation, and surgery have occurred, other treatments remain indefinitely suspended. “The negative impact to the overall well-being of (patients with cancer) is immeasurable,” Koelker says.

Although many healthcare systems are starting to loosen their visitor policies, cancer programs are mostly sticking to the no-visitor policy. “This can be a profound source of stress to patients who find comfort and strength in the presence of a trusted loved one during treatment,” Koelker says. “While it’s too soon to measure, many providers anticipate an overall decrease in (adherence) from patients missing their treatment appointments because their support person can’t be present.”

Some centers allow an exception to the no-visitor policy by permitting one visitor for initial consults, which tend to be overwhelming and full of crucial information. Overall, integrative services such as massage therapy, acupuncture, art and music therapy, and even exercise rehabilitation remain suspended at most comprehensive cancer programs, according to Koelker.

“As institutions move forward, they need to understand the importance of caring for the mind and spirit,” Koelker says. “Providers must enable patients to seek support in a virtual environment, such as virtual support groups, which can help patients feel more connected.”

Providers needn’t stand idly by as people delay cancer care, Patt notes. She suggests three steps that providers can take:

Inform the public that it’s safe to get cancer screening and medical care more broadly. They should announce when they have implemented CDC protocols that make services safe to deliver care.

Stress the importance of cancer screening for reducing cancer-related morbidity and mortality.

Lower or remove barriers, such as lack of transportation, to getting care.

Baylor College of Medicine is devising individualized cancer treatments for patients with early-stage cancers, such as early low-grade endometrial cancer or atypical hyperplasia, which can be treated effectively with hormonal therapy if surgery is delayed, Hoppenot says.

In hospitals where operating rooms aren’t in use, patients who can’t be moved to another hospital but have known metastatic ovarian cancer are being treated with chemotherapy, with a plan for surgery when operating rooms open again. “This is not an uncommon treatment plan for patients, even outside of COVID-19,” Hoppenot says. “Where we have to prioritize, algorithms include surgical risk algorithms (potential need for inpatient or ICU care), potential for cure of the cancer with surgery and symptom control, as well as those with alternative (hormonal or chemotherapy) options until they can have a surgery date.”

Approximately 40% of VCU Massey Cancer Center’s appointments are now virtual. Staff are working to keep patients out of medical facilities whenever possible but still allows visits for treatments, laboratory tests, scans and other things that can only be done in person, McGuire says.

VCU Massey Cancer Center also has implemented a robust testing system; all patients are tested for COVID-19 prior to treatment. Patients scheduled for surgery are tested 48 hours prior to their operation. If the patient tests positive, the procedure is delayed when possible. In rare cases where surgery cannot be rescheduled, special operating rooms are assigned for patients who tested positive for COVID-19. 

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.

Screening and some care have been canceled or deferred. Will more illness and deaths result?

The Pandemic Pause: When Cancer Care Was Put on Hold

Where people work, live and play can greatly affect their health and the quality of healthcare they receive. Research already has shown that these social determinants of health (SDOH) are potent. Now researchers are digging deeper and learning how SDOH affect diseases, including risk for certain cancers and their outcomes after treatment, says Katherine Reeder-Hayes, M.D., M.B.A., M.S., chair of the American Society of Clinical Oncology’s Health Equity Committee. The considerable differences between poor and wealthier patients, as well as between Black and White patients, can often be traced to SDOH, says Reeder-Hayes, who is also an associate professor and chief of breast oncology at the University of North Carolina-Chapel Hill School of Medicine.

Here’s a closer look at how SDOH affect cancer rates in certain populations, how these disparities influence cost and payment of cancer care, and how new payment models are better addressing SDOH.

According to American Cancer Society research, Black males have the highest cancer incidence (549 per 100,000) and death (240) rates of any group identified by race and ethnicity and by gender. Black females have higher cancer death rates than non-Hispanic white females despite a lower incidence rate.

Comorbidities such as diabetes, chronic obstructive pulmonary disease, hypertension, obesity and heart disease affect cancer treatment options and outcomes. Black patients have higher rates of comorbidities, some of which can be attributed to SDOH. Obesity, for example, is more common among Black women and is a risk factor for endometrial cancer. Obesity is linked to SDOH such as food affordability and access to healthy food options or safe spaces for physical activity in patients’ neighborhoods, notes Reeder-Hayes.

