The Fine Line Between Shared and Manipulated Medical Decisions

Spend some time with the Society for Medical Decision Making, and “shared decisions” starts to seem less a clinical ideal and more an offshoot of picking a monthly cell phone plan. The fine line between “motivating” and “manipulating” behavior (albeit sometimes unintentionally) starts to blur.

At the group’s recent annual meeting in Chicago, the differing sensibilities of medical and marketplace ethics were in plain view on a panel entitled (with a nod to the Richard Thaler and Cass Sunstein behavioral economics best-seller), “From a Nudge to a Shove: How Big a Role for Shared Decision Making?”

Peter Ubel, a physician and a professor of marketing and public policy at Duke University, told how some free-market theorists have defined away, “overweight.” Since people know what causes them to put on pounds, goes this reasoning, the weight they are must be the weight they rationally decided to be. (Shades of Dr. Pangloss!)

Unfortunately, eating decisions are not purely rational. Eat in a large group, said Ubel, and lingering at lunch could boost your calorie count by 25 percent. Choose the large plate at the buffet table over the small one and bump up calories another 25 percent. Our brains even seek out the bad: give us two identical crackers, but label one as having a more “unhealthy fat,” and we’ll consistently pick it over the healthier-labeled cracker in a taste test.

On the other hand, use a prominently displayed surcharge – otherwise known as a “fat tax” – for the high-cal choice, and behavior changes. “Sometimes we need to send signals that stigmatize or show what is ‘wanted,’” said Ubel. But the question for society is, “How far do we want to go to change a behavior?”

Kevin Volpp, a physician and behavioral psychologist at the University of Pennsylvania, noted that Britain’s Nuffield Council proposed an “intervention ladder” of the possibilities. They escalate from doing nothing to providing information to enable choice to carrot-type incentives to stick-type incentives to restricting choice and then eliminating choice. One company may provide incentives for smokers to stop; another may just stop hiring smokers while yet another bans smoking even away from the office. It’s all in the name of health – and of lower insurance premiums.

But Volpp, who showed data he’s published in both the New England Journal of Medicine and the Journal of Consumer Psychology, warned of the difference between prodding and punishing employees. Section 2705 of the Patient Protection and Accountable Care Act (ACA) allows employers in 2014 to use up to 30 percent of health insurance premiums to put in place outcomes-based incentives; e.g., smoking status, body mass index and cholesterol levels.  Will those incentives help employee health, asks Volpp, or simply penalize those whose socioeconomic status and environment make them more vulnerable?

Meanwhile, Kit Sundararaman, with a doctorate in communications, talked about how pharmacy benefits manager Express Scripts uses a behavioral science advisory board to help implement “consumerology.”

The goal is “to help our [50 million] members make better choices”: to be more adherent to therapy, to choose “better channels for receiving drugs” (the less costly pharmacy network or home delivery); and to make a better brand-generic decisions, said Sundararaman, adding: “You can’t assume that people are doing what they want to be doing.”

Express Scripts says it helps “activate good intentions.” Using the same kind of “active choice” program that’s helped boost the number of participants in 401(k) retirement plans, Express Scripts pushed consumers to either move to home delivery of maintenance drugs or make a deliberate decision not to. The resulting shift resulted in a savings of $27 per member per year for Express Scripts clients, Sundararaman said.

“Humans are wired for inattention and inertia, not engagement and choice,” she added. “It’s not thinking about pharmacy benefit.”

If these approaches seem to edge near the line separating empowerment from entrapment, researchers conceded as much. Are hard-edged smoking cessation or weight loss programs justified because they help keep down everyone’s insurance costs? What about nudging the elderly lady to choose home delivery of drugs when dressing up to go see the pharmacist is a regular part of her life (as one questioner suggested)? What is the balance between personal freedom and societal obligations? There were no easy answers.

Other sessions raised questions about unintended rather than intended consequences.

