What the Robert Wood Johnson Foundation learned from a six-year exploration
As the bestsellers started piling up, from 2008’s Predictably Irrational and Nudge to 2011’s Thinking Fast, Thinking Slow, the buzz around behavioral economics — the science and practice of nudging people toward a particular decision — could be heard from the classroom to the board room.
Many dismissed it as a passing fad. Some balked at its paternalism. Others considered it “kinda creepy.”
We at the Robert Wood Johnson Foundation were cautiously optimistic. Could behavioral economics, a tool that has helped people save money, also help save people’s lives? Could its power be wielded to make the healthy choice the easy choice? Could we figure out ethical ways to use it to improve the relationship between patients and their provider?
We had a lot to learn, so in collaboration with the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania’s Leonard Davis Institute and the Donaghue Foundation, we invested about $2.5 million dollars to support a group of health researchers to begin experimenting with behavioral economics.
With our funding, they tested how this tool could be used to tackle some truly perplexing health and health care challenges: from helping people who want, but somehow haven’t managed, to make it to the gym or get a flu shot, to guiding people to pick a health plan that works best for them.
Our goal: to gather timely, actionable insights about how to use behavioral economics to improve health, and share them with our colleagues inside and outside our walls — other funders, researchers and curious individuals like YOU — to support our collective efforts to build a Culture of Health.
And we learned a lot!
I’m excited to be able to share some of what we learned, both from the research we directly funded and from the efforts of others in this burgeoning field.
As the popularity of behavioral economics continues — along with misperceptions about how behavioral economics can be used to improve health — the insights from this body of work are so important to those who have not a penny to spare and not a minute to waste.
- Interventions that present choices differently by altering the physical environment can be particularly effective when it comes to health and health care. For example, putting skim milk at eye level on the shelf of a grocery store increases sales and locating hand washing stations at the door to a patient’s room increases hand washing.
- The way choices are “framed” can make health interventions even more effective. Researchers at Massachusetts General Hospital used “traffic light” labeling to indicate the healthiness of food and drinks in their workplace cafeteria. They also rearranged items so that healthier items were more visible. Sales of healthy items jumped, and after two years, employees continued to make healthier choices.
- Positive attributes trump negative attributes when it comes to describing medical effectiveness. A meta-analysis of treatment scenarios showed that people are more likely to undergo both surgical and medical treatments when framed in terms of survival than when framed in terms of mortality.
- Providing a choice between participation and non-participation guides people to actively make decisions. Punam Keller and colleagues found through a series of lab and field experiments that by forcing people to make an active choice (even it means saying “no thanks”) rather than asking them to opt-in, leads to significant increases in participation for health behaviors like getting flu shots, taking health risk assessments, and switching to an automatic prescription refill program.
- Commitment devices can be easy to scale, particularly when they use inexpensive devices such as reward programs or mobile apps. Janet Schwartz and colleagues used a grocery store’s discount program to encourage people to shop healthier–if participants who were already enrolled in the discount program increased their purchases of healthy food they would receive their discount; otherwise, it was forfeited for that month. It worked: participants were more likely to choose healthy options.
Some of the studies we funded failed. And that was awesome.
After all, if a study is well executed, a null result is a success. It tells us what doesn’t work. And in a world where resources are scarce and we have no funding to waste, that’s incredibly important to know.
So here is what we learned about what doesn’t work:
- Setting certain choices as defaults won’t always translate into action — just because a patient signs up to be automatically scheduled for a flu shot each year, doesn’t mean they will show up and get that flu shot.
- Commitment devices are only effective with people who are ready to make a change.
- And even then, after a while, the effects of a commitment device can wear off.
- Commitment devices don’t work when the benefits and trade-offs aren’t salient enough.
- Financial incentives often don’t have long-term effects on behavior in situations where the environment is stacked against sustained behavior change.
- Choice architecture interventions that change the path of least resistance to make the healthy choice the easy choice don’t work when people have strong preferences for an unhealthy behavior.
Now It’s Your Turn!
Look around and you can see behavioral economics at work across the spectrum of health — from the research lab to the doctor’s office, from prevention programs to workplace wellness initiatives. Top medical scholars are incorporating behavioral economics in their research. Entire health systems and government agencies are employing behavioral economics techniques.
At RWJF we’ve embraced behavioral economics in our strategies too. We’re using behavioral economic principles to:
- Inform the structure of incentives for health care providers and to create a practice environment that can improve provider performance and patient experience.
- Craft effective workplace nudges, policies and programs to improve work-life balance for employees.
- Design interventions to increase social belonging and to reduce violence.
We even have red, yellow and green tongs in the salad bar in the foundation’s dining room — traffic light signals that quickly point us toward the healthiest option.