Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Individual behavior plays a central role in the disease burden faced by society. Many major health problems worldwide are exacerbated by unhealthy behaviors. Modifiable behaviors such as tobacco use, obesity, and alcohol abuse account for nearly one third of all deaths in the United States. Realizing the potential benefit of some of the most promising advances in medicine, such as medications to control blood pressure, lower cholesterol levels and prevent stroke, has been stymied by poor adherence rates among patients. Reducing morbidity and mortality may depend as much on motivating changes in human behavior as on developing new treatments.

Economics, as the social science discipline traditionally most closely tied to public policy, could be a key discipline in addressing behaviors that are potentially harmful to health. Yet, conventional economics does not provide satisfactory policy solutions to problems caused by self-harmful behavior because it is premised on a rational choice perspective which, by assuming that individuals make optimal decisions given their information, resources, and preferences, in effect assumes away these problems. The main policy tools suggested by conventional economics – providing information or changing prices -- only partially address these problems because they fail to exploit what is known about human motivation and behavior change.

In this series of papers, we present work using behavioral economic approaches that have recognized the importance of present-biased preferences, loss aversion, and defaults in designing interventions to improve health. The first paper, by Volpp, Pauly, Troxel, Glick, and Audrain, is a randomized controlled trial of financial incentives for smoking cessation among employees at General Electric which tests the effectiveness of providing financial rewards for smoking cessation program completion, smoking cessation in the short term, and smoking cessation in the long term. Smoking cessation program completion rates, short- and long-term cessation rates were significantly higher in the incentive group. The second paper, by Zinman, Karlan, and Gine, examines the impact on smoking cessation rates of a deposit contract system set up through a bank in the Philippines. Subjects were randomized to three different arms, with the intervention group being invited to deposit increasing amounts of money into an account that they could only withdraw if they had a negative cotinine test after 6 months. Smoking rates were 5.5 to 8.1 percentage points higher among participants in this group compared to the control group. The third study by Wisdom, Downs, and Loewenstein examines the impact of providing vouchers for a free lunch at Subway sandwiches based on whether subjects are provided with caloric intake information, daily caloric targets, or a list of low calorie vs. high vs. a combination of low and high calorie options. Information on caloric information or daily caloric targets alone did not change caloric intake, whereas the ordering of presentation of different sandwiches significantly affected sandwich choices and caloric intake.

All 3 of these approaches represent innovative ways in which behavioral economic interventions can be used to improve patient health, and all 3 experiments achieved significant improvements in health as will be described in the individual abstracts.