Featured Health Business Daily Story, Nov. 14, 2012
Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
Through its behavioral science research, Express Scripts Holding Co. has spent a lot of time looking at what leads a consumer to make a decision. Whether we are making decisions about what pharmacy to use or what pet food to buy, the consumer’s brain is inherently limited by three things: inattention, good intentions and inertia, the company suggested at the 26th National Conference on Health, Productivity and Human Capital, held in Washington, D.C., and sponsored by the National Business Group on Health.
“We have good intentions, but we really do stick with the status quo,” remarked Larry Zarin, senior vice president and chief marketing officer at Express Scripts, which hosted an Oct. 17 workshop on patient behavior at the conference. “It takes a lot to move us to do something different, to sign up for something we know that is right, [or] to disenroll from something we signed up for 130 years ago.”
But what if there were three ways to seize a consumer’s attention and influence him to make a decision that could lead to better health outcomes and/or lower costs? Pointing out that the brain can focus on only so much information at a time, Zarin challenged panelists and attendees to consider how they put health care information in the path of consumers. “Good design earns or demands attention,” he said, citing Express Scripts’ first “design principle” when it comes to influencing behavior change. “Location, location, location. We go to where people see information; we don’t try to change that.” An example of good design that creates a captive audience is the offer to donate money to save homeless pets at PetSmart. The option shows up on the electronic kiosk during the transaction and is essentially unavoidable, he explained.
In the experience of Carpenter Co., a Virginia-based manufacturing company, establishing a mail-order pharmacy program with Express Scripts that members can opt out of played to the member’s tendency toward inattention. “Employees want choice but they really don’t want to make a decision,” suggested Benefits Manager Susan Robinson, who also spoke at the workshop. “[Employees] grumbled at first when we said we were putting it in and a lot of them opted out, but they still used the mail order because it’s cheaper. They just wanted to have that choice and we still have really good participation even though we have that choice.”
Through Select Home Delivery — Simple Choice, Express Scripts clients can automatically enroll members in the benefit and give them an opportunity to opt out within the first 60 days by going online or calling a toll-free number. On average, only 12% of members opt out of home delivery, and the program is nearly as effective in improving cost and health outcomes as exclusive home delivery programs, asserts a spokesperson. Express Scripts offers this same type of opt-out mechanism to promote narrow retail pharmacy networks and step therapy.
Glen Stettin, M.D., senior vice president of clinical research and new solutions at Express Scripts, suggested that so much of facilitating behavior change is about targeting patients’ habits. “If you were to ask people — I’ll go with the example of generics — would you rather have a medicine with the same active ingredient, one that costs more or one that costs less? Or take generics versus new drugs: Would you rather have drugs that are time-tested, that have been on the market a long time and the safety profile is well known, or something that’s brand-new, hasn’t been used on a lot of people?” posed Stettin during the workshop.
“People will say they prefer something less expensive or that’s been on the market a long time, but at the same time, if you look at the benefit design, even if they had incentives you still have a significant number of people who haven’t made the switch, and it’s not easy to make the switch,” he observed. “You’ve got to get a doctor to write a new prescription or you’ve got to actively ask your pharmacist to do something differently. And so it’s not that they don’t want to do it — it’s how do you get them over the hurdle?”
“I think that’s true. If you don’t get people’s attention at the right moment, if you don’t trigger the behavior you want, you will fail,” concurred BJ Fogg, Ph.D., who directs the Persuasive Tech Lab at Stanford University, where he directs research on the psychology of persuasion. “Habits do not require a lot of momentum.”
Stettin described an intervention conducted by Express Scripts in which the PBM seizes the moment when people reach out to Express Scripts by calling about a home delivery issue. “We’ll say, ‘By the way, based on your plan design, you’re spending more money on your medication than you need to,’ or ‘One of our pharmacists has some information for you that might be helpful with regard to reducing [the cost of] your medicines. Can I put them on the line?’ We find that 85% of people, when we approach them this way, they’re happy to spend an extra minute on the phone,” revealed Stettin.
One way that PBMs can put information in the path of technology-savvy consumers is through the use of Smartphone applications, added Zarin. Express Scripts offers a mobile app and web portal that provide members with easy access to their pharmacy benefit information. In addition, the PBM tailors savings and adherence interventions to match each individual patient’s lifestyle, from mobile texts and emails to traditional phone calls and letters.
Zarin also posed two other “design principles” to consider when it comes to facilitating behavior change:
Good design activates good intentions. There is a gap between what people want to do and what they actually do, observed Zarin. “It clearly shows in our research that the name of the game is not about changing behavior, but about activating existing intent,” he said. “Think about where that puts the strategy of more education and more information.”
Good design leverages inertia. “Do not take choice off the table, but give people the option to get out,” he advised, hearkening back to the idea of the opt-out mail-order program. Simply say, ‘You’re starting in a wellness program,’ ‘You’re starting in a 401K,’ ‘You’re starting in home delivery,’ etc. Whatever it is, if it’s not right for them, they simply need to go and do something about that.”
One drug-related example is implementing a mandatory generics substitution program. “You can implement that without an appeals process or you can put in an appeals process, in terms of the patient saying, ‘I have a reason why I need this brand medication’ or ‘I just want the brand,’” explained Stettin. “When you do the mandatory [program], you get 100% generic utilization or extremely close to it. When you do the opt out, you get somewhere between 96% to 99.5% because most people, they go along with it. They see the benefit to their pocketbook and they’re not going to go out of their way, back to their doctor, to find out they really don’t need [the brand drug]. By putting it in place that way, by maintaining some kind of choice, it takes advantage of the inertia.”
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