Some of the largest racial disparities occur in breast, prostate and colorectal cancers. “It’s notable that all of these cancers are screen-
detected, and that social determinants at the health system level and individual level — such as access to insurance, proximity to a screening facility, availability of time off work or transportation — can all affect how likely someone is to get screened and therefore how early their cancer is caught and their chance of being cured,” says Reeder-Hayes. But incidence and mortality patterns differ among cancers. For instance, the risk of prostate cancer for Black men is much higher than for White men, whereas breast cancer incidence among Black women and White women is roughly the same. However, the mortality rate for both cancers is higher for Black patients, which appears related to differences in access to treatment, Reeder-Hayes says.

Insurance coverage is another variable in access to cancer treatment. A 2017 study found that only 41% of plans sold on the ACA exchanges had networks that included one of the 71 cancer centers designated by the National Cancer Institute.

“A patient’s choice to go to a top-tier cancer center was essentially cut off because they had insurance through the Affordable Care Act, which, in turn, disproportionately insures minority and lower-income patients and the working poor,” says Reeder-Hayes. “This is an example of social determinants working through the structure of the health system to shunt certain patient groups toward or away from certain types of care — often away from higher quality care.”

Keely Macmillan, M.S., senior vice president for policy and solutions management at Archway Health in Boston and a member of the 

® editorial advisory board, says oncology payment systems haven’t done enough to incentivize care that would address health inequities. “This is partly a reflection of outdated fraud and abuse laws that are prohibitive to innovative ways to address SDOH,” she says. For example, healthcare providers might run afoul of the federal Anti-Kickback Statute if they were to offer transportation or housing assistance, because the statute prohibits offering anything of value in order to get business.

Some good news is that new payment and delivery models are being designed to improve the effectiveness and efficiency of specialty care, including cancer care. CMS’ Center for Medicare and Medicaid Innovation (CMMI) developed the Oncology Care Model (OCM), which aims to incentivize higher quality and more highly coordinated oncology care at the same or lower cost. Under this model, physician practices have entered into episodic payment arrangements that include financial and performance accountability for the total cost of care for patients undergoing chemotherapy.

CMS is also partnering with commercial payers under the model. Practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination, navigation and national treatment guidelines for care. As of the beginning of last year, 138 practices and 10 commercial payers were participating in OCM.

Some features of OCM could potentially address health equity issues, says Macmillan. Program requirements include a documented care plan for each patient containing the 13 components of the Institute of Medicine’s Care Management Plan, including estimated out-of-pocket costs and a plan to address psychosocial needs. Providers who participate in the model receive real-time monthly enhanced oncology services payments — above and beyond fee-for-service payments — to effectively aid in managing and coordinating patient care. Practices can use this additional funding to hire social workers, patient navigators, community health workers and other staff to support patient care plans.

Other features of the OCM’s pricing methodology that might start to address health inequities include an upward price adjustment for patients who are eligible for Medicaid or who qualify for a low-income subsidy. The adjustment reflects higher costs that come with social risk factors, Macmillan says. In addition, an OCM risk adjustment is scheduled to go into effect February 2021 based on whether the patient has metastatic cancer at diagnosis, according to Macmillan. Because Black patients are more likely to receive a diagnosis of metastatic cancer, the risk adjustment might translate into higher-quality care for Black patients with cancer.

OCM also ties part of the payment to providers to the number of comorbidities a patient has, which acknowledges that care for patients with cancer who have comorbidities may be more complex and expensive, Macmillan says. Because many comorbidities can be traced to SDOH, the additional payment is an indirect way of addressing SDOH in the context of oncology payment.

Incorporating a greater focus on SDOH through value-based payment models that are designed to reward quality of care over quantity could help close the widening disparity gap, says Melanie Teske, senior director of provider payment and network innovation at Blue Cross and Blue Shield of Minnesota. The Minnesota insurer is putting a strong focus on shifting to value-based payment models that enable reimbursement based on health outcomes instead of just the number of billable services provided. As a result, providers are rewarded for addressing SDOH issues outside of services paid for under traditional fee-for-service payment, Teske says.

“Value-based payments incentivize healthcare providers to develop and implement care delivery plans that address health inequities and close gaps in care related to SDOH,” says Teske, who says the Minnesota Blues plan is in the early stages of implementing SDOH programs through these agreements. Teske said the insurer created a pilot program with one local care system in 2020 aimed at measuring the impact of SDOH screenings and refining the payment model accordingly. The Minnesota insurer is planning to expand this and other SDOH-
focused payment models broadly in the near future.

