Is a Positive Nudge Better than Fear?

Bruce BroussardIn a series of LinkedIn Influencer blog posts, Humana President and CEO Bruce Broussard shares insights and ideas about the future of health care and discusses the importance of working together to improve the health-care system as well as our own health and well-being. His latest — Is a Positive Nudge Better than Fear? — is reprinted below. To see all of his blog posts, click here.

Fear is used to influence how we behave, how we shop, how we save, what we eat, how much we exercise. From purchasing the safest car to baby-proofing our homes, fear drives us in many ways.

But is fear effective in health? Yes, people will lose weight because they’re afraid of having a heart attack. Yet others will lose weight because they want to have more energy to do the things they love and have a longer, more fulfilling life. When it comes to changing behaviors, is fear the best motivator?

In health care, our ability to change unhealthy behaviors – and thus improve outcomes and lower costs – will determine the sustainability of the system. According to the U.S. Centers for Disease Control and Prevention (CDC), “86 percent of the nation’s $2.7 trillion annual health care expenditures are for people with chronic and mental health conditions.”

Chronic conditions are the most preventable of health issues because they’re the result of unhealthy decisions made over time. This leads to a question: How do you “nudge” people toward positive behavior change?

I recently finished the revised and expanded edition of a book called Nudge, by Richard H. Thaler and Cass R. Sunstein. The authors offer several insights on how unhealthy behaviors can be corrected.

Here are four concepts from the book that grabbed my attention and how each can be used to change unhealthy behaviors among seniors and those living with multiple chronic conditions:

#1: Frame the choice without the negative. Thaler and Sunstein examine how a person with a serious heart disease is presented with a “grueling operation.” They state the following:

“The doctor says, ‘of one hundred patients who have this operation, ninety are alive after five years.’ What will you do? If we fill in the facts in a certain way, the doctor’s statement will be pretty comforting, and you’ll probably have the operation. But suppose the doctor frames his answer in a somewhat different way…‘Of one hundred patients who have this operation, ten are dead after five years.’” Thaler and Sunstein go on to say, “If you’re like most people, the doctor’s statement will sound pretty alarming, and you might not have the operation.” The same goes for doctors themselves. “When doctors are told that ‘ninety of one hundred are alive,’ they are more likely to recommend the operation than if told that ‘ten of one hundred are dead.’”

The Nudge: Physicians, nurses, care professionals and caregivers who care for seniors living with multiple chronic conditions have much influence. It’s natural for a senior not to want to undergo an operation where there is risk. Thaler and Sunstein note that “a good way to increase people’s fear of a bad outcome is to remind them of a related incident in which things went wrong; a good way to increase people’s confidence is to remind them of a similar situation in which everything worked out for the best.” Nudges that frame the positives, while highlighting the ideal outcome, will help people take steps to evolve from unhealthy behaviors.

#2: Don’t underestimate the power of priming. Referred to by the authors as “the somewhat mysterious workings of the Automatic System of the brain,” the concept has been proven to show that “subtle influences can increase the ease with which certain information comes to mind.” The authors write:

“With respect to health-related behavior, significant changes have been produced by measuring people’s intentions. If people are asked how often they expect to floss their teeth in the next week, they floss more. If people are asked whether they intend to consume fatty foods in the next week, they consume less in the way of fatty foods. The nudge provided by asking people what they intend to do can be accentuated by asking them when and how they plan to do it.”

The Nudge: Consistent patient engagement is essential, especially when focused on sustaining behavior change. Physicians don’t have a lot of time outside the office for helping patients make better daily decisions. But by nudging the patient, the care team shows an active interest in the patient’s health and can improve outcomes.

#3: Incentives are a better option than talking down to someone. Thaler and Sunstein describe how a simple nudge can lower the teen pregnancy rate, saying teenage mothers “often become pregnant again within a year or two.”

The two cite a “dollar a day” program, “by which teenage girls with a baby receive a dollar for each day in which they are not pregnant…A dollar a day is a trivial cost to the city, even for a year or two, so the plan’s total cost is extremely low, but the small recurring payment is salient enough to encourage teenage mothers to take steps to avoid getting pregnant again. And because taxpayers end up paying a significant amount for many children born to teenagers, the costs appear to be far less than the benefits.”

The Nudge: Sustaining action requires sustained commitment. For seniors living with chronic diseases like Congestive Heart Failure, where the heart weakens over time, life is already difficult. Positive encouragement, through nudging from the care teams, can help them stay the course.

#4: People can make good decisions when presented with non-biased facts. In the bonus chapter, Thaler and Sunstein discuss how New York City adopted a law requiring fast-food chains to display the caloric intake of each of their foods. The authors applaud the preference of mandating information vs. mandating ingredients.

The Nudge: Many of us have experienced this nudge by reading the information in fast-food restaurants. It’s a powerful influence because it doesn’t pass judgment on an option; it merely states the impact of the decision. Making someone feel guilty for his or her unhealthy decisions over a lifetime won’t change behavior.

For far too long, health in our country has been marketed through fear. Given how unhealthy our country has become, it’s time for a change.

Health is hard, especially for seniors living with multiple chronic conditions, limited financial means, and often limited support from family and friends. We have to avoid talking down to people and painting dire scenarios.

At Humana, we’re responsible for the health and well-being of 14 million Americans; 3.3 million of them are Medicare Advantage members, and many of them are living with chronic conditions. I’ve seen firsthand how a nudge – not fear – from a physician, nurse or other care team member can help a person change behavior for the better.

Let’s build a healthier country with helpful nudges, not fear.

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