Promoting Behaviors with Long Payoff Periods (Happy Halloween)

In the ongoing national conversation about rising healthcare costs, we often neglect to direct our attention to that portion of the healthcare costs that are avoidable. Viewing healthcare costs through this lens identifies opportunities to increase our spending in some areas (e.g., immunizations, medication spend) to address spending in other areas (e.g., emergency room visits) for a lower overall cost of care for a given population. An exclusive focus on individuals with high healthcare spend may not target our resources toward those individuals with the highest avoidable healthcare spend.

Two-thirds of emergency room visits may be more appropriately managed in provider offices or an urgent care center, potentially resulting in $32 billion in savings annually (note: the data to support this contention were provided by UnitedHealth Group, my employer). In 2013, the IMS Institute for Healthcare Informatics suggested that $213 billion of annual healthcare costs due to medications are avoidable. Nearly half those costs were attributed to medication nonadherence, and the rest were distributed across several other causes (delayed evidence-based treatment, antibiotic misuse, medication errors, suboptimal generic use, and mismanaged polypharmacy in the elderly). If a meaningful portion of the avoidable healthcare spend in America is due to behavioral choices, then we should do more to determine what actions we can take to promote healthy behaviors to avoid that spend.

In the 1980s, Geoffrey Rose developed concept that the large number of people with a small elevation in risk contributed more cases of disease than the small number of people with a large elevation in risk. This implies that a population-wide strategy might be more effective than one focused only on high-risk individuals (i.e., “hotspotting”). The concept led to the prevention paradox:

“A preventive measure which brings much benefit to the population [yet] offers little to each participating individual” … and thus there is poor motivation for the subject. … In mass prevention each individual has usually only a small expectation of benefit, and this small benefit can easily be outweighed by a small risk.

The prevention paradox could also explain the limited utility of behavioral nudges to encourage long-term behavior change. In 2013, Harvey Fineberg wrote a JAMA opinion piece highlighting some of the challenges facing disease prevention, including: the success of prevention is invisible, prevention often requires persistent behavior change, the benefits of prevention may be long delayed, and the perception that prevention must generate a positive financial return whereas treatment is worth its cost.

But even these analyses consider the work to address avoidable healthcare costs starting at disease diagnosis. If we agree that at least some chronic conditions are preventable, then perhaps our efforts are better spent promoting the work to prevent those chronic conditions. Commercial payers work on timelines well under three years given the churn in employer-based insurance coverage. Although some unions and employers (e.g., Walmart) can think in longer timeframes, many individuals do not work in the same company or profession over decades. Once a person qualifies for Medicare, much of the avoidable healthcare spend may already be “baked in” due to the acquisition of obesity, long-term tobacco use and/or multiple chronic diseases.

The challenges for promoting long-term behavior change for healthcare do not seem much different from promoting long-term behavior change for financial well-being. For a variety of reasons, young people see the value of visible short-term gains over long-term, less-visible long-term ones that require a sustained commitment to behaviors that may not be immediately pleasant or easy. Some have suggested exposing people to an older version of themselves to generate empathy for that future individual to spark the motivation to do those things we all should do: eat right, exercise, get a hearing aid, learn a new language, stop smoking, lose weight, don’t be lonely, put your financial affairs in order, write letters to your loved ones, do the things you promised yourself you would do (the list is Nicci Gerrard’s, not mine).

As Halloween approaches, the things that frighten me aren’t ghosts and vampires. Instead, I fear decisions or events that could markedly disrupt the lives of my children (e.g., drug addiction, mental illness) or my older self (e.g., dementia, loss of vision and/or hearing). Even though I would like to think I would not use emotional appeals to scare people into making choices that are more consistent with their future self, many of my own decisions with long-term payoffs are shaped by my own fears and insecurities.