Is Patient Engagement Overshooting the Target?

Feb 14, 2013
Since we're wired for inattention and inertia, choice architecture may be more effective than patient engagement in improving patient decisions and health.

Earlier this week, the health policy journal Health Affairs released its February issue, which focused on the topic of patient engagement. Not surprisingly, most of the contributing papers focused on the improved health of more engaged patients, innovative ways to increase engagement and methods to analyze engagement. Embedded in all of this research is the underlying premise that achieving patient engagement is a necessary goal for the healthcare industry.

And I’m not sure I agree with that premise. The ultimate goal should be better health outcomes and lower costs. Patient engagement is one possible means to that end ... and it may not be the most realistic or effective one.

Included in the issue was a paper I co-wrote with my Express Scripts colleagues Steve Miller, Larry Zarin and Sharon Frazee. In the paper,"Choice Architecture Is A Better Strategy Than Engaging Patients To Spur Behavior Change," we offered a contrarian perspective on the topic.

Why Patient Engagement Perhaps Should Not Be the Healthcare Industry’s Aim

While patient engagement is seen as a potentially effective way to improve quality and lower costs in healthcare, a more tempered assessment of patient engagement may be warranted for two primary reasons:

  • Evidence of the effectiveness of interventions to increase patient engagement on health outcomes is not definitive; and
  • Ongoing and sustained patient engagement conflicts with cognitive limitations that are the hallmark of basic human nature.

An Alternative Strategy: Choice Architecture

We have shown time and time again that human attention is both scarce and fragile. This is the gist of the "fifty bits" view of behavior: most of our behaviors are automatic and under the radar, rather than deliberate and overt. The result is a tremendous amount of inattention and inertia.

If people are wired for inattention and inertia – making ongoing patient engagement difficult to achieve – what can be done to improve health decisions over a sustained period of time? Fortunately, a number of strategies from the behavioral sciences have been proven to activate patients’ good intentions. These approaches include opt outs, active choice and precommitment, three choice architecture techniques that encourage better behavior by altering the decision environment.

"Opt out" puts all patients on the path to better behaviors, but allows those individuals who don't want to participate to disenroll – or opt out. This approach is widely used in employer-sponsored personal retirement savings plans, i.e., 401(k) programs, to great effect. We tested opt out in the setting of our most aggressive step therapy programs and were happily surprised. The fraction of patients who opted out of these programs was quite low, ranging from about 2% to 7%.

"Active choice" demands a patient's attention by requiring a person to make a decision. In one of the studies we highlighted in the paper, Express Scripts used active choice when we asked patients currently receiving maintenance medications from retail pharmacies to actively choose between retail pharmacy or home delivery pharmacy, the latter of which offers superior safety, adherence, convenience and safety. Patients were free to choose whichever option they wanted – without penalty – but they had to make an explicit choice. Through this active choice, 39.6% of the patients within the study decided to switch to home delivery.

"Precommitment" is a twist on active choice, in which patients are asked to make a decision in the present about future opportunities. Precommitment is especially powerful because people tend to earnestly plan for better behavior in the future. We investigated the use of precommitment by providing home delivery patients the option to consent ahead of time to switching to lower-cost alternative medications if their physicians approved the changes. Of the 340,683 patients offered the option, 52.8% precommitted to such switches, saving them and their plan sponsors a significant amount of money.

Patient engagement is undoubtedly admirable, but because of the way we're wired, it might not be the most effective way to spur positive patient behavior. Instead, tools like choice architecture account for the very real human tendencies toward inattention and procrastination. Through the use of these methods, we have clearly demonstrated that we can achieve healthier outcomes and more affordable healthcare … even among disengaged populations.


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