The alternative payment models that CMMI has created include waivers to fraud and abuse laws under certain conditions. “However, it is challenging for providers to implement initiatives to address SDOH when the waiver only applies to a subset of their patient population and when they’re unable to reliably identify attributed patients protected under the waiver,” Macmillan says. “With recent reforms to Stark law [the Physician Self-Referral Law], the Anti-Kickback Statute, and Beneficiary Inducement Civil Monetary Penalty Law, hopefully, there will be novel approaches implemented to achieve health equity.”

Other payment models go further in addressing SDOH. CMMI’s new Direct Contracting Model allows direct contracting entities to offer beneficiary engagement incentives, subject to certain limitations, including vouchers for transportation services, vouchers for nutrition and meal programs, telehealth, and other items and services to support chronic disease management, Macmillan says. CMMI has another payment model, Geographic Direct Contracting Model, that allows providers to offer additional enhancements, including subsidies for Part B premiums, Macmillan says.In the Oncology Care First model, a successor to the Oncology Care Model, CMMI announced its intent to continue paying prospective payments for enhanced services. “These capitated payments could be used to address SDOH,” Macmillan says. More information on the new model is expected in spring 2021.

The Program of All-Inclusive Care for the Elderly, a joint Medicare-Medicaid program designed to keep senior citizens living in their homes, is another payment model that can result in resources going toward mitigating harmful effects of SDOH. Participants and their caregivers meet with an interdisciplinary team that includes physicians, nurses, therapists, social workers, dietitians, personal care aides, transportation drivers and others, Macmillan says. Their needs are assessed, and an individualized care plan is developed.

Although some see the aperture of oncology payment slowly beginning to widen to consider SDOH, the focus remains on medical services. In future models, Macmillan says CMS must adopt better ways to account for the effect of SDOH on cost: “The current methodology relies on comorbidities that have been previously documented, and SDOH can inhibit access to care and reduce the likelihood that comorbidities have been previously documented.”

According to Reeder-Hayes, “The strongest predictor of a patient’s chances of beating cancer should not be his or her location, race, income or occupation. Every person deserves a fair opportunity to get high-quality cancer care that’s matched to their needs and values. With some of the most advanced healthcare technology in the world, that is possible.”

“We need to figure out how to design the health system to deliver that fair opportunity,” Reeder-Hayes continues. “If we care enough to invest in data collection about the social circumstances of patients, measure differences in the care delivered based on social factors, make adjustments based on findings, try again and remeasure, we can continue to learn how to be better.”

Along these lines, Manali I. Patel, M.D., M.P.H., M.S., assistant professor of medicine at Palo Alto Veteran Affairs Health Care System, says it will take a village to overcome barriers influenced by SDOH on cancer payments. “It’s important to consider how to ensure that SDOH are identified for patients,” she says. “In some cancer settings, navigators or community health workers have served in that role. Addressing SDOH requires a team-based approach between patients and their caregivers, oncology providers, community-based organizations, payers and policy makers to ensure that multi-level interventions are enacted.”

Karen Appold is a medical writer who lives in the Lehigh Valley region of Pennsylvania.

Adjustments to payment models are beginning to take social determinants into account. 

SDOH: How They Affect Cancer Rates, Care and Payment

Behavioral economics is the study of how individuals analyze economic choices and make decisions. It recognizes that they are not the rational, reasoned people described in classic supply-and-demand economic theory. Instead, because they are emotional and full of cognitive quirks, they do not weigh risk-and-reward issues very well.

“The goal of behavioral economics is to identify the various triggers that shift behavior and then use those triggers to create an environment that makes it easier for individuals to make healthy decisions,” says Rick Leander, CEO of LFB Holdings, a behavioral insights consulting company in Winston-
Salem, North Carolina.

Within behavioral economics, techniques and programs exist to help people make decisions that are presumably better, or at least more rational. The health insurance industry has used these tools to influence behavior in various ways.

One tool is the nudge, a slight tweak of the environment to guide decision-making. Health insurers can use nudges to get members to choose in-network care over out-of-network care by decreasing coverage of the latter. “While the insured party can still choose an out-of-network provider, the higher price orients them toward an in-
network provider,” says Preet Anand, co-founder and president of Snug, an app-based daily check-in service for seniors living alone.

Another tool, hyperbolic discounting, offers something for a limited time after which the offer is gone, says Lisa Freeman Foote, M.A., director of health engagement design at HMS, a healthcare technology company based in Irving, Texas. Freeman Foote says an insurer might, for example, tell members with diabetes, “ ‘We have a limited number of free kits to send to members today to help them manage their blood sugar. Would you like one, before they are no longer available?’ The key is to create a sense of urgency.”

