Rational Decisions Make Bad Table Manners

Dec 17, 2012
How outrage over a greedy table-mate revealed the irrationality behind most decision making.

Before joining Express Scripts, my research focused on how patients should make decisions (rather than how they actually behave). My formal training was in classical economic theory, which assumes that people are rational and behave in their own self-interest. People who know my background often ask how I became so interested in the behavioral sciences.

Looking back, I think it all started at a dinner out among five couples. It became clear that we would simply divide the bill by 10.

There was one fellow in the group – we’ll call him Jack – who drank faster than everyone else and ordered a very expensive dinner. The rest of us moderated our orders, choosing pasta or chicken. At dessert, he ordered a crème brulee and a cappuccino; the rest of us had coffee or sorbet.

I was absolutely livid.

But later I started thinking about my training in grad school. Two things struck me. First, Jack was the only one behaving according to the principles I had learned: He was being logical and acting in his own self-interest. He ordered $30 more stuff than the other nine people but paid only $3 for his extras.

That’s a 10-fold return on investment and a payback period of two hours. Any CFO would be proud.

Second, despite a very expensive education at a highly regarded university, my emotions ruled. All my training was overwhelmed by a sense of fairness violated.

I started to wonder whether healthcare might be barking up the wrong tree by focusing on more patient education and incentives. I started reading – a lot – and became convinced that humans are powerfully wired with certain sentiments that are hard to undo.

We at Express Scripts began to investigate how to re-engineer the pharmacy environment to advantage better behaviors. This would allow the natural inclinations of our members to lead to better decisions over the longer term.

The result of this years-long journey is Consumerology®, the advanced application of the behavioral sciences to healthcare. We use choice architecture, framed messaging and advanced analytics to effectively nudge patients to better decisions and healthier outcomes – all while preserving individual choice.

Looking ahead, Express Scripts will marshal even more tools, including clinical specialization, to drive teachable moments, while we use deeper data to identify in advance which patients will benefit from specific interventions to improve decisions and deliver better outcomes.

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