  • Precision can be perplexing. Adding decimals to the risk estimates on those website health calculators makes them less believable and harder to remember, said Holly Witteman, a University of Michigan researcher. Adding any decimal place data caused up to 10 percent of people to find the risk less believable, while simple integers caused people to “feel” the risk was smaller, no matter what the number. Witteman said it’s unclear if physician perceptions are any less subject to these influences than those of patients.
  • Precision can be paralyzing. Paul Han, a physician at the Maine Medical Center Research Institute, said telling patients about a confidence interval in risk data introduces ambiguity that prompts many to decide not to make a decision or to decide against a proposed intervention.
  • Decisions by the elderly need special attention. Accumulated life experience can compensate for a decline in the deliberative capabilities of the elderly, said Ellen Peters, an associate professor of psychology at the Ohio State University, but choices must be presented in a way that builds on the older brain’s strengths and compensates for weaknesses. Older adults behave more like “experts,” with intuitive decision making, and are guided more by positive than negative information.  “But older adults will probably make worse decisions when it comes to unfamiliar decisions, where the information is complex and changing, particularly those that involve numeric information,” Peters cautioned.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”

7 replies »

  1. I remember reading that consumers tend to choose less aggressive interventions when they are better informed about the options, especially for end of life decisions. These decisions are certainly difficult for individuals and their families, but often they just don’t have the right information or it’s not presented in a way that helps them decide. A trusting relationship is required, and that is not always there.

    I recently heard a mental health clinician talk about her experiences in primary care settings that I found enlightening. She reported that patients often have real barriers to following recommendations that they don’t communicate to their providers – who then start to feel negatively about the patients. She said when she explains some of the issues, those providers begin to problem-solve and engage in real “shared decision-making” where they were more apt to just blame the patient for not complying when they weren’t aware of the issues. It made sense to me – I’ve seen that happen way to many times!

  2. Yeah, I have rarely heard of poor decisions when individuals make choices for a house, a car, or a retirement plan.

    People can choose whatever they want for medical services, but whenever 3rd party money is involved, some caution is advised, because otherwise we (taxpayer, risk sharers in a pool) end up paying for more nonsense then we already do now.

  3. Medical advisors are biased themselves and often don’t understand the level of risk involved in changing or not changing a behavior or intervention. Patients often point this out when they say, “I hear something different from different physicians and other clinicians.” Often they are confused and become distrustful of advice, and I don’t blame them. In my experience, people do best when they can understand the basic information behind a recommendation and evaluate the evidence when deciding what they believe. Many advisors don’t think patients can figure these things out, but lay people often use very sophisticated analytical approaches when purchasing other products, such as a house, a car, or a retirement plan. No one can know and understand everything, but I’ve often found medical experts just as fallible as lay people – but more certain they’re not.

  4. I think the role of the physician or other professional involved with explaining the medical options is to relate them as clearly as they can. Since we can’t fully measure non-verbal communication you may never know how much was explanatory and how much was manipulation.

  5. Do people actually believe that savings per member per year for home delivery is the reason pharmacy benefit managers advocate for home delivery? Does the PBM make the same margin on policy holders choosing home delivery compared to retail? If they did, do you believe they would advocate as strongly for home delivery?

  6. I am really glad you wrote this piece, Michael. The entire dialog regarding changing people’s behaviors, for their own good of course, is extremely disturbing. The underlying abilities embedded in the Internet and social media are a very powerful addition and available to anyone with a enough dollars to spend.
    Interestingly enough, everybody seems to be into behavioral “improvements” nowadays, from the private folks at your conference, all the way to public government, they all seem to be hellbent on changing people’s perceptions of the things they promote, and money is at the bottom of them all (if you search deep enough).
    If the world was a village yesterday, today it is a for-profit lab, and 99% of us are rats.

  7. A very interesting reflection. I missed a bit of emphasis on education, but all in all, an important and well described issue.