Another tool in behavioral economics plays on people’s perceptions of time. Often that means strategically timed emails and text messages to help jog the memory. “For many people, time passes quickly without them realizing it,” Freeman Foote says. “This causes them to sometimes forget that they need to do something because they feel like they just did it.” For example, a woman might forget that it has been two years since her last mammogram.

One of the most noted success stories in behavioral economics concerns organ donations. There is a dearth of critical organs for transplant, both domestically and internationally, says Thomas Rice, Ph.D., a professor at the UCLA Fielding School of Public Health in Los Angeles. States and countries have set “organ donor” as the default on driver’s licenses as a way of increasing donors.

Researchers have found that people rarely choose the cheapest health insurance plan, even when the benefits of alternative plans are identical. When plan benefits are not identical, people often do not comprehend the differences because of cognitive overload. “There are ways to cut down on information overload, including reducing the number of choices available to a manageable number by removing uncompetitive or unpopular plans, removing extraneous information from comparison tables … and using star ratings rather than exact dollar figures to catch the eye,”
Rice says.

But researchers have discovered that the success of interventions predicated on behavioral economics is sensitive to context — meaning what worked in one environment may not work in another, even if the new environment appears identical. “Every intervention should be viewed as a way to learn, to get smarter and to test assumptions that earlier interventions may have supported,” says Leander. “Most behavioral economists consider every one of their interventions an experiment.”

“I am a huge fan of Paul Saffo’s concept of strong opinions weakly held,” Leander continued. “We know that every opinion is based on incomplete information, and that a smart way to think about that reality is to be willing to formulate an opinion based on early and incomplete information and then systematically look for insights that would tear that opinion apart.”

hints at the limitations of behavioral economics. Neither reminders from electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. But Anand does not see the study as evidence that behavioral economic interventions don’t work, because there was already a high level of adherence. “There was very little to improve upon, especially because there were only 150 people in the study,” he says. “In general, medication adherence is thought to be around 50%. (Those are) the conditions and control I would test this against.”

Freeman Foote notes that the goals of the two different messages being sent to the pill bottle group were to provide encouraging nudges to either celebrate the “victory” of taking the pill yesterday or to urge people to take it today, she says. “There is room to improve the messaging by providing stronger language,” says Freeman Foote. “If they tested different messaging, they may have seen that by addressing the severity of not taking the medication exactly as it should be taken. There may have been shifts in adherence or blood pressure levels.”

The COVID-19 pandemic has led to an unexpected increase in the use of telehealth. Freeman Foote says behavioral economics could provide some useful insights into telehealth usage and those who are reluctant to use it: “If we could ascertain more about people’s motivations or lack thereof by addressing barriers, then smart communications and content could be developed using behavioral techniques to continue growing adoption.”

When reflecting upon the successes and failures of behavioral economics used in healthcare, Freeman Foote says she has learned the pitfalls of generalizations. “It’s important to develop tailored and specific communications to meet individuals where they are in their current healthcare journey and plan for that unpredictability,” she says. “There will never be a one-size-fits-all solution, because all people act differently. When taking a more personalized approach, the odds of driving positive behavioral change are greatly increased.”

Leander has learned that shifting behaviors is difficult. “People are wired for instant gratification, yet in healthcare we often ask people to shift behaviors now for benefits that will not show up for years or decades, such as ‘don’t drink sugary sodas to avoid getting diabetes in 20 years.’ We need to find ways to provide shorter-term benefits for these kinds of behavioral shifts.”

Rice has realized that it is difficult to predict how effective a new behavioral economic strategy will be because there is no underlying theoretical model that helps gauge the impact of specific interventions. “One thing that’s great about behavioral economics is that interventions are often very cheap compared to traditional economic incentives,” he says. A study in Africa, for example, found that if a person with HIV has a good chance of winning a very small prize in a lottery, they are more likely to take antiretroviral medications.

The bottom line is that many principles of behavioral economics can be applied to healthcare. “Some work better than others, but all of them have their place and purpose and should be applied and tested appropriately in the industry,” Freeman Foote says.

Insight into people’s irrational choices can improve healthcare.

Karen Appold

Articles

5 Population Health Trends to Watch

The Pandemic Pause: When Cancer Care Was Put on Hold

SDOH: How They Affect Cancer Rates, Care and Payment

Using Behavioral Economics to Influence Healthcare Decisions